Parent Management Training-Oregon Model Research Articles

Exploring mental distress among immigrant mothers participating in parent training

This study of ethnic minority mothers assessed the intervention effects of Parent Management Training — Oregon Model (PMTO) on maternal mental distress. Ninety-six mothers from Somalia and Pakistan and their 3-year-old to 9-year-old children were randomized with respect to enrollment in PMTO or a wait-list condition. Immigrants living in European countries report having significantly more mental distress than natives. Surprisingly, the results in this current study showed that there were low levels of mental distress at enrollment in PMTO among the sample. An analysis of covariance showed that PMTO was not effective in alleviating maternal mental distress in this sample. Ethnicity, family size and the child's age served as moderators on the relationship between enrollment in PMTO or the wait-list condition and maternal mental distress outcomes. None of the subgroup analyses were in favor of the intervention. The results emphasize the importance of research on parent training with immigrant families.

Children With Conduct Problems and Co-occurring ADHD: Behavioral Improvements Following Parent Management Training

To scale up evidence-based treatment of conduct problems, parent management training, Oregon model (PMTO) has been disseminated throughout Norway. This study examined whether Attention Deficit Hyperactivity Disorder (ADHD) predicted the outcomes of PMTO. Of 253 children and families, 97 were reported to have an ADHD diagnosis. Although different at intake, the groups with and without ADHD had close to an equal change in behavioral status following treatment. Maternal depression and family income predicted the combined group's behavior following PMTO. The study indicates that reductions in conduct problems following PMTO are of the same magnitude in children with or without ADHD. However, some characteristics may differentially predict outcomes for children with combined problems.

Implementation of an evidence-based intervention to reduce long-term foster care: Practitioner perceptions of key challenges and supports

Although a growing literature defines significant components of systematic and effective implementation of evidence-based interventions (EBIs), little information exists about real-world successes and setbacks from child welfare practitioners' perspectives. This study sought to identify key challenges and supports during implementation of an EBI to reduce long-term foster care. Semi-structured, individual interviews were conducted with 28 child welfare practitioners implementing an EBI–Parent Management Training, Oregon Model (PMTO). Transcripts were coded and analyzed using theoretical thematic analysis. Member checking was used to confirm identified themes across interviews. Using six implementation factors to organize the results, multiple facilitators and barriers were identified. Study findings suggest that implementation of EBIs in child welfare should consider promoting and ensuring: (a) a learning culture with effective communication, rapid improvement cycles, and timely feedback loops; (b) frequent, direct, supportive, and high-quality coaching and supervision; (c) strong leadership and organizational fit; and, (d) strategies for tailoring the EBI to the child welfare setting, including responses to families' multiple and complex needs and practices for effective client engagement.

Parent Management Training-Oregon Model (PMTO™) in Mexico City: Integrating Cultural Adaptation Activities in an Implementation Model.

This article describes the process of cultural adaptation at the start of the implementation of the Parent Management Training intervention-Oregon model (PMTO) in Mexico City. The implementation process was guided by the model, and the cultural adaptation of PMTO was theoretically guided by the cultural adaptation process (CAP) model. During the process of the adaptation, we uncovered the potential for the CAP to be embedded in the implementation process, taking into account broader training and economic challenges and opportunities. We discuss how cultural adaptation and implementation processes are inextricably linked and iterative and how maintaining a collaborative relationship with the treatment developer has guided our work and has helped expand our research efforts, and how building human capital to implement PMTO in Mexico supported the implementation efforts of PMTO in other places in the United States.

Clustering Practitioners Within Service Organizations May Improve Implementation Outcomes for Evidence-Based Programs

Data for the present study were collected from Parent Management Training Oregon model (PMTO) therapists (n = 83) employed in Norwegian social service organizations. Survey data were analyzed using partial correlation, MANCOVA, and contrast tests. There were statistically significant positive relationships between the number of PMTO therapists working in an agency and respondents reports of: (1) how many families they had treated with PMTO in the past 6 months, (2) PMTO being well integrated in their organization, and (3) how much time they have to practice PMTO in their current position. In addition, practitioners in organizations with more PMTO colleagues were significantly less likely to report that they would stop using the program. Finally, there was a marginally significant positive relationship between the number of PMTO therapists in an agency and practitioners’ reports that they received a sufficient number of PMTO cases. The size of the organization, the number of years therapists had worked with PMTO, and therapist perception of agency leadership were controlled for. Contrast tests suggested that the most prominent differences were between agencies with three PMTO therapists versus agencies with one or two practitioners. There were exceptions to this result; for example, individual practitioners with four or more therapists in their agencies had treated significantly more families with PMTO in the past six months than those with three or fewer therapists. There were large effect sizes for the MANCOVA, F(20, 249) = 10.38, p < .01, η p 2 = .39, as well as the univariate tests. Implementation outcomes were not improved for PMTO therapists if there were practitioners within their agencies working with an evidence-based program other than PMTO. Results suggest that clustering practitioners using the same program within an organization, in groups of three or more, could contribute to successful implementation outcomes for evidence-based programs.

Supplemental Material for Parent Management Training-Oregon Model (PMTO™) in Mexico City: Integrating Cultural Adaptation Activities in an Implementation Model

Supplemental Material for Parent Management Training-Oregon Model (PMTO™) in Mexico City: Integrating Cultural Adaptation Activities in an Implementation Model

Looking Forward

Over the past quarter century, researchers have developed a body of parent training programs that have proven effective in reducing child behavior problems, but few of these have made their way into routine practice. This article describes the long and winding road of implementation as applied to children’s mental health. Adopting Rogers’ (1995) diffusion framework and Fixsen and colleagues’ implementation framework (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005), we review more than a decade of research on the implementation of Parent Management Training—Oregon Model (PMTO). Data from U.S. and international PMTO implementations are used to illustrate the payoffs and the challenges of making empirically supported interventions routine practice in the community. Technological advances that break down barriers to communication across distances, the availability of efficacious programs suitable for implementation, and the urgent need for high quality mental health care provide strong rationales for prioritizing implementation. Over the next quarter of a century, the challenge is to reduce the prevalence of children’s psychopathology by creating science-based delivery systems to reach families in need, everywhere.

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.

Early Initiatives for Children at Risk—Development of a Program for the Prevention and Treatment of Behavior Problems in Primary Services

During the past decade, Norwegian authorities have initiated and funded a project to scale up the use of evidence-based programs for the prevention and treatment of conduct problems in children. The first step in this process was to increase treatment competence by implementing the Parent Management Training-Oregon Model (PMTO) in specialist services for children. The second step was to develop the program Early Initiatives for Children at Risk (Norwegian acronym, TIBIR), designed to identify children with possible conduct problems as early as possible and to offer tailored interventions as part of the ordinary primary services for children in individual municipalities. The theoretical rationale and practical considerations leading to the design of TIBIR are presented, together with the program modules and current research activities. Some of the challenges concerning the program's ability to reach various risk groups are discussed, as are the challenges encountered regarding quality assurance and fidelity maintenance. Finally, some future research questions are presented and discussed.

Working alliance and treatment fidelity as predictors of externalizing problem behaviors in parent management training.

The study investigated treatment fidelity and working alliance in the Parent Management Training-Oregon model (PMTO) and investigated how these relate to children's externalizing problem behaviors, as reported by parents and teachers. Participants were 331 Norwegian parents who rated the client-therapist working alliance at 3 time points (Sessions 3, 12, and 20). Competent adherence to the PMTO treatment protocol was assessed by PMTO specialists from evaluations of videotaped therapy sessions using the Fidelity of Implementation (FIMP) system (Knutson, Forgatch, & Rains, 2003). Parents and teachers reported children's problem behaviors at baseline and at the end of therapy. Structural equation modeling was used to analyze the repeated measures data. Parents reported high and stable levels of alliance and fidelity from Time 1 to Time 3, with no correlational or direct relations between the 2. Treatment fidelity predicted reductions in parent-reported externalizing behavior, whereas working alliance was related to less change in problem behavior. Alliance and fidelity were unrelated to teacher-reported behavior problems. The findings point to treatment fidelity as an active ingredient in PMTO and working alliance as a negative predictor of postassessment parent-reported externalizing behavior. More research is needed to investigate whether these findings can be replicated and extended beyond PMTO.

Can Parent Training Alter Parent Practice and Reduce Conduct Problems in Ethnic Minority Children? A Randomized Controlled Trial

A randomized prevention study for ethnic minority mothers assessed the intervention effects of Parent Management Training-Oregon Model (PMTO) on maternal parent practices and child behavior. Ninety-six mothers from Somalia and Pakistan and their children aged 3 to 9years were randomized to PMTO or a wait-list condition (WLC). Assessments were carried out at the baseline and post-intervention, using standardized measures and a multi-agent approach. All analyses were based on the intention-to-treat principle. Analysis of covariance (ANCOVA) showed that PMTO was effective in enhancing parent practices, with a decrease in harsh discipline and an increase in positive parenting. Moreover, PMTO produced reductions in motherreported child conduct problems. The largest effect sizes were found among mothers who attended more than 50% of the PMTO group sessions. Teacher reports showed, however, that there were no significant intervention effects on conduct problems and social competence in kindergarten or school. The results emphasize the importance and feasibility of offering PMTO to ethnic minority families.

Implementation of Parent Management Training—Oregon Model (PMTOTM) in Iceland: Building Sustained Fidelity

Bringing empirically supported treatments (ESTs) into community settings is a challenge because of threats to therapy adherence. The nationwide implementation of Parent Management Training-the Oregon Model (PMTO) in Iceland was studied by comparing therapists' competent adherence to PMTO across three generations of therapists. To assess therapists' competence and adherence to the PMTO method, the Fidelity of Implementation Rating System (FIMP) was used as the measuring device. Of 16 therapists across three generations who entered training, 12 completed with certification. As expected, each of the three generations obtained adequate FIMP scores. Generations 1 and 3 showed equivalent levels of performance on FIMP scores at certification. A small drop in FIMP scores for Generation 2 was explained in terms of translating and culturally adjusting materials and strengthening training procedures. Results are parallel to earlier findings from the nationwide PMTO implementation in Norway and support the idea that PMTO can be implemented in community settings with high fidelity even when resources are scarce.

Parent Training Among Ethnic Minorities: Parenting Practices as Mediators of Change in Child Conduct Problems

In this study, we examined parenting practices as mediators of changes in child conduct problems in ethnic minority families participating in Parent Management Training—Oregon Model (PMTO). The participants included 96 Somali and Pakistani immigrant mothers and their children living in Norway. The families were randomized to PMTO or a waiting‐list control group. Self‐report assessments were made at baseline and after the intervention using standardized measures. A path model suggested that improvements in the child conduct problems were fully mediated by a reduction in harsh maternal discipline and an increase in positive parenting. When the mediation pathways were tested separately, both the reduction in harsh discipline and the increased positive parenting functioned as mediators of the reduction in child conduct problems. These findings emphasize the importance of including components that address the parent's use of both harsh and positive parenting practices when implementing parenting training among ethnic minority families.

Sustaining Fidelity Following the Nationwide PMTO™ Implementation in Norway

This report describes three studies from the nationwide Norwegian implementation of Parent Management Training-Oregon Model (PMTO™), an empirically supported treatment for families of children with behavior problems (Forgatch and Patterson 2010). Separate stages of the implementation were evaluated using a fidelity measure based on direct observation of intervention sessions. Study 1 assessed growth in fidelity observed early, mid, and late in the training of a group of practitioners. We hypothesized increased fidelity and decreased variability in practice. Study 2 evaluated method fidelity over the course of three generations of practitioners trained in PMTO. Generation 1 (G1) was trained by the PMTO developer/purveyors; Generation 2 (G2) was trained by selected G1 Norwegian trainers; and Generation 3 (G3) was trained by G1 and G2 trainers. We hypothesized decrease in fidelity with each generation. Study 3 tested the predictive validity of fidelity in a cross-cultural replication, hypothesizing that higher fidelity scores would correlate with improved parenting practices observed in parent-child interactions before and after treatment. In Study 1, trainees' performance improved and became more homogeneous as predicted. In Study 2, a small decline in fidelity followed the transfer from the purveyor trainers to Norwegian trainers in G2, but G3 scores were equivalent to those attained by G1. Thus, the hypothesis was not fully supported. Finally, the FIMP validity model replicated; PMTO fidelity significantly contributed to improvements in parenting practices from pre- to post-treatment. The data indicate that PMTO was transferred successfully to Norwegian implementation with sustained fidelity and cross-cultural generalization.

Helping military families through the deployment process: Strategies to support parenting.

Recent studies have highlighted the impact of deployment on military families and children and the corresponding need for interventions to support them. Historically, however, little emphasis has been placed on family-based interventions in general, and parenting interventions in particular, with returning service members. This paper provides an overview of research on the associations between combat deployment, parental adjustment of service members and spouses, parenting impairments, and children's adjustment problems, and provides a social interaction learning framework for research and practice to support parenting among military families affected by a parent's deployment. We then describe the Parent Management Training-Oregon model (PMTO(™)), a family of interventions that improves parenting practices and child adjustment in highly stressed families, and briefly present work on an adaptation of PMTO for use in military families (After Deployment: Adaptive Parenting Tools, or ADAPT). The article concludes with PMTO-based recommendations for clinicians providing parenting support to military families.

Cultural Adaptation of an Evidence Based Intervention: From Theory to Practice in a Latino/a Community Context

The cultural tailoring of interventions to reach underserved groups has moved from descriptive and proscriptive models to their application with existing evidence based treatments. To date few published examples illustrate the process of cultural adaptation. The current paper documents the adaptation of an evidence based parent training intervention, Parent Management Training-Oregon Model (PMTO™), for Spanish-speaking Latino parents using both process (Domenech Rodríguez and Wieling in Voices of color: first-person accounts of ethnic minority therapists, Sage, Thousand Oaks, 2004) and content (Bernal et al. in J Abnorm Child Psychol 23:67-82, 1995) models. The adaptation took place in stages: a pilot study to ensure feasibility, focus groups to establish appropriate format and goals, and a test of the intervention. Throughout the process the treatment manual was treated as a living document. Changes were applied and documented as the team developed improvements for the adaptation. The present discussion details both process adaptations, (e.g., engaging the treatment developer, community leaders, and parents, and decentering the manual), and content adaptations, (e.g., shaping the appropriateness of language, persons, metaphors, concepts, contexts, methods, and goals). The current research provides support for the idea that cultural adaptations can improve service delivery to diverse groups and can be conducted systematically with documentation for replication purposes. Suggestions for improving the empirical measurement and documentation of the adaptation process are included.

Cascading effects following intervention.

Four different sources for cascade effects were examined using 9-year process and outcome data from a randomized controlled trial of a preventive intervention using the Parent Management Training-Oregon Model (PMTO™). The social interaction learning model of child antisocial behavior serves as one basis for predicting change. A second source addresses the issue of comorbid relationships among clinical diagnoses. The third source, collateral changes, describes events in which changes in one family member correlate with changes in another. The fourth component is based on the long-term effects of reducing coercion and increasing positive interpersonal processes within the family. New findings from the 9-year follow-up show that mothers experienced benefits as measured by standard of living (i.e., income, occupation, education, and financial stress) and frequency of police arrests. It is assumed that PMTO reduces the level of coercion, which sets the stage for a massive increase in positive social interaction. In effect, PMTO alters the family environment and thereby opens doors to healthy new social environments.

Implementing the Parent Management Training Oregon model in The Netherlands

In cooperation with its American developers, the Parent Management Training Oregon (PMTO) model was introduced into the Dutch youth care system at the beginning of 2006. In general, implementing new interventions in practice is no simple matter. Several factors related to the socio‐political context, the organizational context, the intervention itself and the professional can facilitate or hinder the implementation process. Therefore, it is essential to establish a good understanding of the factors that may influence the implementation of PMTO in the Dutch context. This paper presents preliminary results of an implementation study of PMTO in four Dutch pilot organizations. Managers as well as (PMTO) therapists completed questionnaires and were interviewed about factors that had a positive or negative effect on the implementation of PMTO. In order to successfully implement PMTO at a national level an implementation strategy should be designed that takes all identified key factors into account.

IMPLEMENTATION OF PARENT MANAGEMENT TRAINING AT THE NATIONAL LEVEL: THE CASE OF NORWAY

This article describes early aspects of the nationwide implementation of an evidence‐based program (EBP) in Norway and the design for studying program fidelity over time. The EBP is the Parent Management Training, Oregon Model (PMTO). The project is a combination of a ‘top down’ initiative at the governmental and ministry level, and a ‘bottom up’ initiative from practitioners seeking effective interventions in the prevention and remediation of behavior problems in children and youth. The main components of the implementation strategy were to (a) establish a national implementation and research center; (b) provide for regional and local participation at county and municipal levels; (c) establish a comprehensive therapist recruitment, training, and maintenance program; (d) create a network for collaboration, supervision, and quality control; (e) conduct clinical outcome research; and (f) study the implementation process. Following the training of three successive generations of PMTO specialists, a study was designed to examine how individual, family, interventionist, organizational, and community characteristics influence program adoption and implementation, as well as how these factors impact upon how PMTO specialists provide the intervention to families with competent adherence to the model. Within the framework of the collaborative North American and Norwegian project, challenges and facilitators in the process of the continental crossing of the PMTO model are discussed.