Child Psychiatry Hum Dev DOI 10.1007/s10578-015-0548-9
ORIGINAL ARTICLE
Dealing with Disobedience: An Evaluation of a Brief Parenting Intervention for Young Children Showing Noncompliant Behavior Problems Cassandra K. Dittman1 • Susan P. Farruggia2 • Louise J. Keown3 Matthew R. Sanders1,3
•
Ó Springer Science+Business Media New York 2015
Abstract The study was a randomized controlled trial evaluating the efficacy of a brief and preventatively-focused parenting discussion group for dealing with disobedient behavior in preschool-aged children. Eighty-five parents with children aged between 3 and 5 years who were concerned about the noncompliant behavior of their child were recruited from Auckland, New Zealand and Brisbane, Australia. Compared to the waitlist control group (n = 40), parents in the intervention group (n = 45) reported greater improvements in disruptive child behavior, ineffective parenting practices and parenting confidence, as well as clinically significant improvements in child behavior and parenting. All of these effects were maintained at 6-month follow up. No group differences were found for parental wellbeing, inter-parental conflict and general relationship quality, although intervention parents reported improvements in parental wellbeing and inter-parental conflict at 6-month follow-up. The findings are discussed in terms of the implications for making brief and effective parenting support available to parents. Keywords Brief parenting interventions Disobedience Preschoolers Behavior problems Triple P
& Cassandra K. Dittman
[email protected] 1
Parenting and Family Support Centre, School of Psychology, The University of Queensland, Brisbane, QLD 4072, Australia
2
The University of Illinois at Chicago, Chicago, USA
3
The University of Auckland, Auckland, New Zealand
Introduction The management of noncompliant or disobedient behavior, which involves a child purposefully not carrying out a behavior requested by a parent or other adult authority figure [1], is a common challenge faced by parents of young children. Some level of disobedient behavior is normative among young children, with prevalence rates for the existence of disobedient behavior ranging from 25 to 65 % [1]. For fewer parents, disobedient behavior is a significant concern; cross-sectional surveys suggest that between 3 [2] and 13 % [3] of parents report that noncompliance in their child is a frequent or severe problem. Thus, a significant proportion of parents struggle with elevated levels of disobedient behavior and would benefit from support [4]. Even for parents whose children are showing levels of disobedient behavior within the normal range for their age, support and assistance for dealing with the behavior in a consistent and positive manner is likely to be helpful. Furthermore, given that early onset conduct problems often persist across the school years and into adolescence, and can have detrimental effects on educational and occupational attainment, social relationships and mental and physical health [5, 6], there are significant public health and community-level benefits for addressing problems with disobedient behavior during early childhood. Behavioral family interventions (BFIs) based on social learning principles have the strongest evidence base for the prevention and early intervention of behavioral disorders in children [4, 7]. However, the time and resource commitment involved in attending a BFI, which typically involves attendance across many weeks in either an individual or group format, is a barrier to many parents accessing such programs [8]. Moreover, for parents who want practical
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advice on how to tackle a specific developmental issue or problem (e.g., disobedience, tantrums, sleeping or mealtime problems), such an intensive program is not required to overcome the management difficulties they are experiencing with their child. According to the principal of minimal sufficiency, parents differ according to the strength of intervention they require to enable them to independently manage a problem [9]. The Triple P: Positive Parenting Program incorporates the principal of minimal sufficiency within its multi-level system of intervention [9]. The population approach taken by Triple P argues that brief, targeted support for parents with low to moderate levels of need is required to prevent the development of more significant problems. Thus, Triple P comprises a tiered system of support that increases in intensity from a universal communication strategy (Level 1), to light touch, low-intensity interventions involving seminars or brief targeted individual or group sessions (Levels 2 and 3), to more intensive small group and individual therapy for parents of children with a broad range of behavior problems and other family risk factors (Levels 4 and 5). The intervention model at Level 3 within the Triple P system originally evolved as three to four 20-minute individual family consultations designed to be delivered by primary care practitioners (e.g., nurses, general practitioners, teachers, early childhood educators). Participation in this intervention has been found to be associated with lower levels of targeted child behavior problems and inappropriate discipline practices, and greater parenting confidence [10, 11], although one more recent small-scale trial with school-aged children found no significant effects of this intervention when compared to care as usual parenting support provided by child health nurses [12]. Recently, a new topic-specific discussion group format has been added to the menu of delivery options for parents and practitioners using Triple P. Like the other interventions at Levels 2 and 3 in the model, the discussion groups are a preventatively-oriented intervention targeted at parents who report discrete child behavior problems that are not complicated by other major behavior management or family problems. However, compared to the individuallydelivered version of Level 3, the discussion group format has benefits for time- and cost-efficiency as it can be delivered to a greater number of parents at once (up to 15 parents). To date, there have been four randomized controlled trials of topic-specific discussion groups in samples of parents with preschool children, including ‘Hassle-Free Shopping’ [13], ‘Hassle-Free Mealtimes’ [14] and ‘Dealing with Disobedience’ [15, 16]. In each of these trials, significant intervention effects for increased parenting confidence and reductions in disruptive behavior problems [13, 15, 16] or specific problematic child behavior [14] were
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maintained at 6-month follow-up. Three of these trials reported intervention effects for ineffective parenting practices [13, 15, 16], while in the Hassle-Free Mealtime study, long-term intervention effects were obtained for mealtime parenting strategies, but not for general parenting practices [14]. While two trials have reported promising effects for parents who participated in the Dealing with Disobedience discussion group, the findings may be partly attributable to the two telephone support sessions that were offered following discussion group participation. Follow-up telephone consultations are often integrated into parenting and other psychosocial interventions as a means of supporting implementation of strategies and assisting with maintenance of treatment effects. However, very few studies have tested whether such support is necessary. Within the literature on self-directed parenting interventions, therapist support has been found to be associated with greater reductions in child behaviour problems immediately post-intervention as well as higher levels of intervention satisfaction compared to a standalone self-directed program [17–19]. In comparison, a smaller-scale study that compared outcomes for parents who did and did not receive follow up telephone support following a 4-session group parenting intervention found that the telephone sessions produced no additional treatment benefits [20]. The interventions tested in these trials were more intensive and longer-term parenting programs carried out over a number of weeks. Drawing on the principle of minimal sufficiency whereby a brief parenting intervention requires minimal therapeutic input and minimal time commitment from parents, this study extends on the previous trials of the Dealing with Disobedience discussion group [15, 16] by examining the effect of the Dealing with Disobedience discussion group delivered alone without telephone support, on child and parent outcomes. Thus, the study provides a preliminary test of whether telephone support is necessary for brief, low intensity forms of parenting intervention. Prior research suggests that parenting interventions afford additional benefits for parents beyond improvements in parenting and child behaviour, particularly related to reductions in parental distress and conflict over childrearing [21, 22]. Whether brief and targeted parenting support also has the potential to influence parents’ wellbeing and relationship has not been routinely examined in previous trials of these interventions, and when it has there have been mixed results. In previous trials of brief Triple P interventions that have assessed parental psychosocial outcomes, two found reductions in parental distress [10, 16], while a third found no significant effects for either parental distress or inter-parental conflict [13]. Thus, the present study expands on this previous research by examining the effectiveness of the dealing with disobedience
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discussion group for improving parental wellbeing and reducing inter-parental conflict about childrearing. Specifically, it was predicted that, compared to a waitlist control group, parents in the intervention condition would report significant reductions at post-intervention in (1) disruptive child behavior problems; (2) inappropriate and ineffective parenting practices; and (3) conflict with their partners over discipline and child-rearing. In addition, it was hypothesised that parents in the intervention condition would report significantly greater improvements at postintervention in (4) their confidence in managing their child’s behavior; and (5) their own wellbeing. Finally, it was hypothesised that (6) intervention gains shown by parents in the intervention condition would be maintained at 6-month follow up.
disobedient behaviour (n = 7), child outside the target age range (n = 6), the parent couldn’t commit to the requirements of the study (n = 5) and the parent was already receiving assistance for their child’s behaviour (n = 3). Figure 1 displays participant flow through the study. Measures Family Background Information Demographic information collected at pre-intervention included questions about parent and children’s gender and age, parental marital status, employment details and education, and family composition and financial status. Child Behavior
Method Participants and Screening Participants were 85 parents with children aged between 3 and 5 years (M = 3.62 years, SD = 0.68) who were concerned about the disobedient or noncompliant behavior of their child. Families were recruited from two locations: Auckland, New Zealand (N = 63) and Brisbane, Australia (N = 24). Parents were mostly mothers (94 %), and ranged in age from 20 to 47 years (M = 37.33 years, SD = 5.08). Parents were generally well-educated, with 70 % of parents having completed a university degree. Around two-thirds (65 %) of the target children were male, and most came from Australian or New Zealand European backgrounds (79 %). Most children resided with two biological parents (82 %), with 18 % of children living in single parent households. Table 1 displays demographic information for each condition. Participants were recruited via community and media outreach or through referral from schools or community agencies in Auckland and Brisbane. Parents who registered their interest for the study participated in a telephone screening interview to assess eligibility. Eligibility criteria were assessed via parent report and included: (a) child aged between 3 and 5 years; (b) parent report of concerns about that child’s disobedient behavior (assessed by the question ‘‘are you concerned about dealing with the disobedience of your child?’’); (c) parent was not receiving services for their child’s behavior problems or for their own psychological difficulties; and (d) the child did not have a developmental disability. Of the 126 parents who were screened, 25 did not meet the eligibility criteria and a further 16 declined to participate, leaving 85 parents who completed the pre-intervention assessment and were randomized to condition. The most common reasons for exclusion were the parent not being concerned about
Parents completed the Eyberg Child Behavior Inventory [ECBI; 23] at each assessment point. The ECBI comprises a list of 36 problem behaviors and parents are asked to rate the frequency of their occurrence on a 7-point scale ranging from 1 (never) to 7 (always) (the Intensity scale), as well as to indicate whether they viewed that behavior as a problem or not (i.e., the Problem scale). The Intensity scale was used in the present study, which had a total possible score of 252. It had good internal consistency in this sample (a = .88) and has been shown to discriminate between children with and without disruptive behavior problems [23]. Parenting and Parenting Confidence Inappropriate discipline practices were measured using the 30-item Parenting Scale [PS; 24]. Each item contains a less effective and a more effective anchor, and parents rate on a 7-point scale the extent to which each end is typical of their disciplinary response. Scores on the PS are summed to yield three subscales; Laxness (total possible score = 77), Overreactivity (total possible score = 70), and Verbosity (total possible score = 49), with higher scores indicating greater use of ineffective parenting strategies. Each of these scales had adequate internal consistency in the current sample (a = .87, .80 and .62, respectively) and have been shown to have good test–retest reliability [r = .83, .82 and .79, respectively; 24]. The scales have also been shown to discriminate between clinic and nonclinic mothers, and to be significantly associated with observed parenting behavior [24]. The Parenting Task Checklist [PTC; 25] contains 28 items and was used to assess parents’ task-specific self-efficacy across two domains; confidence in managing difficult child behaviors like whining, interrupting, and temper tantrums (Behavioral Self-Efficacy) and confidence in managing challenging behavior in different settings, such as out shopping and going to the doctor (Setting Self-Efficacy).
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Child Psychiatry Hum Dev Table 1 Summary of participant demographic characteristics Intervention (n = 45) M
Waitlist (n = 40) SD
M
SD
Child age
3.52
0.66
3.73
Parent age
36.78
5.53
37.95
4.51
1.13
0.87
0.90
0.55
Number of siblings at home
N (%)
N (%)
Male
29 (64)
26 (65)
Female
16 (36)
14 (35)
Mother
41 (91)
39 (98)
Father
4 (9)
1 (2)
0.72
Child gender
Parent relationship to child
Child ethnic/cultural background Australian or New Zealand European
36 (80)
31 (78)
Other
6 (13)
5 (13)
Did not disclose
3 (7)
4 (10)
36 (9) 9 (20)
34 (85) 6 (15)
Family composition Two-parent biological or adoptive One-parent biological or adoptive Annual family income \$40,000
4 (9)
5 (13)
$40,000 to $70,000
12 (27)
4 (10)
[$70,000
26 (58)
25 (63)
3 (7)
6 (15)
Did not know or wish to disclose Parent education High school
4 (9)
6 (15)
Vocational training apprenticeship or diploma
8 (18)
3 (8)
University degree
32 (71)
27 (68)
Did not disclose
1 (2)
4 (10)
Auckland, New Zealand
32 (71)
31 (78)
Brisbane, Australia
13 (29)
9 (23)
Intervention site
Parents are instructed to rate their level of confidence for each item on a scale from 0 (certain I can’t do it) to 100 (certain I can do it). Subscale scores are derived by averaging parents’ responses on the 14 items on each subscale. Both the Behavioral Self-Efficacy and Setting Self-Efficacy scales had excellent internal consistency in this sample (a = .96 and .86, respectively), and have been shown to discriminate between clinic and community mothers [25]. Parental Adjustment and Relationship Functioning The Depression Anxiety Stress Scales [DASS; 26] is a 21-item questionnaire that assesses symptoms of depression, anxiety and stress in adults on a 4-point scale from 0 (did not apply to me at all) to 3 (applied to me very much or most of the
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time). The total score on this scale possessed good internal consistency in this sample (a = .86), and has been found to have good convergent and discriminant validity [27]. The total score was derived by summing all of the items on the scale and multiplying by 2 to obtain a full-scale score comparable to the full 42-item version of the DASS. Thus, the total possible score on the DASS was 126. Parents who were married or in a cohabiting relationship completed the Parent Problem Checklist [PPC; 28] and the Relationship Quality Inventory [RQI; 29]. The PPC contains 16 items covering the extent to which parents disagree over rules and discipline, engage in open conflict over child-rearing issues, and undermine each other’s relationship with their children. Parents were asked to indicate the extent to which each item had been a problem on a 7-point
Child Psychiatry Hum Dev Fig. 1 Participant flow through the study
Enrollment
Assessed for eligibility (n=126)
Excluded (n=41) Did not meet eligbility criteria (n=25) Declined to participate (n=16)
Allocation
Randomized (n=85)
Allocated to intervention group (n=45) Received allocated intervention (n=41) Did not receive allocated intervention (n=4)
Allocated to waitlist control group (n=40)
Follow-Up Lost to follow-up – did not complete postintervention assessment (n=12)
Lost to follow-up – did not complete postintervention assessment (n=2)
Lost to follow-up – did not complete 6-month follow up assessment (n=4)
scale from 1 (not at all) to 7 (very much) (a = .90). The responses were summed for a total possible score of 112. The RQI assessed overall relationship satisfaction. The first five items are rated on a 7-point scale from 1 (very strongly disagree) to 7 (very strongly agree), while the final item, which assessed global relationship satisfaction, was rated on a 10-point scale from 1 (unhappy) to 10 (perfectly happy). The responses are then summed for total score out of 45. The RQI had excellent internal consistency in this sample, a = .96. Intervention Satisfaction After the discussion group, parents completed a 13-item Client Satisfaction Questionnaire [CSQ; 30]. Items were rated on a 7-point scale with higher scores reflecting more satisfaction with the discussion group. The questionnaire contained items related to the quality of the service provided; how well the program met the parent’s and child’s needs and decreased the child’s problem behaviors; and whether the parent would recommend the program to others. Scores range from 13 to 91. The internal consistency of the CSQ was a = .95 in the present sample. Design and Procedure The study was a 2 (condition: intervention vs. waitlist control) 9 3 (time: pre-intervention, post-intervention, 6-month follow up) randomized controlled trial. Ethical approval was obtained from the Human Research Ethics
committees of both universities and informed parental consent was obtained. Once deemed eligible for participation, parents were either emailed a link to complete the pre-intervention assessment (T1) and informed consent process online or were posted these in the mail to complete in hard copy. Randomization was conducted after completion of T1 assessment using a list of computer-generated random numbers. A discussion group was scheduled once a minimum of five parents had completed their T1 and had been assigned to the intervention condition. For parents assigned to the intervention condition, there was an average delay of 20.72 days (SD = 16.15) between completion of T1 and attendance at a group. Intervention parents completed their post-intervention assessment (T2) 4 weeks after they attended the Dealing with Disobedience discussion group. Waitlist control parents completed T2 approximately 6–8 weeks after their T1 assessment; this time lapse allowed for the time it would take for enough participants to be allocated to the intervention condition to form a discussion group (estimated at 2–3 weeks) and for the 4-week post-intervention assessment period for the intervention condition. Intervention parents completed a follow-up assessment 6 months after their T2 assessment. Intervention: Dealing with Disobedience Discussion Group [31] The intervention was a brief and preventively-focused one-off, 2-h discussion group designed for parents seeking specific advice about managing disobedient and
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noncompliant behavior in their preschool-aged child. Children did not attend the session. The group was interactive and discussion-based meaning that parents were encouraged to share their own experiences with disobedient behaviour and participated in a mix of group and individual exercises that helped them apply the ideas and strategies presented to their own situation. A PowerPoint presentation, with embedded video clips showing demonstrations of strategy implementation, was used to aid the facilitator. Parents were taught about reasons for disobedience, including the role of parent behavior in reinforcing noncompliant behavior, the use of positive praise and attention to motivate children to show desirable behavior, and the use of consistent, assertive discipline techniques to manage disobedient behavior and promote compliance. The strategies presented in the group were incorporated into a parenting plan checklist that parents were encouraged to use at home to support strategy implementation. Parents received a workbook that contained the content and exercises covered during the group, as well as a parent tip sheet on managing disobedient behavior to reinforce the material presented during the group and for use at home with partners who did not attend. The groups were facilitated by a registered psychologist trained and accredited through competency-based assessment to deliver Triple P discussion groups. The groups were run according to a standardised manual and intervention fidelity was monitored through the completion of session content checklists. Twelve discussion groups were run with between 4 and 9 parents in each group (M = 6.00, SD = 1.60). While both parents were encouraged to attend the discussion group, only 1 parent was required to complete assessments. In the majority of cases (94 %), this was the mother. Statistical Analyses An intent-to-treat approach was used for all analyses, with the Expectation–Maximization (EM) method used to estimate missing data [32]. Independent groups t tests for continuous variables and Chi square tests for categorical variables on all sociodemographic variables and baseline scores on outcome variables were conducted first to check for adequate randomization and to ensure there were no differences in participant characteristics based on intervention site or attrition status. To evaluate the short-term effects of the intervention, differences between the intervention and waitlist control groups were examined using a series of two-group univariate and multivariate analyses of covariance (ANCOVAs and MANCOVAs) with T2 scores as dependent variables and
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T1 data as covariates. MANCOVAs were conducted on sets of conceptually-related dependent variables: parenting (PS Laxness, Over-reactivity and Hostility scales), parenting confidence (PTC Behavior Self-efficacy, Setting Self-efficacy scales) and parental relationship functioning (PPC and RQI), while ANCOVAs were conducted on the ECBI Intensity scale and the DASS total score. Where multivariate effects were found, univariate F values were examined to determine which variables contributed to the multivariate effect. Effect sizes (Cohen’s d) were calculated to evaluate the level of clinically significant change from T1 to T2. Effect sizes were interpreted as small (d = 0.20), medium (d = 0.50) or large (d = 0.80) [33]. For those measures showing statistically significant change at T2, clinical significance of change was examined using two methods: Chi square analyses of the proportion of participants moving from the clinically elevated to non-clinical range from T1 to T2, and Chi square analyses of the extent to which improvements were reliable or unlikely to be due to chance (i.e., through calculation of a Reliable Change Index [34]). As there was no comparison group at 6-month followup, maintenance of intervention effects was analyzed by a series of multivariate and univariate repeated measures analyses of variance (MANOVAs and ANOVAs) to assess gains from T1 to T3 in the intervention group. An alpha level of .05 was used for all statistical tests as all tests were predicted a priori.
Results Preliminary Analyses There were minimal missing data at each time point (\5 %). Missing values analyses using Little’s criterion [35] indicated that data were missing completely at random [v2 (3313) = 2470.38, p = 1.00] thus the EM method was used to estimate missing data. Independent groups t tests and Chi square analyses on participant demographics and baseline scores revealed that the waitlist control group (M = 3.30, SD = 1.03) had significantly higher T1 scores on the PS Laxness scale than the intervention group [M = 2.78, SD = 0.88; t(83) = 2.51, p = .014]. In addition, participants from Auckland (M = 3.18, SD = 1.00) had higher scores on the PS Laxness scale than those from Brisbane [M = 2.57, SD = 0.78; t(83) = 2.62, p = .011]. There were no other significant differences in demographic characteristics or baseline scores between intervention groups, trial sites or between non-completers and completers (see Fig. 1 for attrition rates at post-intervention and follow up).
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Short-Term Intervention Effects T1 and T2 means and SDs for each condition, along with univariate F values for the results of group analyses and effect sizes are presented in Table 2. There was a significant intervention effect on the ECBI Intensity scale, with parents in the intervention group reporting fewer disruptive behavior problems at T2 than waitlist parents. The effect size for disruptive behavior was large. In addition, there was a multivariate intervention effect on the PS for parenting [F(3, 78) = 3.96, p = .011], with the intervention group showing greater reductions in the use of ineffective discipline practices than the control group on all three scales of the PS at T2. The multivariate intervention effect for parenting confidence on the PTC was also significant, F(2, 80) = 5.10, p = .008. Intervention parents displayed greater improvement at T2 compared to waitlist parents in their confidence in managing different difficult child behaviors (PTC Behavior) and managing their child’s behavior across multiple setting (PTC Setting). All of these had effect sizes in the medium range, with the exception of PTC setting, which fell into the upper end of the small effect range. There were, however, no significant intervention effects in parental adjustment (as measured by the DASS) nor in parental relationship quality [as measured by the PPC and RQI; multivariate F(2, 66) \ 1.00, p = .955].
measure’s published clinical cut-off scores, which are listed in Table 3) to the non-clinical range on the ECBI and all three PS scales. In addition, the proportion of intervention parents who showed reliable improvements was greater than the proportion of waitlist parents on the ECBI, the PS Over-reactivity and Verbosity scales, and the PTC Setting scale (with a trend towards greater reliable improvement on the PTC Behavior scale). Maintenance Intervention Effects Table 4 presents T1 and T3 means and SDs for the intervention condition, along with univariate F values and effect sizes for the results of repeated measures analyses. The intervention group showed significant reductions from T1 to T3 in child behavior, the use of ineffective discipline practices [multivariate F(3, 42) = 16.73, p \ .001], and interparental conflict over parenting [multivariate F(2, 35) = 7.67, p = .002], and significant improvements in parenting confidence [multivariate F(2, 43) = 36.97, p \ .001] and parental wellbeing. The child behavior effect size was in the large range and all of the parent-related variable effect sizes were either in the large or medium range. There was no significant improvement in intervention parents’ general couple relationship quality (as measured by the RQI). Intervention Satisfaction
Clinical Significance of Change Table 3 displays descriptive statistics and v2 values for group comparisons on measures of clinical and reliable change from T1 to T2. Compared to waitlist parents, a greater proportion of intervention parents reported shifts from the clinically elevated (defined as scoring above each
The CSQ was completed by only 25 parents who attended the discussion group. These parents reported being only somewhat satisfied with the discussion group, M = 60.92, SD = 11.41. When asked specifically about the quality of the service they received, 84 % of parents rated the discussion group as ‘good’ or better. Sixty-eight percent of
Table 2 Short-term intervention effects Intervention (n = 45)
Waitlist (n = 40)
Univariate F for group
Pre M (SD)
Post M (SD)
Pre M (SD)
Post M (SD)
139.13 (27.18)
p
Effect size d
115.10 (24.44)
136.96 (23.17)
128.83 (25.13)
9.21
\.001
PS Laxness
2.78 (0.877)
2.40 (0.73)
3.30 (1.03)
3.13 (1.11)
6.82
.011
0.57
PS Over-reactivity
3.13 (0.80)
2.72 (0.70)
3.25 (0.83)
3.17 (0.79)
5.81
.018
0.52
ECBI Intensity
PS Verbosity
0.86
3.66 (0.88)
3.04 (0.78)
4.08 (0.80)
3.81 (0.87)
10.08
.002
0.69
ptc Setting
79.61 (12.45)
87.10 (9.45)
81.96 (11.18)
84.51 (11.99)
4.35
.040
0.45
PTC Behavior
63.65 (20.28)
80.45 (14.82)
64.28 (21.43)
71.25 (21.83)
10.16
.002
0.69
DASS Total
16.48 (11.83)
14.33 (12.45)
19.45 (13.10)
14.12 (10.83)
0.50
.483
0.15
PPC Extenta
36.34 (16.91)
32.54 (14.28)
34.70 (15.72)
32.13 (15.46)
0.01
.921
0.17
RQIa
35.14 (7.70)
35.80 (6.55)
36.28 (7.80)
36.76 (7.21)
0.06
.811
0.06
ECBI Eyberg Child Behavior Inventory, PS Parenting Scale, PTC Parenting Tasks Checklist, DASS Depression Anxiety Stress Scales, PPC Parent Problem Checklist, RQI Relationship Quality Inventory a
Based on N = 37 for the intervention group and N = 34 for the waitlist group
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Child Psychiatry Hum Dev Table 3 Clinical and reliable change at post-intervention Measure (clinical cutoff)
Intervention n/n (%)
Waitlist n/n (%)
Clinically improved
Reliably improved
Clinically improved
Clinical change v2
Reliably improved
Reliable change p
v2
p
ECBI Intensity (C131)
22/28 (79)
25/45 (56)
7/25 (28)
9/40 (23)
13.63 \.001
9.64
.002
PS Laxness (C3.2)
10/13 (77)
8/45 (18)
2/17 (12)
3/40 (8)
13.03 \.001
1.99
.159
PS Over-reactivity (C3.1) PS Verbosity (C4.1)
15/24 (63) 13/24 (54)
9/45 (20) 7/45 (16)
7/26 (27) 5/26 (19)
2/40 (5) 1/40 (3)
.011 .010
4.23 4.23
.040 .040
PTC Setting (B79)
11/18 (61)
14/45 (31)
8/17 (47)
4/40 (10)
\1
.404
5.65
.017
PTC Behavior (B68)
15/20 (75)
25/45 (56)
14/23 (61)
14/40 (35)
\1
.324
3.61
.058
6.41 6.61
Clinically improved, moved from clinical into nonclinical range; Reliably improved, Reliable Change Index [ 1.96; ECBI, Eyberg Child Behavior Inventory; PS, Parenting Scale; PTC, Parenting Tasks Checklist
Table 4 Maintenance effects for the intervention group (n = 45)
Pre M (SD)
Post M (SD)
Follow-up M (SD)
F
p
139.13 (27.18)
Effect size d
115.10 (24.44)
103.80 (20.08)
56.90
\.001
1.14
PS Laxness
2.78 (0.877)
2.40 (0.73)
2.22 (0.65)
22.59
\.001
0.74
PS Over-reactivity
3.13 (0.80)
2.72 (0.70)
2.59 (0.70)
21.14
\.001
0.69
PS Verbosity
3.66 (0.88)
3.04 (0.78)
2.84 (0.66)
50.84
\.001
1.09
PTC Setting
79.61 (12.45)
87.10 (9.45)
92.71 (5.99)
71.89
\.001
-1.51
PTC Behavior
63.65 (20.28)
80.45 (14.82)
86.27 (9.99)
60.83
\.001
-1.28
DASS Total
16.48 (11.83)
14.33 (12.45)
8.99 (9.28)
15.78
\.001
0.60
PPC Extenta
36.34 (16.91)
32.54 (14.28)
27.31 (13.85)
11.01
.002
0.56
RQIa
35.14 (7.70)
35.80 (6.55)
35.40 (6.45)
0.02
.892
-0.04
ECBI Intensity
ECBI Eyberg Child Behavior Inventory, PS Parenting Scale, PTC Parenting Tasks Checklist, DASS Depression Anxiety Stress Scales, PPC Parent Problem Checklist, RQI Relationship Quality Inventory a
Based on N = 37
these parents indicated they were at least ‘satisfied’ with the program overall, compared to 32 % who were ‘dissatisfied’ or ‘neutral’ about their level of satisfaction with the program (none of the parents indicated they were ‘very dissatisfied’). Importantly for examining satisfaction with this reduced form of intervention, when asked about their level of satisfaction about the amount of help they received, 52 % of parents were ‘dissatisfied’ or ‘neutral’, while 48 % were ‘satisfied’ to ‘very satisfied’.
Discussion This study examined the efficacy of the Dealing with Disobedience discussion group, a Level 3 intervention within the multi-level Triple P system consisting of a single 2-h group session. This study built on previous research [14, 15] by providing a preliminary test of the effects of the discussion group as a standalone intervention without any follow-up telephone calls, as well as testing for improvements in parental wellbeing and
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reduction in inter-parental conflict about childrearing. Significant intervention effects were found for disruptive child behavior, ineffective parenting practices, parenting confidence, as well as clinically significant improvements on child behavior and parenting. Importantly, all of these effects were maintained at 6-month follow up. However, no group differences were found for parental wellbeing, inter-parental conflict and general relationship quality, although there were improvements in the intervention condition in parental wellbeing and inter-parental conflict at the 6-month follow-up. A concern about brief interventions is that the effects often diminish over time [36], yet in the present study the effects of the discussion group on child behavior, parenting and parenting confidence were maintained at 6-month follow up. It is likely that parents’ confidence grew as they reduced their ineffective parenting and saw improvements in their child’s behavior. Further, the increase in confidence could encourage parents to continue to improve their parenting and use fewer ineffective practices over time.
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There were no group effects for parental wellbeing, inter-parental conflict or general relationship functioning. For parental wellbeing and inter-parental conflict, it may be the case that the benefits of participating in the discussion groups may not be as evident until more time has passed, as seen by the medium size effects at follow up. Indeed, when examining the change in scores, greater change occurred between T2 and T3 as compared to T1 and T2 (5.34 vs. 2.15 for parental wellbeing and 5.23 vs. 3.80 for interparent conflict). It makes sense that the benefits to parental wellbeing and inter-parent conflict would occur after there has been ongoing improvements in child behavior, parenting practices and parent confidence. While these findings are new, whether these improvements are above and beyond what would have been demonstrated by the control group if they had had a longer waitlist period and completed a parallel follow-up assessment is a question for future research. For general relationship quality, it is likely that the lack of improvement reflected that the families were well functioning at baseline creating a ceiling, as seen by the relatively high scores at T1. These findings support and extend findings from past studies on discussion groups [13–16], particularly the studies on the same Dealing with Disobedience discussion group. In those two trials, the discussion group was followed by two telephone calls to parents to offer support to implement the strategies presented in the group. In both the previous trials with follow-up phone calls and the current without, significant intervention effects were found for disruptive child behavior, ineffective parenting practices and parent confidence that were maintained at follow up. Although recruitment was focused on children with mild levels of disobedience in the three papers targeted at disruptive behavior problems [13, 15, 16], the samples reported a high level of problem behavior, and the brief intervention was still effective. Bearing in mind that a direct comparison of the effects of the discussion group offered with and without telephone support is required to better test the need for follow-up support, the similar findings between the trials of the Dealing with Disobedience discussion group on child behavior and parenting practices are important for four reasons. First, it gives parents the option of participating in the discussion group with or without the follow-up telephone calls. For parents who choose not to have those calls, the program will still meet their needs. Second, it enables the practitioner to provide an equally effective program that requires fewer staffing resources. Third, having a shorter program with similar improvements that are maintained over time is consistent with the principal of minimal sufficiency that parents have access to the level of intervention intensity and duration they require to be self-sufficient in their management of child behavior problems and
parenting challenges [9]. Indeed, the finding that statistically and clinically significant reductions were seen on the ECBI, which assesses a range of disruptive child behaviors other than non-compliance (e.g., aggression, destructiveness) suggests that parents were able to generalize the strategies they learned to manage disobedience to deal with other problem behaviors. Fourth, it indicates that more intensive interventions are not always needed for parents of children with moderate to high levels of behavior problems [15]. Thus, this research along with other papers reporting the benefits of brief parenting interventions, help to challenge traditional notions regarding correct ‘dosage’ of a parenting intervention to enable parents to independently solve problems and generalize to other behavior problems. Despite the strong effects for this intervention, it should be noted that the level of parental satisfaction with this version of the discussion group was not as high as previous trials of the discussion groups. Satisfaction ratings on the same measure were approximately ten points and almost a full standard deviation lower than in the study by Morawska et al. [15] that included telephone calls (M = 60.92 vs. M = 71.28). While this version of the discussion group was effective, the loss of the follow-up call may have resulted in parents being less satisfied with the intervention and particularly with the help that they received. This lack of satisfaction also appears to be reflected by the higher attrition rate when compared to the study by Morawska et al. [15]. It is possible that the follow-up calls act as an important engagement strategy for parents, which in the context of service delivery would be important for increasing the likelihood that parents return to a service if they needed help in the future. There are a number of limitations of the present study that should be noted. First, all of the measures are parentreport; no independent measures of either child behavior or parenting practices were used. Future research would benefit from the inclusion of observational measures or collateral reports from childcare educators or teachers to strengthen conclusions about the effectiveness of the intervention and allow for alternative explanations of the findings. Secondly, despite the ethnic and economic diversity of the communities from which the participants were recruited, those parents that participated were relatively homogenous, limiting the generalizability of the study. Importantly, however, a recent study of the same discussion group intervention with two phone calls reported similar positive intervention effects for low income Spanish Speaking parents in Panama [16]. Future research should aim to increase the diversity of sample to ensure that these findings are generalizable to a wider population of parents. Thirdly, given the strengthening evidence base for the brief discussion group format, future research should move beyond waitlist control conditions. A stronger
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test of the value of brief parenting interventions would be provided through the use of an alternative intervention as the comparator, particularly an existing and more intensive group parenting program. Finally, the groups were delivered in a university setting and not in a community setting where the discussion groups are designed to be delivered. Effectiveness trials are needed to ensure that the current evidence for the efficacy of the discussion groups generalizes to less-controlled community or clinic settings. A step in that direction comes from a large-scale quasi-experimental evaluation of the Triple P system as a public health intervention in two counties in Central Ireland [37] where discussion group interventions were implemented by regular service providers. Similar positive intervention effects for the frequency of disruptive behavior were achieved suggesting that the intervention can be successfully deployed as part of a comprehensive populationbased approach to promoting better parenting. Implications Behavioral family interventions (BFIs) have a strong evidence base for the prevention and intervention efforts to address behavioral problems in children [4, 7]. However, these types of programs often require a large time investment for parents, making them non-feasible at times, as well as a large commitment for practitioners and agencies, reducing the number of parents that can be provided services. The current intervention has a reduced time investment for parents while still being effective in increasing parenting skills and reducing child behavior problems. In addition, the group format of the program allows more parents to participate as compared to a one-to-one program. Combining parents who are able to be supported in a group format will also free up practitioners to deliver more intensive programs to families with more complex needs, helping to maximise the population impact of BFIs. In addition, this discussion group format can be delivered across a number of settings, such as by practitioners in community, educational, health care or workplace settings which can increase the likelihood that parents will receive the support that they need [38]. Making brief and effective parenting support easily accessible and highly visible in the community will help to reduce the stigma of accessing parenting support and may ultimately reduce rates of behavior problems and parenting difficulties at a population level. Summary The present study was a randomized controlled trial evaluating the efficacy of a brief and preventatively-focused parenting discussion group for dealing with disobedient
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behavior in preschool-aged children. Consistent with previous research on this intervention format, parents who participated in the discussion group reported sustained improvements of medium to large effect sizes in disruptive child behavior, ineffective parenting practices and parenting confidence, as well as clinically significant improvements in child behavior and parenting. Importantly, these effects were found without the inclusion of follow-up telephone support, which was incorporated into the delivery model of previous trials of the disobedience discussion group. The efficacy and brevity of this intervention should facilitate the ease at which it can be embedded into existing parenting and family support services, helping improve the accessibility of evidencebased parenting programs in the community. Acknowledgments The authors wish to thank Kirsten Smeets from the University of Auckland and Amy Little from the University of Queensland for their assistance with data collection on this trial. Conflict of interest Dr Dittman is a Triple P trainer and Professor Sanders is the founder and co-author of the variant of Triple P tested in this study. The Triple P—Positive Parenting Program is owned by The University of Queensland (UQ). The University through its main technology transfer company, UniQuest Pty Ltd, has licensed Triple P International Pty Ltd to publish and disseminate the program worldwide. Royalties stemming from published Triple P resources are distributed to the Faculty of Health and Behavioural Sciences at UQ, Parenting and Family Support Centre, School of Psychology at UQ, and contributory authors. No author has any share or ownership in Triple P International Pty Ltd.
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