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Search for unpublished (gray) studies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