J Primary Prevent (2015) 36:33–40 DOI 10.1007/s10935-014-0374-z

ORIGINAL PAPER

One-Year Follow-Up of Guided Self-Help for Parents of Preschool Children With Externalizing Behavior Elena Ise • Frauke Kierfeld • Manfred Do¨pfner

Published online: 21 October 2014  Springer Science+Business Media New York 2014

Abstract Self-help programs are an effective intervention for parents of children with externalizing behavior. A number of studies have shown that selfadministered parent training has positive short-term effects on a child’s behavior, but there is little research done on long-term outcomes. This paper reports results from a 1-year follow-up of a randomized controlled prevention trial of self-administered parent training with minimal therapist contact. In the initial prevention trial, we randomly assigned 48 preschool children with elevated levels of externalizing behavior to either a treatment group (TG) or a waitlist control group (WLC). The intervention consisted of written material and brief weekly telephone consultations. Thirty-six families (25 TG families, 11 WLC families) completed the self-help program. Twenty-five of these participated in a follow-up assessment 1 year after the intervention. There were no significant changes from post-test to follow-up on measures of child behavior (e.g., Attention-Deficit/Hyperactivity Disorder and Oppositional Defiant Disorder symptom rating scales) and parental mental health, indicating that gains achieved post-intervention were maintained for at least 1 year. Moreover, the percentage of children with substantial behavior problems was reduced from

E. Ise (&)  F. Kierfeld  M. Do¨pfner Department of Child and Adolescent Psychiatry and Psychotherapy, Medical Faculty, University of Cologne, Robert-Koch-Str. 10, 50931 Cologne, Germany e-mail: [email protected]

pre-intervention to follow-up. These findings provide evidence that telephone-assisted self-help programs can be effective in the prevention of disruptive behavior problems. Keywords Self-help parenting intervention  Prevention  Externalizing behavior  Preschool children  Parent training  Follow-up

Introduction Early externalizing behavior tends to persist and can lead to long-term problems in adjustment, especially in the context of harsh and inconsistent parenting (Campbell, Shaw, & Gilliom, 2000). Parent training has been shown to be an effective intervention for preschool children with aggressive and oppositional behaviors (Lucia & Dumas, 2013; Pearl, 2009), but attendance rates are often low (Baker, Arnold, & Meagher, 2011). Some of the barriers that prevent parents from participating in parent training (e.g., stigma, travel time) may be overcome through the use of self-help interventions. The effectiveness of selfhelp programs for parents of preschool children with externalizing behavior has been evaluated in a number of recent studies. They have found that these interventions result in significantly fewer child behavior problems and greater parenting skills (McGrath et al., 2011; Sanders, Bor, & Morawska, 2007; Sanders,

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Dittman, Farruggia, & Keown, 2014; Tarver, Daley, Lockwood, & Sayal, 2014). Interestingly, outcomes are enhanced when parents are provided with minimal therapist contact (i.e., brief telephone consultations) in addition to written material (O’Brien & Daley, 2011). Some studies demonstrated that the benefits of selfadministered parent training are stable for up to 6 months, but evidence that gains are maintained for longer periods of time is sparse (O’Brien & Daley, 2011). In this article, we report results from a 1-year follow-up of self-administered parent training, with minimal therapist contact, for parents of preschool children with elevated levels of externalizing behavior (Kierfeld, Ise, Hanisch, Go¨rtz-Dorten, & Do¨pfner, 2013). The results of the initial prevention study indicated that children whose parents completed the intervention showed significantly greater reductions in problem behavior than did children in the untreated waitlist control group. Treated parents reported significant improvements in their ability to deal with difficult parenting situations and in their mental health, but the intervention did not lead to increased scores on a self-report measure of positive parenting.

Methods Participants We recruited children from kindergartens in high, middle and low socioeconomic neighbourhoods. Parents and teachers rated the behavior of 2,845 children using a short version (eight items) of the Child Behavior Checklist (CBCL) Externalizing Scale (Achenbach & Rescorla, 2001). If the sum of parent and teacher ratings was above the 85th percentile of the screening sample, we asked families to participate in a study on the effectiveness of behavioral group training (Hanisch et al., 2010). Children were eligible for the present prevention study if the sum of the parent and teacher ratings was between the 75th and 85th percentile (n = 241). Forty-eight families (20 %) decided to participate in the prevention study and gave informed consent to participate (50 % girls; Mage = 5.2 years). Scores on the short version of the CBCL Externalizing Scale did not differ considerably between children who participated in the study (n = 48) and those whose parents declined

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participation (n = 189; see Kierfeld et al., 2013). Twenty-five children participated in the follow-up (60 % girls, Mage = 6.4 years). Design We randomly assigned families to a treatment group (TG, n = 26) or a waitlist control group (WLC, n = 22) using computerized randomization conducted by a blinded assistant. TG families were offered the intervention during the first treatment phase, whereas WLC families were offered the intervention during the second treatment phase. Data were collected at four assessment points. We conducted the first assessment (T1) immediately before the first treatment phase, the second assessment (T2) after the first treatment phase, the third assessment (T3) after the second treatment phase, and the follow-up assessment (T4) 1 year after completion of the intervention. Figure 1 shows the flow of participants through the trial. Twenty-five TG families completed the allocated intervention during the first treatment phase and participated in the T2 assessment (attrition from baseline: n = 1). Seventeen of these participated in the 1-year follow-up assessment (attrition from baseline: n = 9). Twenty-one WLC families completed the T2 assessment (attrition from baseline: n = 1). Eleven WLC families completed the intervention during the second treatment phase and participated in the T3 assessment (attrition from baseline: n = 11). Eight of these participated in the 1-year follow-up assessment (attrition from baseline: n = 14). WLC children who dropped out during the second treatment phase (n = 10) did not differ significantly (p [ .26) from those whose parents completed the intervention (n = 11) on any outcome measure at T2 (preintervention). In this article, we use ‘‘pre-test’’ to refer to the preintervention assessment (T1 for TG; T2 for WLC), ‘‘post-test’’ to refer to the post-intervention assessment (T2 for TG; T3 for WLC), and ‘‘follow-up’’ to refer to the measurement 1 year after completion of the intervention (T4). The Ethical Committee at the University of Cologne approved all procedures. Intervention Families received a self-help book for parents of hyperactive, impulsive, inattentive, and oppositional

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Fig. 1 Flow of participants through the study

children (Do¨pfner, Schu¨rmann, & Lehmkuhl, 2011). The treatment phase lasted 11 weeks. In week one, we asked parents to read the introduction (psychoeducation). In weeks two through 11, parents read one chapter a week. Each chapter describes step-by-step

instructions for implementing specific interventions (e.g., defining individual problem situations, engaging in positive play interactions, implementing family rules, initiating positive reinforcement and appropriate consequences). Parents received weekly 20 min

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protocol-defined telephone consultations, during which the content of the chapter was reviewed. A more detailed description of the intervention is provided by Kierfeld et al. (2013). Thirty-six families completed the program (TG: n = 25; WLC: n = 11). Each of these families received 11 telephone consultations. Twenty families (56 %) completed the program within the scheduled time (11 weeks). Sixteen families (44 %) needed more time to work through the book and complete 11 telephone sessions (12 or 13 weeks: n = 9; more than 13 weeks: n = 7). In each telephone session, 89 % (on average) indicated that they had read the weekly material (another 6 % had read part of the material), and 75 % (on average) had implemented the described child management techniques. Measures Measures of child behavior included the CBCL (Achenbach & Rescorla, 2001) and DSM-IV-based symptom rating scales for Attention-Deficit/Hyperactivity Disorder (ADHD, 20 items) and Oppositional Defiant Disorder (ODD, 9 items; Do¨pfner, Go¨rtzDorten, Lehmkuhl, Breuer, & Goletz, 2008). Items of the symptom rating scales are graded from 0 (Not at all) to 3 (Very much). We assessed parenting with the 13-item positive parenting scale of the Parent Practices Scale (PPS; Strayhorn & Weidman, 1988). Each item measures parenting behavior on a 4-point rating scale. High scores refer to positive, reinforcing, and supportive parenting. We measured parental mental health with the 42-item Depression Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995). High scores indicate high levels of depression, anxiety, and/ or stress. Research has demonstrated good internal consistency in German preschool samples for all questionnaires (CBCL Externalizing scale: a = .92, CBCL Internalizing scale: a = .85; Plu¨ck et al., 2013; ADHD rating scale: a = .91, ODD rating scale: a = .88, positive parenting scale of the PPS: a = .84, DASS: a = .96; Hanisch et al., 2010). The questionnaires were sent to the families by mail. Missing Data and Statistical Analyses We asked families who completed the post-intervention assessment (n = 36 out of 48) to participate in the 1-year follow-up. The analyses presented in this paper

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are based on these 36 cases. Children whose parents participated in the follow-up assessment (n = 25) and those whose parents declined participation (n = 11) did not differ significantly on any outcome measure at post-intervention (see Table 1). The two groups also did not differ significantly regarding the short-term effects of the intervention (pre-test–post-test difference score; p [ .16 for all outcome measures). We therefore assumed that follow-up data were missing at random (MAR) and imputed missing observations using the expectation maximization (EM) procedure of SPSS 22. The EM procedure was run separately for each measure with pre- and post-test scores serving as predictors. We included 25 TG children and 11 WLC children in the main analyses. The two groups did not differ significantly on any outcome measure at post-intervention (see Table 1) and were grouped into one sample for analyses. Two children had missing posttest scores for the DASS and were excluded from main analyses involving the DASS. We analyzed treatment effects by one-way repeated measure analyses of variance (ANOVA) with planned contrasts (repeated). Due to the large number of dependent variables, we corrected alpha to a = 0.008 (Bonferroni correction for multiple statistical comparisons; 0.05/6 = 0.008).

Results Table 2 presents the results of the repeated measure ANOVA. There was a significant (p \ .001) main effect of time (pre-test/post-test/follow-up) on all outcome measures except PPS (p = .54). Planned contrasts revealed significant decreases (p \ .001) from pre-test to post-test on all outcome measures except PPS (p = .45). There was no significant change in scores from post-test to follow-up on any outcome measure after Bonferroni corrections (CBCL Externalizing: p = .88; CBCL Internalizing: p = .26; ADHD scale: p = .02; ODD scale: p = .21; DASS: p = .06; PPS: p = .73). Pre-test/post-test effect sizes were large for all variables (d = 0.67–1.21) except PPS (d = -0.08). Post-test/follow-up effect sizes for measures of child behavior were negative and of small to moderate magnitude (d = -0.02 to -0.32), indicating a small (but non-significant) worsening of symptoms from post-test to follow-up. The percentage of children who scored one standard deviation or more

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Table 1 Comparison of outcome measures at post-intervention Children who participated in FU assessment (n = 25) M (SD)

Children who did not participate in FU assessment (n = 11)

Independentsamples t tests

M (SD)

t(df)

TG children included in main analyses (n = 25)

WLC children included in main analyses (n = 11)

Independentsamples t tests

p

M (SD)

M (SD)

t(df)

p

Child problem behavior postintervention CBCL externalizing

12.5 (6.4)

13.7 (6.9)

t(34) = -.53

.60

12.8 (6.5)

13.1 (6.7)

CBCL internalizing

6.3 (5.8)

8.8 (5.3)

t(34) = -1.22

.23

7.5 (6.0)

6.1 (4.9)

t(34) = -.14

.89

t(34) = .69

.50

ADHD Rating Scale

12.0 (8.0)

13.5 (6.8)

t(34) = -.53

.60

11.1 (7.0)

13.8 (9. 1)

t(34) = -.67

.51

ODD Rating Scale

5.8 (3.9)

8.2 (4.8)

t(34) = -1.59

.12

6.3 (4.1)

7.0 (4.7)

t(34) = -.49

.63

Parent Practices Scale (PPS) postintervention

28.1 (4.5)

25.5 (5.0)

t(34) = 1.51

.14

26.6 (4.4)

29.0 (5.3)

t(34) = -1.44

.16

Depression Anxiety Stress Scale (DASS) postinterventiona

54.8 (12.7)

60.7 (12.8)

t(32) = -1.24

.22

55.3 (8.9)

59.0 (18.9)

t(32) = -.78

.44

FU 1-year follow-up assessment, TG treatment group, WLC waitlist control group a

Two TG children had missing post-test scores for the DASS. One of them participated in the FU assessment and the other did not

above the mean (t value C 60) on the CBCL and symptom rating scales was reduced from pre-test to post-test (see Table 2). The percentages increased slightly from post-test to follow-up, but did not reach pre-intervention levels.

Discussion The purpose of our study was to report the results of a 1-year follow-up of a randomized controlled prevention trial of self-administered, telephone-assisted parent training for parents of preschool children with externalizing behavior. Consistent with findings from the initial prevention trial (Kierfeld et al., 2013), we found that the intervention led to significant improvements in child behavior and parental mental health. There were no significant changes from post-test to follow-up, indicating that gains achieved at post-test remained stable over time. Moreover, the percentage of children with substantial behavior problems was reduced from pre-intervention to follow-up, suggesting that self-help parenting interventions, with minimal therapist contact, may prevent the development of disruptive behavior disorders. It is worth noting that the intervention did not lead to increased scores on a self-report measure of

positive parenting. A possible explanation is that the positive parenting scale of the PPS asks parents to indicate how often they engage in positive activities with their child, although the intervention focused more on the reduction of coercive parenting behaviors and on functional strategies for difficult parenting situations. In the initial prevention trial (Kierfeld et al., 2013), we used several different measures of parenting and found that the reduction of dysfunctional parenting practices was significantly greater in the treatment than the control group. Neither group reported an increase in positive parenting. Similarly, a recent investigation revealed that decreases in negative parenting behaviors were the strongest mediator of changes in preschool children’s behavior during face-to-face parent training (Hanisch, Hautmann, Plu¨ck, Eichelberger, & Do¨pfner, 2014). These findings suggest that measures of negative parenting are better suited to evaluate the effects of the guided selfhelp intervention than the positive parenting scale of the PPS. We note that only 20 % of the parents whose children were eligible for the initial prevention study participated in the trial. As a consequence, our results may be restricted to parents with high treatment motivation. Parents seemed less motivated to

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13.3 (6.4)

18.4 (7.5)

11.0 (6.2)

26.9 (4.8)

67.6 (16.6)

CBCL internalizing

ADHD Rating Scale

ODD Rating Scale

Parent Practices Scale (PPS)

Depression Anxiety Stress Scale (DASS)a

c

b

a

83

56

50

42

56.5 (12.8)

27.3 (4.7)

6.5 (4.3)

12.5 (7.6)

7.1 (5.7)

12.9 (6.5)

56

19

14

11

58.9 (8.4)

27.5 (4.4)

7.3 (4.4)

14.9 (8.6)

7.9 (5.1)

13.0 (5.9)

M (SD)

64

25

14

14

t value C 60 (%)

Follow-up (n = 36)

0.67

F(2,66) = 20.36 \.001

0.73

F(2,70) = 24.20 \.001

-0.08

0.79

F(2,70) = 19.19 \.001 .54

0.97

F(2,70) = 0.63

1.21

F(2,70) = 38.64 \.001

p

Pre/post effect size: d = (Mpre - Mpost)/SDpre

Post/follow-up effect size: d = (Mpost - MFU)/SDpre

Pre/post effect sizeb

F(2,70) = 33.73 \.001

F(df) time

Repeated measure analysis of variance

Two children had missing post-test scores for the DASS and were excluded from analyses involving the DASS presented in this table

t value: M = 50, SD = 10

20.4 (6.2)

CBCL externalizing

Child problem behavior

t value C 60 (%)

M (SD)

M (SD)

t value C 60 (%)

Post-intervention (n = 36)

Pre-intervention (n = 36)

Table 2 Mean scores and standard deviations of outcome measures at pre-intervention, post-intervention, and 1-year follow-up assessment

-0.14

-0.04

-0.13

-0.32

-0.13

-0.02

Post/follow-up effect sizec

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participate in the follow-up assessment. The fact that parents were not paid or offered incentives for their participation might explain the relatively high dropout rate. In addition, it should be mentioned that all outcome measures were parent-reported. Although we used well-validated measures, it is possible that our posttest data were influenced by socially desirable response bias. However, social desirability is less likely to affect responses at a 1-year follow-up assessment because the alliance between parent and therapist is likely to be weakened. The stability of the treatment effects may therefore be interpreted as evidence against a response bias in our data. Another limitation to our study is the lack of follow-up data in untreated children. Therefore we can only conclude that the benefits were maintained at follow up. Our data do not allow us to conclude whether the difference in outcome between treatment and control group is stable over time. Finally, it is worth noting that we did not systematically collect information on parents’ help-seeking behavior. There was no evidence that parents received additional interventions during the treatment phase, but it is not possible to rule out that parents sought additional help from health services or other sources during the follow-up period. Despite these limitations, our study provides initial evidence that the parent-reported benefits of telephone-assisted parent training are maintained for at least 1 year. This is an important finding because it demonstrates that self-help parenting interventions, with minimal therapist contact, may be an effective alternative to face-to-face parent trainings, even over the longer term. Therapists who provide telephoneassisted parent training to parents with sufficient treatment motivation can devote more of their time and resources to more complex cases. To conclude, our study adds to the growing body of evidence that guided self-help programs are useful in primary prevention of behavioral and emotional problems in children (e.g., Bouchard, Gervais, Gagnier, & Loranger, 2013; Sanders et al., 2007). Acknowledgments We would like to thank all the children and their parents for participating in this study. Conflict of interest Manfred Do¨pfner is the author of the selfhelp book ‘‘Wackelpeter & Trotzkopf’’ on which the intervention was based. He receives royalties from the publisher.

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J Primary Prevent (2015) 36:33–40 Sanders, M. R., Dittman, C. K., Farruggia, S. P., & Keown, L. J. (2014). A comparison of online versus workbook delivery of a self-help Positive Parenting Program. Journal of Primary Prevention, 35, 125–133. Strayhorn, J. M., & Weidman, C. S. (1988). A parent practices scale and its relation to parent and child mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 27, 613–618. Tarver, J., Daley, D., Lockwood, J., & Sayal, K. (2014). Are self-directed parenting interventions sufficient for externalising behaviour problems in childhood? A systematic review and meta-analysis. European Child & Adolescent Psychiatry. doi:10.1007/s00787-014-0556-5

One-year follow-up of guided self-help for parents of preschool children with externalizing behavior.

Self-help programs are an effective intervention for parents of children with externalizing behavior. A number of studies have shown that self-adminis...
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