Conceptual Model/Overview of Program

Noncompliance (i.e., excessive disobedience to adults) is consistently reported to be the most prevalent behavior problem for clinic-referred and non-referred “normal” children alike, and is currently viewed as a keystone behavior in the development and maintenance of conduct disorders. “Helping the Noncompliant Child” (HNC) (Forehand & McMahon, 1981; McMahon & Forehand, 2003) is based on a parent training program originally developed by Hanf at the University of Oregon Medical School in the late 1960s (e.g., Hanf & Kling, 1973) to treat noncompliance in young (3–8 years of age) children with a range of developmental disabilities (see Reitman & McMahon, 2010). While several independent groups of clinical researchers have adapted Hanf’s original program, the adaptation by the current authors (Forehand & McMahon, 1981; McMahon & Forehand, 2003) is one of the most formally operationalized and evaluated versions of this approach to working with young children with conduct problems. The purpose of this chapter is to provide a description of the theoretical assumptions that underlie HNC, an overview of the program, and a summary of its empirical support. We also provide a description of a typical HNC case, and conclude with remarks concerning future directions.

Longitudinal studies have shown that there are multiple pathways that lead to the development of conduct problems (e.g., Moffitt, 1993, see Chap. 3). The “early-starter” (Patterson, Capaldi, & Bank, 1991) pathway is characterized by the onset of conduct problems in the preschool and early school-age years, and by a high degree of continuity throughout childhood and into adolescence and adulthood. It is thought that these children progress from relatively less serious (e.g., noncompliance, temper tantrums) to more serious (e.g., aggression, stealing, substance abuse) conduct problem behaviors over time; that overt behaviors (e.g., defiance, fighting) appear earlier than covert behaviors (e.g., lying, stealing); and that later conduct problem behaviors expand the children’s behavioral repertoire rather than replace earlier behaviors (e.g., McMahon, Wells, & Kotler, 2006; Patterson, Reid, & Dishion, 1992). Furthermore, there is an expansion of the settings in which the conduct problem behaviors occur over time, from the home to other settings such as the school and the broader community.

The primary role of family socialization processes in the development of the early-starter pathway has been described and empirically demonstrated by Patterson and his colleagues (e.g., Chamberlain & Patterson, 1995; Patterson, 1982; Patterson et al., 1992). Patterson emphasizes the coercive, or controlling, nature of conduct problem behaviors and has developed the coercion model to account for their development and maintenance (see Fig. 7.1 for an example). The model describes a process of “basic training” in conduct problem behaviors that occurs in the context of an escalating cycle of coercive parent–child interactions in the home that begins prior to school entry. The proximal cause for entry into the coercive cycle is thought to be ineffective parental management strategies, particularly in regard to child compliance with parental commands or instructions during the preschool period. As this process continues over long periods, significant increases in the rate and intensity of these coercive behaviors occur as family members are reinforced by engaging in aggressive behaviors, which temporarily decrease or even appear to halt the child’s inappropriate behaviors. Furthermore, the child also observes his or her parents engaging in coercive responses, and this provides the opportunity for modeling of aggression to occur over time (Patterson, 1982).

Fig. 7.1.
figure 1

The coercive process between a parent and child. From Forehand, R., & Long, N. (2002). Parenting the strong-willed child: The clinically-proven five-week program for parents of two-to six-year-olds (2nd ed.), New York: McGraw-Hill.

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Upon school entry, the child’s coercive style of interaction is likely to extend to interactions with teachers and peers, resulting in frequent disciplinary confrontations with school personnel, rejection by peers, and continued coercive interchanges with parents (e.g., Patterson et al., 1992). By age 10 or 11, this recurrent constellation of negative events places the child at increased risk for association with deviant peer groups in middle school and high school (with a likely escalation in conduct problem behaviors). Adolescents who have progressed along the early-starter pathway are not only at significant risk for continuing to engage in more serious conduct problem behaviors throughout adolescence (e.g., delinquency, substance abuse) and into early adulthood, but as adults they are also at increased risk for other psychiatric diagnoses and a variety of negative life outcomes (e.g., lower occupational adjustment and educational attainment, poorer physical health) (e.g., Farrington, 2003; Kratzer & Hodgins, 1997).

Noncompliance appears to be a keystone behavior in the development of conduct problems. It appears early in the progression of conduct problems and continues to be manifested in subsequent developmental periods (e.g., Chamberlain & Patterson, 1995), playing a role in later academic and peer relationship problems. Low levels of compliance are also associated with referral for mental health services in children with conduct problems (Dumas, 1996). Furthermore, intervention research has shown that when child noncompliance is targeted, there is often concomitant improvement in other conduct problem behaviors as well (Russo, Cataldo, & Cushing, 1981; Wells, Forehand, & Griest, 1980). All of these findings support the key role that noncompliance plays in conduct problems.

Because of the significant role of early parent–child interaction in the development of conduct problems, family-based interventions have been widely employed. Such approaches have typically been based on a social learning-based “parent training” model of intervention (e.g., Miller & Prinz, 1990). The underlying assumption of this model is that a parenting skills deficit has been at least partly responsible for the development and/or maintenance of the conduct problem behaviors. This type of intervention has been shown to be very effective in working with this population (e.g., Maughan, Christiansen, Jenson, Olympia, & Clark, 2005; McMahon, 2006). Furthermore, parent training may have significant preventive effects, especially if it is applied during the preschool period (e.g., Reid, 1993), or is a component of broader preventive interventions for school-age children at risk of conduct problems (e.g., Conduct Problems Prevention Research Group, 1992).

Description of HNC

Objectives

The long-term goals of HNC are the secondary prevention of serious conduct problems in preschool and early elementary school-aged children and the primary prevention of subsequent juvenile delinquency and related problems (e.g., substance use, school dropout). Consistent with the developmental and social-learning based assumptions on which HNC is predicated, the short-term and intermediate objectives include: (a) disruption of the coercive style of parent–child interaction which characterizes these families and the establishment of more positive, prosocial interaction patterns; (b) improved parenting skills in terms of more accurate tracking and attending to the child’s appropriate behavior, increased use of praise and other positive verbal statements to the child, ignoring of minor inappropriate child behaviors, provision of clear and appropriate instructions to the child, and provision of appropriate consequences for child compliance, noncompliance, and other behaviors; and (c) increased child prosocial behaviors and decreased conduct problem behaviors, especially noncompliance. It has been shown that increased compliance to ­parental instructions results in a decrease in other conduct problem behaviors such as physical and verbal aggression, temper tantrums, and inappro­priate talk (e.g., sassiness); furthermore, children’s competencies increase as they learn more prosocial ways of interacting with their parents, siblings, teachers, and peers (McMahon & Forehand, 2003).

Targeted Population

HNC is designed for parents and their 3–8-year-old children who are demonstrating noncompliance and other conduct problems. There are no specific inclusion or exclusion criteria for parent participation. Involvement of both mothers and fathers is actively encouraged, but participation by both parents is not mandatory. While families from lower socioeconomic backgrounds are more likely to drop out than other families (McMahon, Forehand, Griest, & Wells, 1981), HNC is as effective with lower socioeconomic families who complete the program as it is for families in other socio­economic brackets (Rogers, Forehand, Griest, Wells, & McMahon, 1981).

Although HNC has been most extensively evaluated with populations of children with conduct problems, it has also been successfully adapted and employed with several other high-risk populations of children and parents, including children with developmental disabilities (Breiner, 1989; Breiner & Forehand, 1982; Forehand, Cheney, & Yoder, 1974; Hanf & Kling, 1973), children with attention-deficit/hyperactivity disorder (ADHD; e.g., Long, Rickert, & Ashcraft, 1993; Pisterman et al., 1989), as a component of interventions for mothers at risk for child abuse and neglect (e.g., Lutzker, 1984; Wolfe, Edwards, Manion, & Koverola, 1988), and as a preventive intervention for children of substance abusing parents of various ethnicities (Kumpfer & DeMarsh, 1987; Kumpfer, Molgaard, & Spoth, 1996). In addition, HNC may be beneficial as part of a broader treatment plan when working with children who (a) are enuretic or encopretic, (b) fail to adhere to medical regimens, and (c) are hospitalized in inpatient psychiatric units (see Wells, 2003). Portions of HNC have been successfully adapted for the parent group component of the Fast Track program (Conduct Problems Prevention Research Group, 1992; McMahon, Slough, & the Conduct Problems Prevention Research Group, 1996) and the Multi­modal Treatment Study for ADHD (MTA; Wells et al., 2000). Fast Track and the MTA are large, multisite studies that investigated the effectiveness of multicomponent interventions (both of which included parent training) for preventing the development of serious conduct problems in young ­at-risk school-aged children and children with ADHD, respectively.

HNC is best suited for indicated (i.e., manifest conduct problems) and selected (i.e., at-risk) populations. Reducing child noncompliance and other conduct problems and improving parent–child interactions are important because of their immediate effects on the family (indicated) and for reducing the risk for the development of more serious forms of conduct problems in later childhood and adolescence (selected).

Assessment

An important aspect of HNC is a thorough assessment of the parent–child relationship (McMahon & Forehand, 2003). The multimethod assessment process used to accomplish this consists of an interview, observations of parent and child interactions, questionnaires completed by the parent, and parent-recorded data. Daily situations, which frequently are problematic for noncompliant children, are assessed during the interview (e.g., going to bed at night, taking a bath, disrupting the parent during a tele­phone conversation). If a parent experiences a problem in any area, a detailed description is requested regarding how he or she handles the situation, how the child responds, and how often the problem occurs.

After the interview, which typically lasts 45 min, the parent and child are observed in two structured toy-play situations, labeled “Child’s Game” and “Parent’s Game.” These observations last from 5 to 10 min each. The Child’s Game consists of a parent following rules and activities determined by the child; The Parent’s Game requires the parent to engage the child in activities according to rules of the parent’s choosing. These brief interactions give the clinician an idea of how the parent and child interact. (When feasible, observational data can also be collected in the home setting, preferably at a time when child problem behaviors typically occur.)

The questionnaires focus on the parents’ report of the child’s functioning (e.g., Achenbach and Rescorla’s [2000, 2001] Child Behavior Checklist) and on the parents’ personal and marital functioning (e.g., Beck, Steer, & Brown’s [1996] Beck Depression Inventory-II; Porter & O’Leary, 1980 O’Leary-Porter Scale). Questionnaires can identify problems that the therapist may have inadvertently missed during the interview, as well as supplemental information gained from the interview, observations, and parent-recorded data. Furthermore, the questionnaires that address parental functioning can identify problems causing severe distress that may impede parents’ implementation of the parenting program.

Finally, parents identify the three child behaviors that are of greatest concern and record their occurrence for 4 consecutive days. This provides specific information concerning the frequency of various problematic child behaviors in the home setting. If the initial assessment indicates that child behavior problems are also occurring in the preschool or school setting, then similar methods are used to gather information from that setting to determine whether school-based intervention is also warranted.

With the information gathered from interviews, observations, questionnaires, and parent-recorded data, the therapist can re-examine the following issues: Is child noncompliance in multiple situations the primary issue? Can parenting practices be modified to influence the child’s behavior? Is family stress, other than that caused by the child’s behavior, relatively low, or addressable through other interventions? If the answer to each of these questions is yes, then HNC is a reasonable choice for intervention.

In our experience, there are some situations in which HNC is contraindicated. For example, HNC may not be appropriate for some children with disorders on the autism spectrum since this parenting intervention relies upon parental attention to help change behavior. If such attention is aversive to the child, then HNC (in its complete package) is probably not an appropriate intervention. Parental psychosis, other serious mental illnesses, and/or significant substance use problems that are not being effectively treated may preclude successful involvement in HNC if they interfere with the parent’s ability to follow through with this intervention.

Format

The primary format for HNC is sessions conducted by a therapist with the parent(s) and child. We employ a controlled learning environment in which to teach the parent to change maladaptive patterns of interaction with the child. Sessions are typically conducted with individual families rather than in groups, although the program has been adapted for use in a group format (e.g., Baum, Reyna-McGlone, & Ollendick, 1986; Conners, Edwards, & Grant, 2007; Long & Forehand, 2000a, 2000b; McMahon et al., 1996; Pisterman et al., 1989) as well as a self-directed format (e.g., Forehand & Long, 2010; Long et al., 1993). Ideally, intervention occurs in playrooms equipped with one-way mirrors for observation, sound systems, and unobtrusive one-way radio devices (e.g., “bug-in-the-ear”) by which the therapist can communicate unobtrusively with the parent; however, these accouterments are not necessary for the successful implementation of HNC.

The number of sessions necessary for the completion of each phase of HNC depends upon the speed with which the parent demonstrates competence in the skills being taught and the child’s response to this intervention. The mean number of sessions necessary to complete HNC has been approximately 8–10 sessions, with a range of 5–14 sessions. Sessions are typically held once or twice per week, and each session is 75–90 min in length.

Session Content

After completion of the assessment, the therapist presents a conceptualization of the child’s noncompliance and other conduct problems in the context of Patterson’s (1982) coercion theory and presents the rationale for HNC (e.g., the role of parent–child interaction in the development and maintenance of the conduct problems; the focus on changing child noncompliance). An overview of the content (i.e., the various parenting skills) and the process (e.g., the use of didactic instruction, modeling, rehearsal, practice with the child in session and in the home, behavioral criteria) of the program is then presented.

HNC consists of two phases. In each phase, a series of parenting skills are taught in a sequential manner. During the Differential Attention phase (Phase I), the parent learns to increase the frequency and range of social attention to the child and reduce the frequency of competing verbal behavior. A major goal is to break out of the coercive cycle by establishing a positive, mutually reinforcing relationship between the parent and child.

The parent is first taught to attend to and describe the child’s appropriate behavior (Attends) while eliminating commands, questions, and criticisms. The second segment of Phase I consists of teaching the parent to use verbal (e.g., praise) and physical (e.g., hugs) attention contingent upon appropriate behaviors (Rewards) and to actively ignore minor inappropriate behaviors (Ignoring). The parent then learns to develop programs to simultaneously increase desirable child behaviors and decrease less appropriate competing behaviors through the systematic use of contingent attention and ignoring (i.e., differential attention). (See Table 7.1 for a description of Phase I parenting skills.)

Table 7.1. Phase 1 skills (Adapted from McMahon & Forehand, 2003)
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In Phase II of HNC (Compliance Training), the primary parenting skills are taught in the context of the Clear Instructions Sequence (see Fig. 7.2). The Clear Instructions Sequence consists of three paths. The therapist first teaches the parent to use appropriate commands (Clear Instructions) to increase the likelihood of child compliance. The parent is taught to give direct, concise instructions one at a time, and to allow the child sufficient time to comply (see Table 7.2). If compliance is initiated within 5 s of the clear instruction, the parent is taught to praise or attend to the child within 5 s of the compliance initiation (Path A). If compliance is not initiated, then the parent gives the child a warning (“If you don’t …, then you will have to go to time out.”). If the child initiates compliance within 5 s, the parent praises and attends to the child (Path B). However, if the child does not comply with the warning, then the parent is taught to implement a brief time-out procedure that involves placing the child in a chair for 3 min (Path C) (see Table 7.3). If the child does not remain in the chair, then one or more back-up procedures are used, including additional time, response cost, and/or removal to a different room. Following time out, the command that originally elicited noncompliance is repeated. Compliance (Path A) is followed by contingent attention from the parent. Noncompliance is followed by implementation of Path B, and if necessary, Path C.

Fig. 7.2.
figure 2

Flowchart of the Clear Instructions Sequence. From McMahon, R.J., & Forehand, R.L. (2003). Helping the noncompliant child: Family-based treatment for oppositional behavior (2nd ed.). New York: Guilford Press. Reprinted with permission.

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Table 7.2. Clear instructions (From McMahon & Forehand, 2003)
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Table 7.3. The Clear Instructions Sequence (From McMahon & Forehand, 2003)
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When using the Clear Instructions Sequence successfully at home, the parent is taught to use Standing Rules as a supplement to this sequence. Standing Rules are “if... then” statements (“If you hit your brother, then you must go to time out.”) that, once stated and explained to the child, are permanently in effect. Because Standing Rules provide an immediate consequence for the child’s inappropriate behavior, they can be particularly useful for situations in which there is a danger to the child, someone else, or property. Finally, the therapist teaches the parent to implement the Phase I and Phase II parenting skills in situations outside the home (e.g., riding in the car, shopping, visiting others). Although booster sessions are not a formal part of HNC, many clinicians have found it helpful to schedule at least one follow-up booster session 1–2 months after the last regular treatment session.

Adjuncts to the basic HNC program have been developed for teaching maternal self-control procedures (Wells, Griest, & Forehand, 1980); the social learning procedures underlying the parent training program (McMahon, Forehand, & Griest, 1981); and procedures to enhance general family functioning, especially with regard to developmentally appropriate parental perceptions of the child’s behavior, marital adjustment, parental personal adjustment, and the parents’ extrafamilial relationships (Griest et al., 1982). Instruction in these adjunctive procedures can be integrated into the basic parent training program or, in the case of the maternal self-control procedures, immediately following completion of the parent training program.

Teaching Methods

HNC is an active intervention that places substantial emphasis on helping the parent to become competent and comfortable with the various parenting skills taught in the program. For each skill, the following procedures are used:

  1. 1.

    The procedure and rationale for each skill are explained, and the underlying social learning principles on which the skill is based are briefly presented.

  2. 2.

    The therapist demonstrates the skill via modeling and role playing.

  3. 3.

    The parent practices the skills with the therapist, who role plays the child.

  4. 4.

    The child is taught the procedure. First, a developmentally appropriate explanation of the procedure is given to the child by the parent and therapist. The child repeats the procedure verbally and participates in role plays of situations involving the procedure.

  5. 5.

    The parent practices with the child in the intervention setting. The therapist observes and coaches.

  6. 6.

    The parent practices with the child in the intervention setting but without ongoing feedback from the therapist.

  7. 7.

    Specific homework is assigned to practice the skills on a daily basis at home, both in structured practice sessions with the child and, as the parent progresses through the program, at various times throughout the day (e.g., in Phase I, the parent develops programs to increase at least three child behaviors using the new skills).

  8. 8.

    Parents are given handouts specific to each parenting skill for reference in the home setting, and data sheets to record practice sessions and use of the new parenting skills in the home.

An optional activity (that has not been part of the formal evaluation studies) is referring parents to relevant sections of the self-guided program for parents presented in Forehand and Long (2010) (see below).

Progression to each new skill in HNC is determined by the use of behavioral and temporal (number of sessions) criteria. The therapist uses observational data collected during each session to determine whether the parent–child pair has attained the behavioral criteria necessary for movement to the next step of the program. The behavioral criteria ensure that the parent has attained an acceptable degree of competence in a particular skill before being taught additional parenting techniques. This is critical since the parenting skills build on one another. In addition, these criteria allow for the individualization of HNC by allocating training time more efficiently since they allow the therapist to concentrate his or her attention on the more serious parenting skill deficiencies. Because HNC is typically conducted with individual families and because of the competency-based approach to intervention, there is ample opportunity for family members to discuss other issues of personal concern.

Staffing

A single therapist per family is sufficient to conduct HNC successfully. However, if resources permit, use of a co-therapist can increase the therapist’s flexibility in demonstrating various skills to the parent (e.g., the therapist role-plays the parent while the co-therapist role-plays the child), and can serve as a useful in vivo training experience for new therapists.

Evaluations of the HNC program have been based on implementation by individuals with at least a bachelor’s degree in psychology, most typically clinical psychology graduate students. Implementation by others may be appropriate with adequate training and supervision. Ideally, the therapist should have a background in psychology or education, and should be familiar with social learning principles and their application to child behavior.

Program Materials

A comprehensive presentation of the theoretical assumptions; assessment procedures; format, content, and teaching methods; and empirical support for HNC is contained in the therapist’s manual (Helping the Noncompliant Child: Family-Based Treatment for Oppositional Behavior; McMahon & Forehand, 2003). This manual, available from Guilford Press (www.guilford.com), also contains copies of program-specific assessment materials, parent handouts, and charts. A 70 min videotape (Forehand, Armistead, Neighbors, & Klein, 1994) that portrays the intervention procedures employed in the program is available for training therapists from ChildFocus (500 Crosswind Drive, Charlotte, VT 05445). A supplemental self-help book for parents that employs similar skills and teaching techniques (Parenting the Strong-Willed Child; Forehand & Long, 2010) is available from McGraw-Hill (http://books.mcgraw-hill.com). A leader’s guide for a 6-week parenting class curriculum program (Parenting the Strong-Willed Child (PSWC); Long & Forehand, 2000a), based on the Forehand and Long (2010) book, is available from Dr. Nicholas Long, UAMS Department of Pediatrics, Slot 512-21, 1 Children’s Way, Little Rock, AR 72202.

Empirical Support

HNC has been extensively evaluated. See Table 7.4 for a listing of evaluation studies concerning outcome and generalization. The following section summarizes this body of research (also see McMahon & Forehand, 2003, Chap. 10, for a more detailed summary).

Table 7.4. Outcome-related investigations of HNC (Adapted and expanded from McMahon & Forehand, 2003)
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Research Design/Sampling Strategy Used to Evaluate HNC

The samples of children who participated in evaluations of the different aspects of HNC were referred to outpatient mental health clinics for excessive levels of noncompliance and other conduct problem behaviors. Various designs have been employed to examine different questions related to the outcome, generalization, and social validity of HNC. Comparison conditions that have been employed in these studies include waiting-list control (Peed, Roberts, & Forehand, 1977), non-referred “normal” samples (e.g., Wells, Forehand, & Griest, 1980), variations of the basic parent training program including component analyses (e.g., McMahon, Forehand, & ­Griest, 1981), and alternative interventions (Baum et al., 1986; Long et al., 1993; Wells & Egan, 1988). Excluding studies employing single-subject designs, sample sizes with clinic-referred or risk samples have ranged from 8 to 71 families. Attrition has been minimal in the treatment outcome studies at post-intervention assessments (i.e., <20% dropout; Furey & Basili, 1988; McMahon, Forehand, Griest, & Wells, 1981). However, it was significantly higher (38–50%) in three longer-term (8 months; 4.5–10.5 years; 14 years) follow-up studies (Forehand & Long, 1988; Griest, Forehand, & Wells, 1981; Long, Forehand, Wierson, & Morgan, 1994). Studies of component analyses of HNC usually involved non-referred samples of children and/or parents. (See McMahon & Forehand, 2003, Chap. 10, for a description of these studies.)

Outcome Measures

Two primary types of measures have been employed in the outcome evaluation studies: direct observation and parent-report measures. These measures have been collected immediately prior to and after the intervention, as well as at various follow-up assessments. With respect to direct observation, trained observers collected these data in the home (and, in some studies, in the school) setting, usually in blocks of four 40 min ­observations conducted on different days. The Behavioral Coding ­System (Forehand & McMahon, 1981) includes both parent (e.g., commands, rewards, attends) and child (e.g., compliance, noncompliance, ­inappropriate behavior) behaviors. The Behavioral Coding System has been shown to have adequate psychometric properties and to be sensitive to treatment effects. Parent-report measures included questionnaires designed to assess parental perceptions of the child’s behavior/adjustment (e.g., Parent Attitudes Test [Cowen, Huser, Beach & Rappaport, 1970]; Becker Bipolar Adjective Checklist [Becker, 1960]) and the parent’s personal/marital adjustment (e.g., Beck Depression Inventory [Beck, Rush, Shaw, & Emery, 1979]; Marital Adjustment Test [Kimmel & VanderVeen, 1974]).Footnote 1 The Parent’s Consumer Satisfaction Questionnaire (Forehand & McMahon, 1981; McMahon & Forehand, 2003) assesses parental satisfaction with the overall program, the teaching format and parenting techniques, and the therapist. It has been administered immediately following intervention and at subsequent follow-ups. Various other measures have been employed in different studies.

Evaluation Results/Program Efficacy

HNC has been extensively evaluated in terms of its efficacy, generalization, and social validity. Short-term efficacy and setting generalization from the clinic to the home have been demonstrated for both parent and child behaviors, as well as parents’ perceptions of their children (e.g., Peed et al., 1977). Furthermore, these improvements occur regardless of families’ socioeconomic status (Rogers et al., 1981) or age of the children (within the 3–8 year-old range; McMahon, Forehand, & Tiedemann, 1985), suggesting these two variables do not moderate treatment outcome. Two studies have failed to find evidence for setting generality to the classroom, but there was also no evidence of a behavioral contrast effect, since there were no systematic increases or decreases in child inappropriate behavior in the classroom (Breiner & Forehand, 1981; Forehand et al., 1979).

Maintenance of the effects of HNC has been documented in several studies (e.g., Baum & Forehand, 1981; Forehand & Long, 1988; Forehand et al., 1979; Long et al., 1994), with follow-up assessments ranging from 2 months to 14 years after treatment termination. Forehand and Long (1988) demonstrated that relative to a non-referred “normal” sample, a sample of children who had participated in HNC 4.5–10.5 years earlier (and who were now between the ages of 11 and 14) were functioning well. Long et al. (1994) reported similar findings at a 14-year follow-up. The young adults (17–22 years old; M = 20 years) who had participated in HNC as children reported comparable levels of delinquency, drug use, psychopathology, self-esteem, academic progress, and quality of relationship with parents to those reported by young adults in the “normal” ­community ­comparison group. Sibling ­generalization has been ­demonstrated by ­Humphreys, ­Forehand, McMahon, and Roberts (1978), who showed that mothers employed the skills they had learned in HNC with untreated siblings who responded by being more compliant to maternal directives. Finally, improvement in child compliance has been shown to be accompanied by decreases in other overt conduct problem behaviors, such as aggression, tantrums, whining, and inappropriate verbal behavior, thereby supporting behavioral generalization of HNC (Wells, ­Forehand, & Griest, 1980).

With respect to the social validity of HNC, child compliance and inappropriate behavior have improved to within the normal range by the end of treatment, although mothers’ perceptions of the children’s adjustment appear to lag slightly behind the children’s behavioral improvements. However, by 2 months after the conclusion of treatment, mothers’ perceptions are consistent with the children’s improved behavior and are comparable to those of mothers of “normal” children (Forehand, Wells, & Griest, 1980). High parental ratings of the acceptability of, and satisfaction with, HNC in general and its components have also been documented (e.g., Baum & Forehand, 1981; Cross Calvert & McMahon, 1987; Forehand et al., 1980; McMahon, Tiedemann, Forehand, & Griest, 1984). There is also evidence that parental participation in HNC can have positive effects on parents’ levels of depressive symptoms (extending at least 2 months beyond the end of the intervention) (Forehand et al., 1980; Forehand, Furey, & McMahon, 1984) and a shorter-term effect on marital satisfaction (Brody & Forehand, 1985; Forehand, Griest, Wells, & McMahon, 1982).

Several procedures have been evaluated as adjuncts to the basic parent training program. These include maternal self-control procedures (Wells, Griest, & Forehand, 1980); training the parents in the social learning principles underlying the parent training program (McMahon, Forehand, & Griest, 1981); and a multimodal package (“parent enhancement therapy”) designed to enhance general family functioning, which includes components related to parental perceptions of the child’s behavior, marital adjustment, parental personal adjustment, and the parents’ extrafamilial relationships (Griest et al., 1982). In general, these studies have supported the efficacy of these adjunctive procedures in enhancing the generalization and/or maintenance of effects, over and above those gains obtained in the basic HNC program.

Two studies have compared the effects of HNC with other interventions for children with conduct problems. Wells and Egan (1988) found that HNC was more effective than systems family therapy on observational measures of parent and child behaviors. The two treatment groups did not differ on parental self-report measures of personal (depression, anxiety) or marital adjustment. Baum et al. (1986) reported that a group version of HNC was more effective at post treatment and at a 6–8-month follow-up than a parent discussion group based on the Systematic Training for Effective Parenting (STEP) program (Dinkmeyer & McKay, 1976).

In addition, Long et al. (1993) reported that parents of children with ADHD who received a self-guided written booklet explaining the HNC parenting skills reported less intensive oppositional behavior than did the parents of children with ADHD who did not receive the booklet. (All of the children were receiving medication to address the ADHD symptoms.) Finally, Conners et al. (2007) evaluated the effects of the Parenting the Strong-Willed Child (PSWC) parenting class curriculum program with 71 Head Start parents. Parents reported significant decrements in both the frequency and intensity of child behavior problems, reductions in parenting stress, and improvements in their parenting behaviors. All changes were sustained 6 months later.

External Reviews

Several external reviews of child mental health or parenting programs have resulted in the HNC program being identified as an evidence-based intervention. In a review of “best practices” lists (Metzler, Eddy, & Taylor, 2002), HNC was included as 1 of the top 21 evidence-based family-focused programs. It has been included on lists of the most effective programs focusing on the treatment of conduct problems (Brestan & Eyberg, 1998; Eyberg, Nelson, & Boggs, 2008), intrafamilial child abuse (e.g., Saunders, Berliner, & Hanson, 2001), the prevention of substance abuse and delinquency (Alvarado, Kendall, Beesley, & Lee-Cavaness, 2000; Webster-Stratton & Taylor, 2001), and “mental disorders” (Greenberg, Domitrovich, & Bumbarger, 1999). For example, the Strengthening America’s Families Project (sponsored by the Office of Juvenile Justice and Delinquency Prevention and the Center for Substance Abuse Prevention) identified HNC as one of seven Exemplary I Programs (out of more than 500 programs examined) (Alvarado et al., 2000). Most recently, HNC has been listed as one of only 16 evidence-based psychosocial treatments for youth with conduct problems (Eyberg et al., 2008), and received top ratings from the National Academy for Parenting Practitioners’ listing of evidence-based parenting programs in the U.K. Training sessions have been conducted in multiple states and provinces (e.g., Arkansas, Colorado, Florida, Georgia, Idaho, Massachusetts, Michigan, New Hampshire, New York, Ohio, Oklahoma, Vermont, Washington, Alberta, and British Columbia,) in North America, and HNC is being implemented widely in Illinois through the Illinois Department of Mental Health and in New Hampshire by state-funded community mental health agencies.

Case Study

When Michael was 2-years old, his parents started worrying that his behavior was more difficult to manage than most children his age. Michael’s parents indicated that he was “very stubborn” and that “he had a mind of his own.” At the time, however, his parents did not become overly concerned because they were told frequently by friends and family members that “he’s just all boy,” and that “it’s just the terrible twos – he’ll grow out of it.” Unfortunately, Michael’s behavior did not improve as he became older. By the time he was 4-years old, he was described as “defiant.” His parents stated that he would rarely follow their instructions and that typically he “only wants to do what he wants, when he wants, and how he wants.” In their attempts to increase Michael’s compliance, they often resorted to yelling and threatening him, even though they realized that this was not very effective. They also were concerned that their general relationship with Michael was steadily deteriorating. At the urging of his preschool teacher, the parents spoke to their pediatrician about Michael’s behavior and the pediatrician referred them to a psychologist. At this time, Michael was almost 5 years old.

The psychologist conducted an evaluation that included a parent interview, behavioral questionnaires, and a clinic observation of Child’s Game and Parent’s Game. On the basis of this evaluation, the psychologist concluded that the primary problems were Michael’s noncompliance and related negative parent–child interactions. Michael was reported, and observed, to ignore most of the instructions his parents gave him, resulting in his parents becoming very frustrated. Also, the parents were observed to give numerous vague, unclear instructions to Michael. On the basis of her assessment, the psychologist made the DSM-IV diagnosis of oppositional defiant disorder (ODD) and recommended the HNC treatment program. The therapist discussed the rationale for HNC and presented an overview of the treatment. The therapist explained the primary goals of HNC, which were to: (a) change the coercive cycle of their interactions with Michael, (b) enhance the positive quality of their interactions with him through increased use of positive attention, ignoring minor inappropriate behaviors, and providing clear and appropriate instructions and consequences for his behavior; and (c) increased prosocial behaviors and fewer conduct problem behaviors, especially noncompliance, from Michael. An overview of the different skills involved in the two phases of HNC was provided (Phase 1 – Differential Attention, and Phase 2 – Compliance Training). Also, the structure of how the parents would learn these skills was explained (i.e., didactic presentation by the therapist, discussion, demonstration, role playing, practicing with Michael – with feedback provided by the therapist, handouts reviewing the content of the program, and homework/practice assignments). The parents then were asked to discuss whether they wished to participate in HNC, and to let the therapist know of their decision within the week. The parents decided to participate in HNC, and the first treatment session was scheduled.

Session 1

The first treatment session started with Michael being given a setting instruction. He was told to play quietly by himself and that if he interrupted the therapist and his parents while they were talking, they would ignore him. The therapist then demonstrated the ignoring procedure to Michael. During the session, the parents were also prompted to praise him for complying with the setting instruction. By the end of the session, the parents were beginning to praise Michael at appropriate intervals without a prompt from the therapist.

The bulk of the session was devoted to introducing the skill of attending (which is the first skill in Phase 1). The therapist explained that attending is a skill that is used to let Michael know that his appropriate behavior is noticed, and behavior that receives attention from his parents typically increases. The parents were told that attending involves describing Michael’s appropriate behavior, and it is practiced within what is called the Child’s Game. The Child’s Game involves the parent letting the child take the lead in playing and the parent takes a non-directive role during these practice sessions (e.g., the parent does not give directions or ask questions during the Child’s Game). After explaining attending, the therapist modeled the skill of attending with the parents playing the role of the child. The parents then practiced attending with the therapist playing the role of the child. Throughout this practice, Michael watched attentively. The therapist took opportunities to include Michael in the activity, first by making explanatory statements about what his parents were doing, and then by gradually including Michael in the Child’s Game activity. The therapist then had the parents practice attending only with Michael, while the therapist observed and provided feedback. The parents had a difficult time, as do many parents, with being non-directive. They had a tendency to ask Michael questions (e.g., “What are you making?”) and to give indirect directions (e.g., “Why don’t you build a tower?”). The therapist pointed out their questions and directions and made suggestions of appropriate attending statements that could be used in their place (e.g., “You’re putting the round block on top of the square block …. You’re making it higher and higher.”). At the end of the session, the parents were given handouts reviewing what had been covered in the session and the homework assignment was discussed (i.e., daily 10–15 min practice of attending within the Child’s Game).

Session 2

At the beginning of the session, the therapist had Michael’s parents each spend 5 min practicing attending with Michael within the Child’s Game. The therapist observed and coded these interactions and noted that both parents were still giving too many instructions and asking too many questions during the Child’s Game. Also, although they were giving some appropriate attending statements, the rate of attending was still relatively low. Michael’s parents reported that they had practiced attending on all but one day and that Michael seemed to enjoy their attention during the Child’s Game. The therapist gave the parents feedback based on the observed/coded interactions. The remainder of the session was devoted to the parents practicing attending with Michael (with the therapist coaching the parents; i.e., providing prompts/feedback). The parents were instructed to continue daily practice of attending with Michael within the Child’s Game.

Session 3

This session, as did all subsequent sessions, started with an observation of the Child’s Game that was coded by the therapist. The parents were observed to be improving in their use of attending, but they had not yet met the behavioral criteria to move on to learning the next skill in Phase I. The therapist and parents discussed the daily practice sessions and the therapist answered the parents’ questions about attending. The remainder of this session was spent with the therapist coaching the parents (in the skill of attending) while they practiced with Michael within the Child’s Game. The parents were instructed to continue daily practice of attending within the Child’s Game.

Session 4

During the observation at the beginning of the session, the parents met the behavioral criteria for attending. Therefore, the therapist introduced the next Phase I skill of rewarding. The therapist discussed the different types of rewards as well as the characteristics of effective rewards. The therapist then modeled the skill of rewarding with one of the parents playing the role of the child. The parents then practiced rewarding as the therapist played the role of Michael. As with attending, the therapist gradually included Michael in the practice activity, after providing him with verbal explanations and demonstrations about rewards. Michael’s parents spent the remainder of the session practicing rewarding and attending with Michael and the therapist provided feedback and coaching. The parents learned effective rewarding much more easily than they had learned attending. At the end of the session, the parents were instructed to practice both attending and rewarding daily with Michael within the Child’s Game.

Session 5

The parents met the behavioral criteria for rewarding during the observation period at the beginning of this session. The parents also reported that Michael was enjoying the Child’s Game and was responding well to both the attending and rewarding. In this session, the skill of ignoring was introduced as an active procedure. The therapist discussed the characteristics of effective ignoring as well as appropriate and inappropriate behaviors to ignore. The therapist then modeled ignoring and had the parents role play ignoring with her. After explaining and demonstrating ignoring to Michael, the parents practiced attending, rewarding, and ignoring while the therapist provided prompts and feedback. At the end of this session, the therapist helped the parents develop a differential attention plan using attending and rewarding to increase Michael’s use of age-appropriate language and ignoring to decrease his use of baby-talk.

Session 6

The parents reported that the differential attention plan was working in that Michael had been using less baby-talk in the last few days. The therapist then helped the parents develop a second differential attention plan. This time the therapist let the parents take more of the lead in developing the plan. That plan focused on increasing Michael’s use of appropriate table manners. During the remainder of this session, Phase II of the program (Compliance Training) was introduced. The therapist discussed the importance of giving Michael clear instructions and their relationship to compliance. The therapist then reviewed and discussed the characteristics of clear instructions and gave examples of both unclear and clear instructions. Next, the parents were presented with a series of clear and unclear instructions to see if they could accurately differentiate them. Once the parents understood the importance and characteristics of clear instructions, the therapist introduced Path A of the Clear Instructions Sequence. Path A involves attending/rewarding compliance to clear instructions. The concept of the Parent’s Game (the parent directs the play) was then introduced for the practice of Phase II skills. The parents role played Path A with the therapist, and the therapist explained and demonstrated Path A with Michael. Finally, the parents practiced Path A with Michael while the therapist provided prompts and feedback. The parents were then given their homework assignment, which involved practicing Path A with Michael.

Session 7

The remaining pathways (Paths B and C) of the Clear Instructions Sequence were introduced and discussed. Path B (warning following noncompliance to a clear instruction) was role played with the therapist playing the role of the child; subsequently, the process was explained to and demonstrated for Michael. Time out was discussed and the specific procedure was presented to the parents. The parents had used a different time-out procedure unsuccessfully in the past with Michael. Therefore, the therapist stressed the importance of following the HNC time-out procedure guidelines. The therapist discussed the rationale for certain characteristics of the time-out procedure that were different from how the parents had used it in the past (e.g., they had talked to Michael during time out; they had not used a quiet contingency). The therapist then helped the parents problem-solve issues related to time out such as the best location for time out in their home. Next, Path C (use of time out for noncompliance) was role played. The therapist and parents then discussed and role played some specific challenges to time out, including tardy compliance, refusal to stay in time out, and compliance only to the warning. After explaining and demonstrating Path C to Michael, the remainder of the session involved the parents practicing the Clear Instructions Sequence (Paths A, B, C) within the Parent’s Game with Michael (while the therapist provided prompts and feedback). Michael was issued a warning (Path B) during the practice, but he complied with the warnings so he did not have to go to time out (Path C).

Session 8

The parents and therapist discussed how the Clear Instructions Sequence and time out had been going at home. The parents reported that Michael had been to time out on three separate occasions since the last session; on one of those occasions, the parents had to cycle through the Clear Instructions Sequence (including time out) twice before Michael complied with the original instruction. Utilizing the Parent’s Game, the parents spent the majority of this session practicing the Clear Instructions Sequence (all three pathways) while receiving prompts and feedback from the therapist.

Session 9

The therapist and parents discussed issues related to the Clear Instructions Sequence and time out that had come up at home since the last session. The parents reported that Michael’s noncompliance was decreasing, as he had only had to go to time out once during the last few days. The parents practiced the Clear Instructions Sequence within the Parent’s Game with the therapist providing feedback. The remaining focus of this session was on introducing Standing Rules (“if … then” statements) to the parents and Michael, and how they are used to supplement the Clear Instructions Sequence. The therapist helped the parents generate one Standing Rule: If Michael hit anyone (e.g., his sister, the parents, peers), then he went immediately to time out.

Session 10

The parents reported that Michael was much more compliant and had been following the Standing Rule. During the past week, they reported that he only had to go to time out twice (once for noncompliance and once for breaking the Standing Rule). The primary focus of this session was on generalization. The therapist helped the parents learn how they could use both Phase I and Phase II skills to help deal with situations outside of the home. They discussed the situations outside the home that the parents indicated were most likely to be problematic (e.g., stores, restaurants, and the car). For example, when taking Michael to the grocery store, the therapist emphasized the importance of involving Michael in shopping (e.g., having him place items in the cart) and using attending and rewarding to reinforce his cooperative involvement. The parents were advised to issue clear “do” instructions (such as “keep your hands in the cart”), as needed, to which they could then attend and reward compliance. Finally, the parents were also advised to think in advance about an appropriate setting for time out (e.g., in the store or removing the child to the car) should it become necessary while they were shopping.

Session 11

This session involved discussing situations that had occurred outside the home over the past week and how the parent used Phase I and Phase II skills. The parents reported that the week had gone well, including trips to stores and a meal at a restaurant. The therapist discussed the progress they had made with Michael and pointed out that they now had a set of skills that they could use not only to maintain Michael’s improved behavior but also to address future behavior problems. The remainder of the session was spent reviewing the various skills, stressing the importance of consistency, encouraging the continued use of Phase I skills, and answering questions from the parents. The therapist said that she would check in with the parents by phone in 1 month to see how things were going with Michael.

Conclusions/Future Directions

In this chapter, we have provided an overview of the theoretical and conceptual basis for family-based interventions with children who present with excessive noncompliance; a description of the HNC intervention; a summary of its empirical support; and a case study describing a typical progression through the program. As we move forward in the years ahead, we plan to focus our activities in two separate yet interrelated areas: (a) further dissemination of HNC to “real-life” settings and other populations of children, and (b) expanded research efforts. With respect to the former, we are working with colleagues who are implementing HNC through the community mental health system in New Hampshire (Dr. Sarah Stearns); adapting HNC to children with ADHD (Drs. Howard Abikoff and Laurie Miller-Brotman at New York University); and implementing (and possibly adapting) HNC with Mexican immigrant families in Illinois (Dr. Ane Marinez-Lora at the University of Illinois-Chicago). The latter two ventures are being conducted in the context of research trials; in addition, we hope to expand the research base on HNC by conducting both large-scale efficacy trials as well as effectiveness trials focused on the dissemination and implementation of HNC in community settings. We are currently in the process of conducting a randomized-controlled study of the self-directed version of this program (Forehand & Long, 2010). We also plan to further evaluate the parenting class version (Conners et al., 2007), which involves six 2-h class sessions focused on the key elements of the HNC program. These HNC-based interventions are intended for use with selected populations (i.e., those families who have children who have less severe disruptive behavior and are at risk for the development of conduct problems). Through the development and evaluation of these other service delivery approaches, we hope to positively impact a broader population of families who could benefit from learning the skills taught in HNC. Finally, we plan to continue to conduct component analyses of HNC to identify mechanisms of action and to “fine-tune” the effects of the intervention.