parent management training (pmto) program implementation and research in norway terje ogden ”the...
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PARENT MANAGEMENT TRAINING (PMTO) Program implementation and research in Norway
Terje Ogden ”The Behavior Center – Unirand”
Norwegian Center for Studies of Conduct Problems and Innovative Practice,
Unirand, University of Oslo
The Behavior CenterAdministration
National Implementation
Team for childrenResearch Unit
NationalImplementationTeam for youth
Program director4 National consultants
6 Regional coordinators
Research director Research consultant
Data manager7 Researchers
Program director6 National consultants
The logistics team
Programdevelopment
Dissemination
Adoption
Fidelity/Adherence
Adaptation
Out-comes
Implementation
Readiness Context
Factors influencing program outcomes
Implementation of Parent Management Training in Norway
A national top-down implementation project initiated by the Ministry of Child and Family Affairs in cooperation with 3 other ministries (Education, Health and Social affairs, Justice)
Adoption and implementation of PMTO at a) the regional and b) municipal level
Training 3 generations of PMTO therapists (1999-2006)
Therapist training program
Training the trainers: the first generation of PMTO specialists A 2 year extensive PMTO training program in Norway based on the
principles of social interaction learning theory (SIL) (Patterson, 1982;2002) and PMTO procedures (Forgatch, 1994).
Training, supervision and certification by senior therapists from Oregon Social Learning Center (OSLC)
Training the second and third generation of PMTO therapists: A PMT-O National Implementation Team with a program director, 4
national consultants and 6 regional coordinators, responsible for the training
The first generation of PMTO specialists working as trainers and supervisors of new candidates
The PMTO training program
Training program based on the principles of social interaction learning theory (SIL) (Patterson, 1982;1996) and PMTO procedures (Forgatch, 1994).
Didactic instruction, videotaped examples, and role play demonstrating the procedures.
All sessions were video-taped and about 20% were transcribed, translated into English and subject to feedback from experienced clinicians at the OSLC.
Training three generations of PMTO therapists/specialists (1999-2006)
The 1st generation recruited from Child and Adolescent Mental Health Services and from the Child Welfare Services in all regions of Norway (G1: N=33, 1999-2001)
The 2nd generation also recruited from the specialist child and youth services in a 1.5 year training program (G2: N=84, 2001-2003)
Pre-assessment of 19 agencies (sites), negotiating administrative support, adequate working conditions and necessary equipment for the candidates
The 3rd generation recruited from various municipal child and youth services (G3: N=70, 2004-2006)
The 4th generation starting 2006
PMTO – clinical outcome study
A clinical trial with 100 families randomly distributed to PMTO and treatment as usual
Measuring changes in child behavior at home and at school using multi-informant behavioral assessment, parent reports, observations and background information
Children aged 12 years or younger with physical and verbal aggression, excessive noncompliance, delinquent behaviors, frequent escalating conflict between parent and child and out-of-control behavior
Intervention: training in the core PMTO elements 1) encouragement, 2) discipline, 3) monitoring, 4) problem solving and 5) positive involvement
Intake battery
Child’s mood Describe your friends Adaptation to school
Child Behavior Checklist (CBCL) parents Parent information about the child’s development and functioning Family economy and parents health Mutual adaptation in partner relationship Parents social support Cohesion and adaptation in the family (FACES) Parent Daily Report (PDR) Parent satisfaction with the treatment
Social skills – parent and teacher ratings (SSRS) Teacher Report Form (TRF) Teacher ratings of parent monitoring
Video recording and coding of structured family interaction tasks
Structured family interaction tasks are video recorded before and after treatment (playing/planning, problem solving/hot topics, waiting and evaluating)
Reliable coding with Family and Peer Process Code (FPPC) Real time coding of:
Activity, Withdrawal Contents
Affect is registered for each content code
Total Aversive Behavior score (TAB) Coders Impression Scale
Studying implementation and fidelity drift of PMTO
A collaborative research project on implementation, outcome effectiveness and fidelity drift between OSLC and the Behavior Center
Marion Forgatch (PI), Dave DeGarmo and Gerald Patterson, Oregon
Social Learning Center (OSLC) Richard Price, University of Michigan Terje Ogden (PI) and Kristine Amlund Hagen, The Behavior Center,
Unirand, University of Oslo The logistics team: Eyvind Elgesem, Carl Ivar Holmen, John Kjøbli,
Kristin Nordahl
The studies are sponsored by the National Institute of Drug Abuse (NIDA) and the Norwegian Ministry of Child and Family affairs
Aims of the study
A Norwegian RCT (N=100), a non-randomised replication study, and the study of fidelity drift over time and across successive generations of PMTO therapists
To study the fidelity to PMTO core components as practiced during the effectiveness trial and examine if fidelity and variation in delivery of PMTO affect parenting outcomes.
To analyze PMTO fidelity changes within specialists over time and as a function of training successive generations of Norwegian PMTO therapists.
FIDELITY WITHIN THE SIL FIDELITY WITHIN THE SIL MODELMODEL
Agency Characteristi
cs
Interventionist
Characteristics
Family Characteristi
cs
FidelityChange
ParentingChange Child
Behavior
Assessment of treatment fidelity
Treatment fidelity or adherence is measured by rating competent adherence to the intervention protocol and scored by Fidelity of Implementation Rating System (FIMP) (Forgatch & Rains)
Hypothesis: High scores on the PMTO treatment fidelity measure (FIMP) will increase the quality of the parenting
Year 2Fidelity
Year 3Fidelity
Year 4Fidelity
Year 1
Fidelity
Agency Characteristics
Interventionist Characteristics
Family Characteristics
Agency Characteristics
Interventionist Characteristics
Family Characteristics
Agency Characteristics
Interventionist Characteristics
Family Characteristics
Agency Characteristics
Interventionist Characteristics
Family Characteristics
Repeated measurements of treatment Repeated measurements of treatment fidelity over 4 yearsfidelity over 4 years
AgencyCharacteristics
G1Fidelityn = 33
G2Fidelityn = 84
InterventionistCharacteristics
FamilyCharacteristics
TrainingQuality of G2
G3Fidelityn = 70
TrainingQuality of G3
AgencyCharacteristics
InterventionistCharacteristics
FamilyCharacteristics
AgencyCharacteristics
InterventionistCharacteristics
FamilyCharacteristics
The study ofThe study of
therapist therapist
intergenerational intergenerational
fidelity driftfidelity drift
Obstacles and challenges
Characteristics of a structured treatment program: Short term intervention with predefined core components, Measuring behavioral change and monitoring treatment
fidelity A general limited faith in parents’ abilities to care for their
children and change problem behavior Program myths:
Works only in family with resources Too little flexibility Superficial behavior change Too litle focus on the child
Bringing research into the implementation:
Adding research to the implementation increased the work-load and challenges for the project
Introducing randomized controlled trials and quantitative group designs in clinical research
The recruitment of therapist (intervention + control) and the randomization procedure slowed down the referral process
New and challenging procedures: Video recordings of family interaction (FPPC) and therapy sessions (FIMP)
Overcoming obstacles at the program level
Long term planning and implementation
Continued and consistent support from the program developers Marion Forgatch, Gerald Patterson and their colleagues at OSLC
Establishing PMTO therapist networks and continued supervision
Developing training programs, handbooks and material in Norwegian
Negotiating training programs and the scope and contents of interventions with the municipalities
Facilitators at the national level
Increased professional demand for effective and empirically based methods to treat and prevent behavior problems in children
‘Champion advocates’ at the national, regional and local level generating interest, motivation, enthusiasm and effort
A genuine interest and commitment at the political and administrative level - consistent funding
Establishing a national implementation and research center and a national training program
Positive feedback from families and from the media
That was all!
Thank you!