Joumal of Family Psychology 2014. Vol. 28. No. 2. 236-243

© 2014 American Psychological Association 0893-320O/14/$12.OO DOI: 10.1O37/a0035991

BRIEF REPORT

Predicting Success in an Online Parenting Intervention: The Role of Child, Parent, and Family Factors Cassandra K. Dittman

Susan P. Farruggia and Melanie L. Palmer

The University of Queensland

The University of Auckland

Matthew R. Sanders

Louise J. Keown

The University of Queensland and The University of Auckland

The University of Auckland

The present study involved an examination of the extent to which a wide range of child, parent, family, and program-related factors predicted child behavior and parenting outcomes after participation in an 8-session online version of the Triple P-Positive Parenting Program. Participants were mothers and fathers of 97 children aged between 3 and 8 years displaying elevated levels of disruptive behavior problems. For both mothers and fathers, poorer child behavior outcomes at postintervention were predicted by the number of sessions of the intervention completed by the family. For mothers, postintervention child behavior was also predicted by the quality of the mother-child relationship at baseline; for fathers, baseline child behavior severity was an additional predictor. Mothers' postintervention ineffective parenting was predicted by session completion and preintervention levels of ineffective parenting, whereas the only predictor of fathers' ineffective parenting at postintervention was preintervention levels of ineffective parenting. Socioeconomic risk, parental adjustment, and father participation in the intervention were not significant predictors of mother- or father-reported treatment outcomes. The implications of the findings for the provision of online parenting support are discussed. Keywords: behavior problems, online interventions, parent training, predictors

There is clear evidence that parenting programs based on social teaming models should play a primary role in any large-scale approach aimed at optimizing child and adolescent wellbeing (Mercy & Saul, 2009). However, an ongoing challenge in maximizing the population-level benefits of evidence-based parenting support is parents' wilhngness to participate in a parenting program (Sanders, Markie-Dadds, Rinaldis, Firman, & Baig, 2007). Self-directed programs are one means of improving participation rates, and are considered a valuable altemative to practitionerdelivered programs. These programs preserve the privacy of par-

ents, reduce stigma associated with attending parenting services, and address logistical barriers (e.g., geographic or financial constraints, scheduling confiicts, long community waiting lists). Selfdirected parenting programs are also effective; a recent review found they produced treatment effects similar to practitionerdehvered support (O'Brien & Daley, 2011). Online parenting programs have very recently been added to the menu of self-directed delivery options. Two randomized, controlled trials indicate that these programs produce lasting improvements in child behavior and parenting skills and confidence when delivered with (Enebrink, Hogstrom, Forster, & Ghaderi, 2012) and without (Sanders, Baker, & Tumer, 2012) professional contact. In addition, a third controlled trial, from which the data for the present study were drawn, found that an 8-session online version of the Triple P-Positive Parenting Program was not inferior in its positive effects on child behavior and parenting in comparison with a bibliotherapy version (Sanders, Dittman, Farruggia, & Keown, in press). Triple P OnUne (TPOL) was associated with large intervention effects from pre- to postintervention on child behavior, parenting, parenting confidence, and parent-child relationship quality (d = LOO to á = 1.54); medium effects for reductions in risk of child maltreatment, interparental conflict, and parental stress (d = 0.49 to d = 0.66), and small intervention effects for reductions in parental depression (d = 0.27) and anxiety (d = 0.38).

This article was published Online First March 10, 2014. Cassandra K. Dittman, Parenting & Family Support Centre, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia; Susan P. Farruggia and Melanie L. Palmer, School of Learning, Development, and Professional Practice, The University of Auckland, Auckland, New Zealand; Matthew R. Sanders, Parenting & Family Support Centre, School of Psychology, The University of Queensland and School of Learning, Development, and Professional Practice, The University of Auckland; Louise J. Keown, School of Learning, Development, and Professional Practice, The University of Auckland. Correspondence conceming this article should be addressed to Cassandra K. Dittman, Parenting & Family Support Centre, School of Psychology, The University of Queensland, Brisbane QLD Australia 4072. E-mail; c.dittman @ uq.edu .au 236

PREDICTING ONLINE PARENTING INTERVENTION SUCCESS Despite their effectiveness, a concern commonly raised about self-directed programs is that they may not be effective for certain families, such as those from low socioeconomic backgrounds or with high levels of family or child dysfunction, because of a need for practitioner support to ensure skill acquisition and generalization and promote retention (O'Brien & Daley, 2011). However, research on the extent to which basehne child and family characteristics predict outcome after self-help parenting interventions is severely limited, and there is no research on predictors of outcome in online interventions. Meta-analyses of predictors of outcome in face-to-face parent training suggest that socioeconomic disadvantage, particularly low family income and parent education, is associated with both poorer parenting and child behavior outcomes (Lundahl, Risser, & Lovejoy, 2006; Reyno & McGrath, 2006), whereas matemal mental health and preintervention severity of child behavior have also been found to undermine positive changes in child behavior after intervention (Reyno & McGrath, 2006). In the few studies that have looked at this issue in self-directed programs, treatment outcome was not predicted by socioeconomic factors (Calam, Sanders, Miller, Sadhnani, & Carmont, 2008; Lavigne et al., 2008). Parental mental health difficulties and higher levels of dysfunctional parenting were found to be important for predicting poorer parenting outcomes in one study (Calam et al., 2008), whereas in a second study, matemal depression was not a significant predictor of child behavior outcomes (Lavigne et al., 2008). The present study explored the role of a wide range of factors in predicting levels of ineffective parenting and dismptive child behavior after participation in TPOL. We focused on the online program because it is the newest format of parenting programs, little is known about factors that moderate online effectiveness, and it has the most potential to reach vast numbers of parents, including those from vulnerable or high-risk circumstances. Five classes of factors were examined: child and family sociodemographic factors, severity of child behavior, parenting factors, parental adjustment, and program-related factors (e.g., program completion, father participation). Because of meta-analytic findings that fathers tend to make fewer changes compared with mothers in their parenting behavior following a parenting program (Lundahl, ToUefson, Risser, & Lovejoy, 2008), we conducted separate mother and father analyses to examine whether predictors are different according to parent gender.

Method Methodological details are provided in Sanders et al. (in press) but are summarized below. The study was approved by the University of Auckland's Ethics Review Board.

Participants Participants were New Zealand parents of 97 children (71% male) aged between 3 and 8 years (M = 5.63 years, SD = 1.65 years) with elevated levels of dismptive behavior problems (88% of the sample were in the clinical range on the Eyberg Child Behavior Inventory). Children largely came from New Zealand European backgrounds (92%), with representation from Maori (4%) and Pacific Islanders (4%). Most children (79%) lived with their two biological or adoptive parents, with smaller numbers

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living in sole parent (15%), and in step- or blended families (6%). Parents in one- and two-parent households were invited to participate, with both parents in two-parent households encouraged to take part. This resulted in 94 mothers and 75 fathers completing the baseline assessment; 2 mothers and 9 fathers declined participation in the study. The mother sample comprised entirely biological or adoptive mothers, whereas the father sample comprised 72 biological and three step-fathers. The mean age of mothers was 37.58 years {SD = 6.33 years), and the mean age of fathers was 39.44 years {SD = 6.67 years). Approximately half the sample was university educated (45% mothers, 50% fathers), and an additional quarter of parents had completed some form of postsecondary school education, including a trade or apprenticeship (7% mothers, 17% fathers) or vocational training certificate (20% mothers, 8% fathers). Half of families (52%) had a combined annual family income of over $NZ70,000 (approximately $US57,600) and 19% eamed less than $NZ40,000 per year (approximately $US32,900).'

Measures Family background information. Demographic information collected at preintervention included questions about parent and children's gender and age, parental marital status, employment details, education, family composition, and income. Child behavior. Parents completed the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), which required parents to rate the frequency of 36 problem behaviors on a 7-point scale (the Intensity scale, a = .86). Parenting. Parenting variables were ineffective discipline, parenting confidence, parent-child relationship quality, child maltreatment risk, and parental attributions regarding child misbehavior. Ineffective discipline was measured using total scores on the 30-item Parenting Scale (PS; Amold, O'Leary, Wolff, & Acker, 1993; oi = .85) in which parents rated on a 7-point scale the extent to which they engaged in a range of discipline responses. Parenting confidence was assessed using the Parenting Task Checklist (PTC; Sanders & Woolley, 2005; a = .93); the PTC measured parents' task-specific confidence in managing difficult child behaviors generally (e.g., temper tantmms) and in different settings (e.g., out shopping). Parents were instmcted 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). Parent-child relationship quality was assessed using 11 items (Metzler, Biglan, Ary, & Li, 1998; a = .83) on which parents rated agreement with positive and negative aspects of spending time with their child on a 7-point scale. Child maltreatment risk was assessed using the risk subscale of a brief version of the Child Abuse Potential Inventory (Brief CAP; Ondersma, Chaffin, MuUins, & LeBreton, 2005; a = .83). Parents indicated agreement or disagreement to 34 risk statements. Parental attributions regarding child misbehavior (Pidgeon & Sanders, 2004; a = .89) was assessed by asking parents to respond to six child behavior scenarios by indicating on a 6-point scale the degree to which they believed misbehavior was intentional, the child's fault, or attributable to something stable or intemal to the child. ' The median annual family income in New Zealand in 2010 was $64,272 (Statistics New Zealand, 2010).

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Parental adjustment. Parental adjustment variables were emotional adjustment, anger, and interparental conflict. Parental emotional adjustment was measured using total scores on the 21-item Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995; a = .92), which assessed symptoms of depression, anxiety, and stress on a 4-point scale. Parental anger was measured by the 50 items on the Parental Anger Inventory (PAI; Sedlar & Hansen, 2001a = .95) describing common child behavior and discipline issues and how angry the situation makes the parent on a 5-point scale. Interparental confiict (two-parent families only) was assessed by the Parent Problem Checklist (PPC; Dadds & Powell, 1991; a = .90), a 16-item scale covering the extent to which parents disagreed or engaged in open conflict over discipline and other child rearing issues on a 7-point scale. Program-related factors. Four program-related factors were also assessed; the number of sessions completed, father participation, Intemet confidence, and computer confidence. Number of sessions completed was of a total of 8 and reflected number of sessions completed by the family as reported by the Intemet program (i.e., not necessarily each member of two-parent fatnilies). All content within a module (i.e., exercises, video clips, and audio and written material) needed to have been viewed by the user for the Intemet program to consider a session completed. Father participation was measured by a dichotomous self-report variable on which parents indicated whether the online sessions were mostly or entirely completed by the mother (no/low father participation) versus sessions being mostly or entirely completed together with a partner or by the father alone (high/equal father participation). Intemet confidence and computer confidence were measured by two items in which parents indicated how confident they were using either the Intemet or computers in general on a 5-point scale from 1 (not at all confident) to 5 (totally confident).

Procedure Participants were recruited via cotnmunity and media outreach throughout New Zealand. Three hundred fifty parents from a mix of urban and rural locations responded and participated in a telephone screetiing interview designed to describe the study requirements and assess eligibility, which included report by the parent participating in the screening interview of elevated disruptive child behavior problems, based on their scores on a 15-item version of the ECBI (Metzler, Sanders, Rusby, & Crowley, 2012; see Sanders et al., in press for full details). Parents could not be in the process of receiving services, nor could the child have a developmental disability. Parents from 193 eligible families completed consent forms and baseline assessment, and were randomly allocated to receive TPOL (n = 97) or the Every Parent's workbook (n = 96). This study focused on the TPOL participants. Postintervention assessment was completed by parents 14 weeks after they were given access to TPOL. Except for the demographic items, all measures were completed at pre- (Tl) cind postintervention (T2).

Triple P Online TPOL (Tumer & Sanders, 2011) is an 8-session behavioral family intervention formatted for delivery over the Intemet. TPOL addresses identical content areas and parenting strategies as other Level 4 Triple P programs. Sessions 1 to 4 cover identical content

as the first four sessions of face-to-face versions of Triple P (i.e., principles of positive parenting, causes of child behavior problems, encouraging desirable behavior, teaching new skills and behaviors, and managing misbehavior). Parents are then taken through an example of applying positive parenting strategies to managing disobedience in Session 5, and Sessions 6 and 7 cover strategies for planning ahead for high-risk times. Session 8 covers strategies for maintaining change, encouraging confidence and building social skills in children. TPOL is designed to promote engagement and program compliance through user-friendly navigation, appealing graphics, video demonstrations of parenting skills, and "voxpops" from parents describing their experiences. Additional features include computer-assisted goal setting, probes and exercises to check mastery, and downloadable worksheets, tip sheets, and podcasts. The program provides parents with a customizable and printable notebook that automatically records parent's goals and exercise responses.

Results Data analyses were based on the 86 mothers and 61 fathers (from 89 families) who completed both the pre- and postintervention assessments, representing a retention rate of 91% for mothers and 80% for fathers. Except for mother scores on the Brief CAP, on which mothers who did not complete postintervention had significantly higher risk scores (M = 8.67; SD = 5.61) than mothers who did complete postintervention (M = 5.79; SD = 4.60), í(188) = .28, p = .024), there were no differences on demographics or baseline assessment scores between those who completed Tl and T2 and those who did not, nor were there significant differences between families who had fathers complete Tl and those that didn't. Table 1 shows descriptive statistics for all continuous variables. With regard to program completion, 45% of families completed all 8 sessions, 12% completed 6-7 sessions, 30% completed 3-5 sessions, 9% completed 1-2 sessions, and 3% did not complete any sessions. In 42% of families, the online

Table 1 Descriptive Statistics for Continuous Predictor and Criterion Variables Variable Predictor variables Parent age Child age ECBI PS total PTC behavior PTC setting P-C relationship Brief CAP Parent attributions DASS PAI PPC Intemet confidence Computer confidence Criterion variables T2 ECBI T2 PS Total

Mothers mean {SD)

Fathers mean {SD)

37.58 (6.33) 5.63 (1.65) 155.44 (20.64) 3.35 (0.56) 67.86(14.03) 79.20(10.23) 41.11(6.97) 5.13(4.01) 65.67(12.49) 19.86(14.35) 123.77 (29.69) 34.41 (14.00) 3.23 (0.69) 3.17(0.81)

39.44 (6.67) 5.63 (1.65) 140.53 (26.06) 3.10(0.60) 74.62(19.87) 84.43(11.46) 47.91 (8.21) 4.40 (4.57) 62.11(19.13) 14.10(15.36) 111.73(35.38) 32.02(13.75) 3.34 (0.79) 3.28 (0.88)

114.17(23.77) 2.50 (0.70)

117.33(27.43) 2.76 (0.69)

PREDICTING ONLINE PARENTING INTERVENTION SUCCESS

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Table 2 Bivariate Correlations Among Predictor and Criterion Measures for Mothers and Eathers Mothers (n = 86) Measure

Correlation with T2 ECBI

Predictor variables Parent education Family income Parent age Child age Child gender Child ethnicity ECBI PS total PTC behavior PTC setting P-C relationship Brief CAP Parent attributions DASS PAI PPC Sessions completed Father participation Intemet confidence Computer confidence

.13 .12 .09 .04 -.21 -.06 .27* .18 -.15 -.14 -.31" -.00 .07 -.02 .23* .12 -.33" .01 -.07 -.06

Note, P-C = PAI = " Only

Fathers (n = 61)

Correlation with T2 PS Total .04 .16 .14 .17 -.20

.05 .10 .52*** -.27* -.14 -.07

Correlation with T2 ECBI .06 -.28* .00 .21 .10

-.12 .46*" .20 -.07 -.06 -.03

.03

.50"*

.06 -.00 .25* .26* -.45*" -.25* -.08 -.01

.40"

.45"* .23 .29* -.43" -.15 .02 .02

Correlation with T2 PS Total -.07 -.18 -.14 .22 .17 -.20 .18 .58*** -.31* -.03 -.12 .30* .15 .33" .19 .11 -.22 -.16 -.05 -.07

ECBI = Eyberg Child Behavior Inventory; PS = Parenting Scale; PTC = Parenting Tasks Checklist; parent-child; CAP = Child Abuse Potential inventory; DASS = Depression Anxiety Stress Scales; Parental Anger Inventory; PPC = Parent Problem Checklist. completed by married or cohabiting parents, so based on « = 76 for mothers and n = 59 for fathers.

'p ***

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DITTMAN, FARRUGGIA, PALMER, SANDERS, AND KEOWN

evidence-based parenting support to fatnilies from a wide range of backgrounds and circumstances. The finding for mothers that perceived parent-child relationship quality predicted child outcomes more powerfully than preintervention child behavior is consistent with converging evidence from both longitudinal studies of typical development and randomized intervention trials linking lower levels of positive parentchild interactions to the development of conduct problems (Gardner, Hutchings, Bywater & Whitaker, 2010). Moreover, given evidence that change in positive parenting skill is a mediator of child outcomes in face-to-face delivery, future online trials could test whether improvements in parent-child relationship quality explain long-term child behavior outcomes (Gardner et al., 2010). Father participation was not a significant predictor of either matemal or patemal outcomes, suggesting that online parent training may produce benefits for families where fathers are unable or unwilling to participate. However, it should be noted that the measure of father participation assessed only direct participation in TPOL. Fathers who did not take part may have benefitted indirectly via parenting conversations with their partner or observational modeling of their partner's use of new strategies. Furthermore, based on findings from practitioner-delivered programs, father participation in online parent training may matter more for maintaining intervention effects, than for immediate program outcomes (Bagner & Eyberg, 2003). Nonetheless, the higher dropout of fathers compared with mothers from pre- to postintervention, alongside relatively low direct father participation in the online program, provides yet another example of the difficulties faced in engaging and retaining fathers in parent training programs, both in research and clinical settings (Phares, Fields, Kamboukos, & Lopez, 2005). Further research is needed, with larger samples of fathers, to clarify the impact of father involvement on the shortand long-term outcomes of parenting interventions, and to find effective strategies for increasing father engagement. These findings need to be considered in the context of the small sample size, especially of fathers, which precluded the use of multilevel modeling to statistically assess for differences between predictors for mothers and fathers. In addition, relative homogeneity in the characteristics of participating families, and the resulting limited statistical variability, may explain why demographic factors did not predict intervention outcomes. Although there was some diversity in the economic circumstances of the sample, it was limited in cultural and ethtiic diversity and mostly comprised well-educated parents. Moreover, parents self-referred firom the community rather than being clinic-referred, and children displayed clinically elevated but not formally diagnosed dismptive behavior problems. Thus, there is clearly a need for additional research that aims to identify predictors of treatment response to online parent training, particularly with samples of fatnilies experiencing higher levels of adversity and from diverse socioeconotnic and cultural circumstances. This line of research has realworld value as it will help guide clitiical decisions about providing adjunctive professional or peer support, especially given the finding reported here that program completion was a key factor in determining outcome. Indeed, using online technologies to deliver parenting support may be a particularly protnising avenue for engaging disadvantaged fatnilies who have traditionally low participation rates in face-to-face interventions. Rates of Intemet use, particularly on mobile devices, are increasing among individuals

from low-income, low-education, or minority backgrounds (Zickuhr & Smith, 2012), and consumer preference research suggests that the Intemet is a highly favored way of receiving parenting information by vulnerable and low-income parents (Love, Sanders, Metzler, Prinz, & Käst, 2013).

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Received October 1, 2012 Revision received April 9, 2013 Accepted November 27, 2013

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