Efforts to prevent and treat children's behavior problems have been relatively successful in recent years, but there is still a feeling among program developers that parent training interventions too often do not work.

A few packages, such as Incredible Years and Triple P, have earned themselves a solid reputation around the world, but even they routinely encounter certain parents whom they identify as "resistant" or "not ready for therapy".

Stephen Scott, who directs the UK National Academy for Parenting Practitioners, says the remedy is an improvement in practitioner skills – more theoretical knowledge; greater flexibility.

The logic of the the most successful parenting programs rests on social learning theory. If children are rewarded with attention or approval for a particular benign behavior, they are more likely to repeat it; conversely, if they are ignored or punished for misbehaving, they are less likely to make the same mistake again.

In many cases, simply teaching parents something as basic as how to reward good behavior and punish the bad has the effect of reducing and preventing conduct problems. But inside around a quarter of families there is no change.

Stephen Scott and his Australian colleague Mark Dadds from the University of New South Wales say work with families calls for a theory-driven eclectic approach. Practitioners should draw on four key sources of insight and be able to “swing them in and out of action systematically according to what is happening with the family”.

They recommend attachment theory; systems theory; cognitive factors and attribution theory and motivational interviewing. They argue that in proper combination they will increase engagement, decrease resistance and facilitate problem-solving when things don’t go entirely to plan.

Scott and Dadds offer the common scenario of parents who, as a result of parent training, may understand how they should behave, but cannot change because they are emotionally blocked. “He’s horrible and ruins my life by winding me up; why should I be nice to him?” and “he’s so delicate and precious, it will harm him if I upset him by being firm” are typical expressions of a self inflicted form of double-bind.

They argue that social learning-based training does not address such thoughts and feelings, but cognitive factors and attribution theory can provide a useful set of guiding principles. Sometimes open acknowledgment will be enough; at other times the “eclectic” practitioner will need to take time to reframe a parent’s thoughts.

Experienced clinicians themselves, they write that more persistent obstructions and aggression may yield to the application of attachment theory; should other family members be barring progress systems theory may help. When families are reluctant to engage with the intervention, suspicious of any outside authority or threatening to disengage or drop out, shared empowerment and motivational interviewing techniques are more likely to get things back on track.

They acknowledge that many skilled practitioners are likely to adopt these approaches as a matter of instinctive routine with “hard to reach” families.

However, they say that unless their various ad hoc strategies are aligned with a theoretical rationale they will be difficult to replicate, and it will be harder still to test the value the permutations of an “eclectic approach” scientifically.

They suggest that once these broader theoretical foundations have been established, practitioners will be able to “think creatively, from first principles, about how to understand family difficulties and then generate practical solutions”.

See: Scott S and Dadds M (2009) “Practitioner Review: when parent training doesn’t work: theory-driven clinical strategies”, The Journal of Child Psychology and Psychiatry, 50, 12, 1441-1450.