The Society for Clinical Child and Adolescent Psychology ... · • Curriculum of Parent Training...
Transcript of The Society for Clinical Child and Adolescent Psychology ... · • Curriculum of Parent Training...
The Society for Clinical Child and Adolescent Psychology (SCCAP):
Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent
Mental Health Problems
With additional support from Florida International University and The Children’s Trust.
Keynote Evidence-based Parenting Programs for the Treatment of Children with Externalizing Problems
Charles E. Cunningham, Ph.D. Department of Psychiatry & Behavioural Neurosciences
Jack Laidlaw Chair in Patient-Centred Health Care Faculty of Health Sciences
Michael G. DeGroote School of Medicine McMaster University
Goals of the Presentation
• Overview Parent Training for Externalizing Problems
• Learning Process
• Curriculum of Parent Training Programs
• Evidence from Meta Analyses
• Efficacy of Parenting Programs
• Efficacy of Training Components
• Efficacy of Curriculum Components
• Promising Directions
The Evolution of Social Learning Parent Training Programs (Selected)
Community Parent Education Program (Cunningham, 1995)
Triple P (Sanders, 1999)
Hanf’s 2 Stage Program (1973)
Helping the Noncompliant Child (Forehand & McMahon 1981)
Defiant Children (Barkley, 1987)
Parent-Child Interaction Program (Eyberg)
Incredible Years (Webster-Stratton, 1988)
Social Learning Parenting Programs: Common Learning Processes
• Homework Review
• Modeling (Live or Videotaped)
• Role Playing or Practice w/ Child
• Homework Goal Setting
• Public Posting
• Self Monitoring
• Readings (e.g. Social Learning Principles)
Parenting Programs: Common Evidence-Based Curriculum
• Attending Strategies
• Rewards
• Planned Ignoring
• Effective Commands
• Transitional Strategies (When-Then)
• Planning Problem Solving
• Point Systems
• Time Out
Efficacy of Parenting Programs
Systematic Reviews & Meta-analyses
Systematic search of electronic data bases
Search for unpublished (gray) studies
Formal Inclusion & Exclusion Criteria
Coding
Statistical Analysis (Meta Analysis)
Methodological Quality Assessment (e.g., Jadad Scale)
Effect Size Estimate
Moderator Analysis
Fail Safe (File Drawer) Statistics
Effect Size Calculation
(Post MeanRx –Post MeanControl)/Pooled SD
.2 = small but significant effect
.5 = moderate effect
.8 = large effect
(Cohen, 1988)
Efficacy of Parenting Programs?
Efficacy = Performance under optimal conditions
Effectiveness = Real World Performance
Cost Effectiveness
Measuring Outcomes
Parent Report
Direct Observation
Home
Clinic Lab
Parent Reports vs Direct Observation
0.67
0.44
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Parent Report Direct
Observation
(DPICS)
Dretzke et al., (2009) 57 Randomized Trials
Moderate Effect on Parent Report Smaller Effect on
Direct Observations
Effect of Parent Training on Knowledge & Self Efficacy
0.39 0.38
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Knowledge Self Efficcy
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Small to Moderate Effect on Parental Knowledge
and Self Efficacy
Internalizing vs Externalizing Problems
0.25
0.4
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Externalizing Internalizing
Parent Training Improves Internalizing & Externalizing Problems
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
File Drawer Analyses
Unpublished non-significant results that would have to exist to reduce effect size to nonsignificance:
51 (Maughan et al., 2005)
250 (Kaminiski et al., (2008)
Efficacy of Parent Training Components
Live or Recorded Demonstrations of Parenting Skills
Modeling:
Modeling Parenting Skills: Effect on Externalizing Problems
0.16
0.39
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
No Modeling Modeling
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Significantly Better Outcome Associated with Programs Using Modeling
Practice with Own Child
Practice with Own Child: Effect on Parenting Skills
0.33
0.91
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
No Practice Practice with Child
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Greater Improvement in Parenting Skills Associated with Programs Including
Practice with Child
Practice with Own Child: Effect on Externalizing Problems
0.18
0.69
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
No Practice Practice with Child
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Greater Improvement in Externalizing Problems
Associated with the Inclusion of Practice with Child
Written, verbal, or behavioral assignments to complete between sessions
Homework:
Effect of Homework: Externalizing Problems
0.39 0.38
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
(Exte
rnalizin
g P
roble
ms)
No Homework Homework
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
No Difference in Outcome Associated with Programs
Including Homework
Effect of Program Duration
0.96
0.50.45
0.08
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
(Betw
een G
roup D
esig
ns)
1 to 5 6 to 10 11 to 15 16 +
Source: Maughan et al., School Psychology Review (2005)
Shorter Programs Associated with Improved Outcomes
Does Father Participation Influence Parent Training Outcomes?
Impact on Parenting: Fathers vs Mothers
0.84 0.84
0.530.49
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Mothers Fathers
Post Follow-up
Source: Lundahl et al. Research in Social Work Practice (2008)
Impact on Parenting Greater for Mothers
Reported Impact on Child Behavior: Fathers vs Mothers
0.910.99
0.68
0.85
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Mothers Fathers
Post Follow-up
Source: Lundahl et al. Research in Social Work Practice (2008)
Mothers Report Greater Improvement in Child Behavior
Involvement of Fathers: Impact on Child Behavior
0.2
0.48
0.63
0.39
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Post Follow-up
Mothers Only Mothers + Fathers
Source: Lundahl et al. Research in Social Work Practice (2008)
Effect of Father Involvement on Child Behavior Significant at Post but Not F/U
Involvement of Fathers: Impact on Parent Perceptions
0.630.59
0.39
0.69
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
Post Follow-up
Mothers Only Mothers + Fathers
Source: Lundahl et al. Research in Social Work Practice (2008)
Effect of Father Involvement on Perceptions Not Statistically Significant
Efficacy of Parent Training Content
Positive Interaction
Following child’s interests, showing enthusiasm, providing positive attention
Parenting Skills Linked to Outcomes: Positive Interaction with Child
0.13
0.36
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
None Positive Interaction
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Programs Increasing Positive Interaction Yield
Better Outcomes
Responsiveness, Sensitivity Nurturing
Responding sensitively to child’s emotional needs (e.g. soothing, developmentally appropriate physical contact and affection)
Parenting Skills Linked to Outcomes: Responsiveness, Sensitivity, Nurturing
0.22
0.58
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
None Responsiveness
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Programs Teaching Responsiveness Yield Better Externalizing
Outcomes
Time Out (from positive reinforcement)
Parenting Skills Linked to Outcomes: Time Out from Positive Reinforcement
0.15
0.54
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
None Time Out
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Programs Teaching Time Out Yield Better
Externalizing Outcomes
Educating parents to teach children to share, cooperate, use good manners, & get along with siblings, peers or adults
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Promoting Social Skills:
Components Linked to Ext Outcomes: Teaching Child Social Skills
0.38
0.02
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
(Exte
rnalizin
g P
roble
ms)
None Teach Social Skills
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Teaching Social Skills Associated with Less
Impact on Externalizing Problems
Incredible Years Child Training: Dinosaur School
22 Small Group Child Sessions
Interactive Videotape Modeling (100 vignettes)
social skills
empathy, anger management
cooperation at home and school
Role Playing & Problem Solving with Puppets
Homework Exercises
Source: Webster-Stratton & Hammond, 1997
Incredible Years with 4-8 Year Olds:
CBCL Total Problems
65.5
5655.1
65.3
57.1 57.7
67.766.4
50
60
70
80
T-S
core
s
Parent
Training
Parent+Child
Training
Control
Pre Post 1 Yr F/U •22 Parent Group Sessions
•22 Group Child Sessions (Dinosaur School)
Source: Webster-Stratton & Hammond, 1997
Addition of Child Training % Clinically Improved1 (1 Yr FU)
60
73.7
95
0
20
40
60
80
100
% C
linic
ally
Im
pro
ved
Parent
Training
Child Parent +
Child Training
Source: Webster-Stratton & Hammond, 1997
• 22 sessions
• 4-8 Year Olds
• 130% decrease total child deviant behavior at home
•P+CT>PT
•P+CT vs CT (.10)
Ancillary Services:
Supplementary services (e.g., mental health or substance abuse services, case management, referrals, stress/anger management adults
Inclusion of Ancillary Services: Effects on Parenting Skills
0.6
0.31
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
None Ancillary Services
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Providing Ancillary Services Associated with Less Impact on
Parenting Skills
Inclusion of Ancillary Services: Effects on Externalizing Problems
0.51
0.16
0
0.2
0.4
0.6
0.8
1
Effect
Siz
e
None Ancillary Services
Source: Kaminski et al. Journal of Abnormal Child Psychology (2008)
Providing Ancillary Services Associated with Less Impact on
Externalizing Problems
Limitations of Current Models
Family Risks Predict Poor Outcome
0.52
0.33
0.21 0.2
0
0.2
0.4
0.6
0.8
1
Mean W
eig
hte
d E
ffect
Siz
e
Income Barriers Family Size Single Parent
Source: Reyno & McGrath. Journal of Child Psychology & Psychiatry (2006)
Low Income, Barriers, Large Family Size, and Single Parent Status Associated with Less
Improvement
Parent Risk Factors Predict Poor Outcome
0.39
0.27
0.230.16
0
0.2
0.4
0.6
0.8
1
Mean W
eig
hte
d E
ffect
Siz
e
Maternal
Psychopathology
Education Depression Stress
Source: Reyno & McGrath. Journal of Child Psychology & Psychiatry (2006)
Parental Psychopathology, Limited Education, Depression, & Stress
Associated with Less Improvement
Logistical Factors Preventing Participation in Parenting Programs
3431
18
107
0
10
20
30
40
50
Perc
ent
of
Inte
rvie
ws
Time of
Session
Busy Shifts Child
Care
Travel
Source: Cunningham et al., Journal of Consulting & Clinical Psychology (2000)
Latent Class Segmentation Analysis
Overwhelmed (16%) Action (41%)
Information (43%)
Source: Cunningham et al., Journal of Abnormal Child Psychology (2008)
Group vs Individual Approaches?
-50
-25
0
25
50
75
100
Alone Parenting
Group
Alone with
Coaching
Group +
Coaching
Utility
Valu
e
Overwhelmed Information Action
*
Source: Cunningham et al. Journal of Abnormal Child Psychology (2008)
Overwhelmed (16%) & Information Focused (43%) Segments Prefer Non
Group Services
41
50
28
46
38
0
20
40
60
80
100
Perc
ent
Enro
llin
g
Cunningham (1995) Cunningham (2000) ADHD/ODD Barkley(2000)
Moderate Severe
Utilization of Group Parent Training: Prospectively Screened Samples
Cunningham et al., Journal of Child Psychology & Psychiatry (2007) Cunningham et al., Journal of Consulting & Clinical Psychology (2000) Barkley et al., Journal of Abnormal Child Psychology (2000)
Preferred Program Format (n= 1060)
-40
-30
-20
-10
0
10
20
30
40
Internet E-Mail Phone Face to Face
Utility
Valu
e
Segment 1 Segment 2 Segment 3
Phone Contacts Preferred by Segments 2 (17%) & 3 (35%)
Segment 1 (48%) Prefers Face to Face Services
Source: Cunningham et al. In preparation (2008)
Self Directed Readings Plus Therapist Support
69 Families of Preschoolers from Germany
10 Chapter Triple P Parenting Book
Video Demonstrating Parenting Skills
7 Telephone Conversations with Facilitator
Therapist-Supported Bibliotherapy: Impact on Externalizing Problems
0.11
0.83
0
0.2
0.4
0.6
0.8
1
Eff
ect
Siz
e1
Control SDPT+T
Source: Hahlweg et al., Behavior Modification (2010)
1(Pretest Mean-Post Test Mean)/SD Difference
Self Directed Parent Training Plus Therapist Phone Support Reduced
Externalizing Problems
Therapist-Supported Bibliotherapy: Impact on Internalizing Problems
0.05
0.51
0
0.2
0.4
0.6
0.8
1
Eff
ect
Siz
e1
Control SDPT+T
Source: Hahlweg et al., Behavior Modification (2010)
1(Pretest Mean-Post Test Mean)/SD Difference
Self Directed Parent Training Plus Therapist Phone Support Reduced
Internalizing Problems
Limitations
Meta Analyses are Not Experimental Manipulations
Most Reviews Focus on Parents of Young Children
Conclusions
Parent Training Effective for Externalizing Problems
Broad Outcomes (e.g., Internalizing Problems)
Focused Programs More Effective
Parent & Family Risk Factors Moderate Outcome
Many Parents Do Not Use Available Programs
Fathers Benefit & Improve Short Term Outcomes
Design Factors Influence Utilization
New Delivery Modes May Reduce Barriers
For more information, please go to the main website and browse for workshops on this topic or check out our additional resources.
Additional Resources Online resources: 1. COPE website: http://www.rfts.ca/cope/index.html 2. Society of Clinical Child and Adolescent Psychology website: http://effective childtherapy.com 3. Center for Children and Families website: http://ccf.fiu.edu
Books: 1. Barkley, R. A (Ed.) . (2005). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press. 2. Weisz, J.R., & Kazdin, A.E. (Eds.). (2010). Evidence-based psychotherapies for children and adolescents. New York: Guilford Press.
Peer-reviewed Journal Articles: 1. Dretzke, J., Davenport, C., Frew, E., Barlow, J., Stewart-Brown, S., Bayliss, S., Taylor, R.S., Sndercock, J., & Hyde, C. (2009). The clinical effectiveness of different parenting programmes for children with conduct problems: A systematic review of randomized controlled trials. Child and Adolescent Psychiatry & Mental Health, 3, 7. 2. Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36, 567-589. 3. Maughan, D. R., Christiansen, E., Jenson, W. R., Olympia, D., & Clark, E. (2005). Behavioral parent training as a treatment for externalizing behaviors and disruptive behavior disorders: A meta-analysis. School Psychology Review, 34, 267-286. 4. Reyno, S. M. & McGrath, P. J. (2006). Predictors of parent training efficacy for child externalizing behavior problems – a meta-analytic review. Journal of Child Psychology & Psychiatry, 47, 99-111.
Full Reference List Full reference list with additional information on evidence-based parenting programs for children with disruptive behavior. Websites: 1. COPE website: http://www.rfts.ca/cope/index.html 2. Society of Clinical Child and Adolescent Psychology website: http://effective childtherapy.com 3. Center for Children and Families: http://casgroup.fiu.edu/CCF/index.php Books: Barkley, R.A. (1987). Defiant children: A clinician's guide to parent training. New York: Guilford. Barkley, R. A (Ed.) . (2005). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and
Treatment. New York: Guilford Press. Cohen, J. (Eds.). (1988). Statistical Power Analysis for the Behavioral Sciences. New Jersey: Lawrence
Erlbaum Associates Inc. Forehand, R. L., & McMahon, R. J. (1981). Helping the noncompliant child: A clinician's guide to parent
training. New York: Guilford Press. Webster-Stratton, C. (Ed.). (1984). The Incredible Years Parent Training Manual: BASIC Program. Weisz, J.R., & Kazdin, A.E. (Eds.). (2010). Evidence-based Psychotherapies for Children and Adolescents.
New York: Guilford Press. Peer-reviewed Journal Articles: Cunningham, C. E., Boyle, M., Offord, D., Racine, Y., & Hundert, J., Secord, M. & McDonald, J. (2000). Tri
Ministry Project: Correlates of school-based parenting course utilization. Journal of Consulting and Clinical Psychology, 68 (5), 928-933.
Cunningham, C. E., Bremner, B., & Boyle, M. (1995). Large group school-based courses for parents of preschoolers at risk for disruptive behaviour disorders: Utilization, outcome, and cost effectiveness. Journal of Child Psychology and Psychiatry, 36, 1141-1159.
Cunningham, C. E., Deal, K., Rimas, H., Buchanan, D. H., Gold, M., Sdao-Jarvie, K., et al. (2008). Modeling the information preferences of parents of children with mental health problems: a discrete choice conjoint experiment. Journal of Abnormal Child Psychology, 7(36), 1128–1138.
Dretzke, J., Davenport, C., Frew, E., Barlow, J., Stewart-Brown, S., Bayliss, S., Taylor, R.S., Sndercock, J., & Hyde, C. (2009). The clinical effectiveness of different parenting programmes for children with conduct problems: A systematic review of randomized controlled trials. Child and Adolescent
Psychiatry & Mental Health, 3, 7. PMCID: PMC2660289
(Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660289/?tool=pmcentrez) Hahlweg, K., Heinrichs, N., Kuschel, A., & Feldmann, M. (2008). Therapist assisted self-administered
bibliotherapy to enhance parental competence: Short- and long-term effects. Behavior Modification, 32 (5), 659-681.
Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36, 567-589.
Lundahl, B. W., Tollefson, D., Risser, H., & Lovejoy, M. C. (2008). A meta-analysis of father involvement in parent training. Research on Social Work Practice, 18(2), 97–106.
Maughan, D. R., Christiansen, E., Jenson, W. R., Olympia, D., & Clark, E. (2005). Behavioral parent training as a treatment for externalizing behaviors and disruptive behavior disorders: A meta- analysis. School Psychology Review, 34, 267-286.
Reyno, S. M. & McGrath, P. J. (2006). Predictors of parent training efficacy for child externalizing behavior problems – a meta-analytic review. Journal of Child Psychology & Psychiatry, 47, 99-
Full Reference List
111. Sanders, M. R. (1999). Triple P-Positive Parenting Program: Towards an empirically validated multilevel
parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child & Family Psychology Review, 2, 71-90.
Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65(1), 93-109.
Other: Hanf, C., & Kling, F. (1973). Facilitating parent-child interaction: A two-stage training model.
Unpublished manuscript, University of Oregon Medical School. Retrieved from http://www.EffectiveChildTherapy.fiu.edu