Abstract
Family resources have been associated with health care inequality in general and with social gradients in treatment outcomes for children with behavior problems. However, there is limited evidence concerning cumulative risk—the accumulation of social and economic disadvantages in a family—and whether cumulative risk moderates the outcomes of evidence-based parent training interventions. We used data from two randomized controlled trials evaluating high-intensity (n = 137) and low-intensity (n = 216) versions of Parent Management Training—Oregon (PMTO) with a 50:50 allocation between participants receiving PMTO interventions or regular care. A nine-item family cumulative risk index tapping socioeconomic resources and parental health was constructed to assess the family’s exposure to risk. Autoregressive structured equation models (SEM) were run to investigate whether cumulative risk moderated child behaviors at post-treatment and follow-up (6 months). Our results showed opposite social gradients for the treatment conditions: the children exposed to cumulative risk in a pooled sample of both PMTO groups displayed lower levels of behavior problems, whereas children with identical risk exposures who received regular care experienced more problems. Furthermore, our results indicated that the social gradients differed between PMTO interventions: children exposed to cumulative risk in the low-intensity (five sessions) Brief Parent Training fared equally well as their high-resource counterparts, whereas children exposed to cumulative risk in the high-intensity PMTO (12 sessions) experienced vastly better treatment effects. Providing evidence-based parent training seem to be an effective way to counteract health care inequality, and the more intensive PMTO treatment seemed to be a particularly effective way to help families with cumulative risk.
Highlights
It is well established that behavioral problems in childhood negatively impact children’s long-term well-being through an association with school problems, work problems, social exclusion, and poor health (Maughan et al 1985; Rutter et al 1970; Sroufe et al 2009)
The results showed that the children in the Parent Management Training —Oregon (PMTO) group from families with one additional cumulative risk generally experienced more benefit from treatment; in T2, behavior problems were reduced by an average of 16% of a standard deviation for each accumulated risk (ß = −0.16, p < 0.01; results were standardized on Y only)
Differences between the groups were significant for cumulative risk scores above 0.9, meaning that group differences between those who received parent training and those who received regular care were significant for families with one or more risks
Summary
It is well established that behavioral problems in childhood (i.e., conduct problems, oppositional behaviors, and inattentive problems) negatively impact children’s long-term well-being through an association with school problems, work problems, social exclusion, and poor health (Maughan et al 1985; Rutter et al 1970; Sroufe et al 2009). In caring for behavior problems, social gradient approaches have commonly focused on family resources in the form of socioeconomic status (SES), typically assessed in terms of parental income and education level (Leijten et al 2013). SES has been proposed as a “fundamental cause” of health inequality, structuring (un-) favorable mechanisms across contexts and diseases (Link and Phelan 1995; Muntaner et al 2013). This implies that high SES families enjoy a vast number of flexible assets that they can use to their advantage to implement protective strategies and produce favorable treatment outcomes
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