Behavioral Parent Training Interventions Research Articles

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

ABSTRACTThe present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent–child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study’s limitations, and future directions for research are further discussed.

Characteristics of Parents of Children with ADHD Who Never Attend, Drop Out, and Complete Behavioral Parent Training

Behavioral parent training (BPT) is an evidence-based intervention for the treatment of attention-deficit/hyperactivity disorder and related disruptive behavior disorders in youth. Although efficacious, dropout from BPT is a notable issue, particular for high-risk families. The literature suggests that parental factors (stress, psychopathology and cognitions) may be particularly important in understanding which parents dropout from BPT. To date, however, limited attention has been given to how these factors may be related to dropout at varying points during BPT. Secondary data analyses from a completed clinical trial of a traditional BPT intervention is presented herein. Forty participants were classified into three groups based on timing of dropout from BPT (enrolled in but never attended BPT; dropped out during BPT, and completed BPT). Parent-level factors (stress, depressive symptoms, parental efficacy, and parental attributions for child behavior) were assessed at baseline and post-treatment (parental perceived barriers to treatment) to determine if these factors were differentially related to dropout group status. Results suggested that parents who never attended BPT were more likely to have lower parental efficacy and greater maladaptive attributions regarding their child compared to parents who dropped out from BPT and those who completed BPT. Moreover, parents perceptions of the relevance of BPT was lower in the never attended group and the dropped out from BPT group compared to the completed BPT group. Results of the study have implications for tailoring engagement strategies focused on parental cognitions throughout the process of BPT, particularly for high-risk families.

Measurement Issues: Large effect sizes do not mean most people get better - clinical significance and the importance of individual results.

This paper seeks to compare group statistical analysis with effect size, group measures of clinical significance (Reliable Change Index and normative comparison), and individual analysis of clinical significance. Measures of variables important to parenting and child behavior improvement (Parenting Scale, Eyberg Child Behavior Inventory, and Parenting Stress Index [PSI]) were administered pre and post for a 9- to 10-week group Behavioral Parent Training Intervention. Analysis compares traditional group statistical significance testing with group measure of clinical significance and individual analysis of clinical significance. All three measures demonstrated statistically significant differences from pre to post, with large effect sizes. Group measures of clinical significance, however, demonstrated meaningful change only on the PSI, while individual analysis showed improvements of 54% of participants at best and 0% at worst. Individual analysis of clinical significance provides valuable information in treatment outcomes and should be included as a standard practice in outcomes research.

Effects of a video feedback parent training program during child welfare visitation

Behavioral parent training programs have documented efficacy for improving behaviors among parents and their children and are frequently used by child welfare agencies to prevent removal of a child from the parental home or to facilitate reunification. Although an ideal time for parent training might be during supervised visits where parents may practice skills with their children under the guidance and support of a therapist or caseworker, this is not typically the case. Most often, parents within the child welfare system receive parent training in small groups without their children present, and to date, few studies have examined effects of behavioral parent training interventions during supervised visitation. In this study, concurrent multiple baseline across behaviors design was used to examine effects of a behavioral parent training program, Filming Interactions to Nurture Development (FIND), on parental skill acquisition with four mothers who had lost custody of their children but were being considered for reunification. Children emitted little or no problem behaviors during baseline or intervention, so parenting behavior was the primary dependent variable. Results obtained across participants documented a clear functional relation between implementation of the FIND intervention and increases in developmentally supportive parenting behaviors. Results of social validity and contextual fit measures suggest the intervention was perceived by mothers to be positive, feasible, and appropriate within the child welfare context. Practical and conceptual implications, limitations of this study, and directions for future research are discussed.

Child Welfare Involved Parents and Pathways Triple P: Perceptions of Program Acceptability and Appropriateness.

Nearly half of children in the child welfare system have clinically significant behavior problems and are at risk of developing disruptive behavioral disorders. Yet, behavioral parent training interventions, which are the most effective way to treat these problems, are rarely provided to child welfare involved families. As a result, little is known about the acceptability and appropriateness of these parent training interventions with these families. This qualitative study explored implementation outcomes of an evidenced-based parenting intervention, Pathways Triple P, with families in the child welfare system. Semi-structured interviews were conducted with parents investigated for child maltreatment (n=47); following participation in the Pathways Triple P. Parents were asked about their perceptions of acceptability (program satisfaction) and appropriateness (program fit). Despite the complicated and often chaotic lives common among this vulnerable population, study findings suggest that most parents found the intervention to be useful and relevant. Pathways Triple P's content, structure and materials for parents were key aspects of acceptability and appropriateness. Barriers to participation were also identified separately for parents who did not receive the full dosage of the intervention. Study findings indicate that Pathways Triple P is a promising strategy to improve behavioral health outcomes for maltreated children and increase positive parenting behaviors for child welfare involved parents.

Interventions for Parents of People with Intellectual Disabilities

Parents of children with intellectual disabilities (ID) consistently report higher levels of parenting stress than parents of typically developing children, which has psychological and physical consequences for both the parent and child. Further, high levels of parenting stress are often associated with poor outcomes in behavioral interventions for children with ID. Thus, parental stress and mental health concerns in general are critical targets for intervention. Nevertheless, there are few evidence-based treatments aimed at reducing stress in parents of children with ID. Parent-led support groups are the most common type of intervention for these parents; however, little empirical evidence is available to support the efficacy of these interventions. Other evidence-based interventions include mindfulness, cognitive-behavior therapy, respite, and behavioral parent training interventions. We argue for a combined intervention model that addresses both parental stress and child behavior problems directly in order to optimize outcomes for children with ID and their families.

A behavioral parent-training intervention for a child with avoidant/restrictive food intake disorder.

Avoidant/restrictive food intake disorder (ARFID) is a feeding disorder classification in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM–5; American Psychiatric Association, 2013) that describes a pervasive and disruptive pattern of food refusal and/or severe food selectivit

Self-Reported Parenting of Clinic-Referred and Non-referred Mexican American Mothers of Young Children

Behavioral parent training (BPT) interventions for child behavior problems have been based on decades of research that demonstrate links between particular parent behaviors and child externalizing problems. However, the majority of this research has been conducted with European-American (EA) families, and less is known about whether these findings can be generalized to Mexican Americans (MAs). In the current study, we investigated self-reported parenting practices that have been associated with externalizing behavior problems among EA families (harsh parenting, inconsistency, and low parental warmth), to determine if those practices can also differentiate MA mothers whose young children have clinically significant behavior problems from MA mothers whose children do not have behavior problems. Participants were 115 MA families with young children, 58 with a child with clinically significant behavior problems and 57 with a child in the normal range for such problems. Results indicated that MA mothers whose children have behavior problems self-reported significantly less warmth and consistency and more harsh parenting compared to parents whose children's behavior was in the normal range. These findings indicate that parenting behaviors that are associated with externalizing behavior problems among EA families are associated with the same problems among MA families with young children, suggesting that parent training interventions designed to target these behaviors are also likely to be relevant to MA families with children in this age range. However, findings also indicate that parenting behaviors differ depending on acculturation level, suggesting that BPT programs must respond to variation in normative parenting practices for MA families.

Behavior management for school-aged children with ADHD.

Behavior management treatments are the most commonly used nonpharmacologic approaches for treating attention-deficit/hyperactivity disorder (ADHD) and associated impairments. This review focuses on behavioral parent training interventions for school-age children in the home setting and adjunctive treatments developed to extend effects across settings. Empirical support includes numerous randomized clinical trials, systematic reviews, and meta-analyses showing positive effects of these interventions on child compliance, ADHD symptoms and impairments, parent-child interactions, parenting and parenting stress. These studies support categorization of behavior management treatment as a well-established, evidence-based treatment of ADHD. Factors for consideration in clinical decision making and directions for research are provided.

Assessing the Key to Effective Coaching in Parent-Child Interaction Therapy: The Therapist-Parent Interaction Coding System.

This paper describes the initial evaluation of the Therapist-Parent Interaction Coding System (TPICS), a measure of in vivo therapist coaching for the evidence-based behavioral parent training intervention, parent-child interaction therapy (PCIT). Sixty-one video-recorded treatment sessions were coded with the TPICS to investigate (1) the variety of coaching techniques PCIT therapists use in the early stage of treatment, (2) whether parent skill-level guides a therapist's coaching style and frequency, and (3) whether coaching mediates changes in parents' skill levels from one session to the next. Results found that the TPICS captured a range of coaching techniques, and that parent skill-level prior to coaching did relate to therapists' use of in vivo feedback. Therapists' responsive coaching (e.g., praise to parents) was a partial mediator of change in parenting behavior from one session to the next for specific child-centered parenting skills; whereas directive coaching (e.g., modeling) did not relate to change. The TPICS demonstrates promise as a measure of coaching during PCIT with good reliability scores and initial evidence of construct validity.

Improving nutrition in toddlers with cystic fibrosis: Feasibility of a behavioral parent-training intervention.

This study tested feasibility of a developmentally sensitive adaptation of a behaviorally based group parent-training intervention designed to improve adherence to cystic fibrosis nutrition recommendations and address a variety of mealtime behavior management problems. Modifications to the original intervention are described. Parents of 4 children ages 21 to 31 months with cystic fibrosis participated. Two children were malnourished and had primary goals of increasing intake and weight; 2 were adequately nourished and had primary goals of improving diet quality. Additional data are provided for 1 child regarding child disruptive behavior. Anthropometric data were collected at baseline, pre- and posttreatment, and follow-up and retrospectively via chart review. Families completed 3-day diet diaries across 2 baseline weeks, 6 weeks of intervention, and at a 12-week postintervention follow-up. Data support acceptability of this intervention to parent participants. The 2 malnourished children increased caloric intake throughout the intervention and demonstrated clinically significant weight gains at posttreatment. Furthermore, these gains were maintained at follow-up. One of the 2 adequately nourished children demonstrated improved diet quality. Findings provide some support for the feasibility for parent group intervention providing training in cystic fibrosis-specific child behavior management skills to multiple families. Preliminary results suggest that this intervention may provide benefits to parents who often struggle with the demands of nutrition requirements and toddler behavior.

Duration and mutual entrainment of changes in parenting practices engendered by behavioral parent training targeting recently separated mothers.

Parent management training (PMT) has beneficial effects on child and parent adjustment that last for 5 to 10 years. Short-term changes in parenting practices have been shown to mediate these effects, but the manner in which changes in specific components of parenting are sequenced and become reciprocally reinforcing (or mutually entrained) to engender and sustain the cascade of long-term beneficial effects resulting from PMT has received modest empirical attention. Long-term changes in parenting resulting from the Oregon model of PMT (PMTO) over a 2-year period were examined using data from the Oregon Divorce Study-II in which 238 recently separated mothers and their 6- to 10-year-old sons were randomly assigned to PMTO or a no treatment control (NTC) group. Multiple indicators of observed parenting practices were used to define constructs for positive parenting, monitoring and discipline at baseline, and at 6-, 12-, 18- and 30-months postbaseline. PMTO relative to NTC resulted in increased positive parenting and prevented deterioration in discipline and monitoring over the 30-month period. There were reliable sequential, transactional relationships among parenting practices; positive parenting supported better subsequent monitoring, and positive parenting and better monitoring supported subsequent effective discipline. Small improvements in parenting resulting from PMTO and small deteriorations in parenting in the NTC group may be sustained and amplified by mutually entrained relationships among parenting practices. These data about the change processes engendered by PMTO may provide information needed to enhance the power, effectiveness, and efficiency of behavioral parent training interventions.

Barriers to Success in Parent Training for Young Children With Developmental Delay

The purpose of this study was to examine the effect of cumulative risk on dropout and treatment outcome in parent training. Participants were 44 families of young children (mean age of 49.59 months) who presented with elevated externalizing behavior problems and developmental delay or borderline developmental delay. All families were offered to receive Parent-Child Interaction Therapy (PCIT), an evidence-based, behavioral parent-training intervention, at a hospital-based outpatient clinic. Cumulative risk was calculated as a sum of risk variables, including socioeconomic disadvantage (poverty, low maternal education), family structure (single-parent household), and maternal risk characteristics (minority status, lower intelligence, and parental distress). Families with higher cumulative risk scores, especially those with three or more risks, were more likely to drop out of treatment and display diminished treatment response in child behavior and parenting skills compared with families with lower cumulative risk scores. However, only two individual risk factors (i.e., minority status and family structure) predicted dropout, and one individual risk factor (i.e., maternal education) predicted outcome. These findings suggest that it can be useful to conceptualize risk factors as having a cumulative, in addition to individual, influence on parent-training interventions for children with developmental delay and have significant implications for clinical practice. It is important for clinicians to regularly assess for risk factors, and future research should examine ways in which clinicians can improve retention and outcome of parent training in the presence of multiple risk factors.

An Initial Investigation of Baseline Respiratory Sinus Arrhythmia as a Moderator of Treatment Outcome for Young Children Born Premature With Externalizing Behavior Problems

The aim of the current study was to examine the moderating effect of baseline respiratory sinus arrhythmia (RSA) on Parent-Child Interaction Therapy (PCIT), a behavioral parent-training intervention, for young children born premature. In this pilot randomized controlled trial, 28 young children (mean age of 37.79months), who were born <37weeks gestation and presented with elevated externalizing behavior problems, were randomly assigned to an immediate treatment or waitlist control group. RSA, which provides an approximate marker of individual differences in cardiac vagal tone, was measured during a baseline period. Past research has generally shown that higher levels of baseline RSA correlate with various positive psychological states (e.g., empathy, sustained attention), whereas lower levels of baseline RSA correlate with less optimal psychological states (e.g., higher externalizing behavior problems). Results indicated that baseline RSA significantly interacted with treatment condition in predicting changes in child disruptive behavior. Specifically, low levels of baseline RSA were associated with greater improvements in child disruptive behavior following PCIT. While acknowledging the caveats of measuring and interpreting RSA and the need to include a sympathetic-linked cardiac measure in future research, these findings provide preliminary evidence that children with lower capacity for emotion regulation receive even greater treatment gains. Future research should also examine the moderating effect of RSA in larger samples and explore the potential mediating role of RSA on behavioral parenting interventions.

Psychosocial treatments for attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder requiring developmentally sensitive interventions across the lifespan. Although pharmacotherapy traditionally has been considered the first-line treatment for ADHD, many individuals continue to experience significant functional impairment or choose not to pursue pharmacotherapy. Thus, evidence-based alternatives or adjuncts to pharmacologic treatment for individuals with ADHD are needed. Behavioral parent training and behavioral school interventions are the only empirically supported nonpharmacologic interventions for children and adolescents with ADHD. This article reviews recent additions to the ADHD literature, including evaluations of behavioral interventions in traditional clinical practice and schools, treatment efficacy for preschool-aged children and adults, and the investigation of a novel treatment for individuals with the predominantly inattentive subtype of ADHD.

The Treatment of Conduct Problems in Children With Callous-Unemotional Traits.

The aim of this study was to examine the impact of callous-unemotional (CU) traits on treatment outcomes and processes in a 10-week behavioral parent-training intervention with young boys referred for conduct problems (N = 56; mean age 6.29 years). CU traits were associated with greater conduct problems at pretreatment and with poor outcomes at 6-month follow-up. CU traits uniquely predicted clinical outcomes when analyzed in relation to conduct-problem severity, other predictors of antisocial behavior, and parents' implementation of treatment. Boys with high CU traits were less responsive to discipline with time-out than boys without CU traits and reacted to this discipline with less affect. These findings present important implications for the role of child temperament in intervention for conduct problems.

Interpersonal skills training to reduce aggressive and delinquent behavior: limited evidence and the need for an evidence-based system of care.

The prevention of aggressive and delinquent behavior during childhood and adolescence is one of the highest priorities for public health and crime prevention. The most common approach to preventing or treating these conduct problems has been to provide interpersonal skills training to the affected youth. This paper reviews all randomized controlled trials evaluating interpersonal skills training programs as an intervention to reduce conduct problems. Research shows that such programs have weak empirical support as isolated interventions. An alternative evidence-based system of care is described. Such a system would include behavioral parent training and behavioral classroom-based interventions for young children at risk of developing problems, as well as multisystemic family therapy or multidimensional treatment foster care for chronic delinquents. Within such a network of services, interpersonal skills training could play an important supportive role. Such a system holds the greatest promise for reducing the prevalence of aggressive and delinquent behavior in communities.

Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Reviews and evaluates psychosocial treatments for attention deficit hyperactivity disorder (ADHD) in children and adolescents according to Task Force Criteria (Lonigun, Elbert, & Johnson, this issue). It is concluded that behavioral parent training and behavioral interventions in the classroom meet criteria for well-established treatments. Cognitive interventions do not meet criteria for well-established or probably efficacious treatments. Issues regarding the evaluative process are discussed and future directions for psychosocial treatment for ADHD are outlined.

Father Involvement in Parent Training for Oppositional Child Behavior

Outcome literature (1981 to 1988) on behavioral parent training interventions for nonhandicapped children with oppositional behavior is reviewed to assess the extent and effects of father involvement in parent training. Thirteen studies were found that included some father involvement. Weaknesses of these studies include a failure to observe and measure changed in father-child interactions, a lack of emphasis on the impact of the marital relationship, a lack of attention to similarities in parental child management strategies, and a lack of assessment of paternal characteristics. Further research to assess the effects of including fathers on parent training outcomes can improve the efficiency and effectiveness of these interventions.