the society for clinical child and adolescent psychology ... · • curriculum of parent training...
TRANSCRIPT
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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.
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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
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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
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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)
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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)
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Parenting Programs: Common Evidence-Based Curriculum
• Attending Strategies
• Rewards
• Planned Ignoring
• Effective Commands
• Transitional Strategies (When-Then)
• Planning Problem Solving
• Point Systems
• Time Out
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Efficacy of Parenting Programs
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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Search for unpublished (gray) studies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
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Effect Size Calculation
(Post MeanRx –Post MeanControl)/Pooled SD
.2 = small but significant effect
.5 = moderate effect
.8 = large effect
(Cohen, 1988)
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Efficacy of Parenting Programs?
Efficacy = Performance under optimal conditions
Effectiveness = Real World Performance
Cost Effectiveness
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Measuring Outcomes
Parent Report
Direct Observation
Home
Clinic Lab
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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
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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
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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)
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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)
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Efficacy of Parent Training Components
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Live or Recorded Demonstrations of Parenting Skills
Modeling:
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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
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Practice with Own Child
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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
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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
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Written, verbal, or behavioral assignments to complete between sessions
Homework:
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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
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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
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Does Father Participation Influence Parent Training Outcomes?
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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
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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
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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
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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
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Efficacy of Parent Training Content
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Positive Interaction
Following child’s interests, showing enthusiasm, providing positive attention
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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
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Responsiveness, Sensitivity Nurturing
Responding sensitively to child’s emotional needs (e.g. soothing, developmentally appropriate physical contact and affection)
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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
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Time Out (from positive reinforcement)
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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
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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:
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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
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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
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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
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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)
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Ancillary Services:
Supplementary services (e.g., mental health or substance abuse services, case management, referrals, stress/anger management adults
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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
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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
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Limitations of Current Models
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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
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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
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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)
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Latent Class Segmentation Analysis
Overwhelmed (16%) Action (41%)
Information (43%)
Source: Cunningham et al., Journal of Abnormal Child Psychology (2008)
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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
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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)
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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)
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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
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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
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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
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Limitations
Meta Analyses are Not Experimental Manipulations
Most Reviews Focus on Parents of Young Children
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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
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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.
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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-
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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