Outpatient treatment of the acting out child: Procedures, long term follow-up data, and clinical problems

Parenting in the USA: Growing Adversity

This article focuses on a discussion of selected social and economic stressors facing an increasing number of US families. The specific stressors discussed are violence, poverty and single-parent families. Such stressors have both a direct and an indirect impact on children. It is asserted that parenting (including parental functioning) is a primary mediating and/or moderating variable in regard to the indirect impact these stressors have on many children, especially young children. It is recommended that programs targeting the impact of adversity on children should take a broad ecological approach including a focus not only on the children but also on their parents.

Family Behavior Therapy in a Conduct-Disordered and Substance-Abusing Adolescent

The present case study describes a Family Behavior Therapy (FBT) method used to treat an adolescent substance-dependent youth who evidenced co-occurring symptoms of conduct disorder and major depressive disorder. The case example includes a description of the youth's assessment, including mental status, relevant background information, substance abuse history, use of standardized measures and urine drug assay tests, diagnostic impressions, conceptualization, and method of developing the treatment plan. Implementation of the FBT program is fully delineated, including examples of completed therapy worksheets and ongoing assessments of drug use, conduct, school performance, and mood. Results, albeit uncontrolled, indicated significant progress throughout intervention and at 6 month follow-up.

A Promblem Solving Training Program for Parents of Children with Attention Deficit Hyperactivity Disorder

A behavior management approach is presented that is designed to enhance the active involvement of children with ADHD in managing their own behavior. In this program emphasis is placed on parents presenting behavior management situations as those where their child must make a choice between compliance and noncompliance. Each of these alternatives is linked to a consequence that is meaningfully connected to the antecedent behavior. Parents are also given instruction in acknowledging feelings, the use of process questions, anger management, and communication skills. The intervention is being delivered in both an individual program of therapy in which pairs of parents meet with the therapists and a group program in which 8-10 parent pairs meet with a pair of therapists. Preliminary findings indicate that the program is effective in reducing parental stress, improving the parents' perception of the child, and improving parental problem solving skills in behavior management situations. The effects appear to be stronger for individual as compared to group therapy.

Evidence-Based Psychological Treatments of Pediatric Mental Disorders

With many youth presenting to primary care settings for mental health difficulties, knowledge of the respective evidence-based psychotherapies is imperative in ensuring that these youth receive the appropriate interventions in a timely manner. Most frequently, children present with internalizing and/or externalizing disorders, which cover a broad range of common pediatric mental disorders. Treatments of these disorders generally incorporate cognitive and/or behavioral components, which are derived from theoretical underpinnings and empirical support. Although the interventions share common components, they are distinctive in nature and are further tailored toward the idiosyncratic needs of children and their families. Careful consideration of the apposite intervention and individual needs of youth are pertinent to the effective amelioration of symptomology.

Developing Community Reinforcement and Family Training (CRAFT) for Parents of Treatment-Resistant Adolescents

We describe a project focused on training parents to facilitate their treatment-resistant adolescent's treatment entry and to manage their child after entry into community-based treatment. Controlled studies show that Community Reinforcement and Family Training (CRAFT) is a unilateral treatment that fosters treatment entry of adults; however, there are no controlled trials for parents with a substance-abusing child. We examined the behavioral parent training literature to guide us in tailoring CRAFT for parents of adolescents. We discuss adaptations to CRAFT, outcomes and experiences gained from a brief pilot of the revised CRAFT program, and the future directions of this work.

Conduct Problems and Treatment across Home and School: A Review of the Literature

Treatment of conduct problems in the home setting has received much attention in the literature, and there are well established, empirically derived treatment programs that have been demonstrated to be effective. However, treatment for conduct problems in the classroom has not received a comparable amount of attention, and the intervention programs are diverse, occasionally lacking empirical support, and often not consistent with strategies used in the home setting. As past research has demonstrated that conduct problems in multiple settings is related to poorer prognosis, it is logical to suggest that interventions should focus on as many of the settings as possible in which a child displays the behaviour problems. This paper reviews the literature on the effects of conduct problems in the classroom, on teacher managerial skills, and on interventions across the home and school settings. It is concluded that classroom management of conduct problems could be improved by providing a hierarchical system of intervention strategies.

Handling Parents' Concerns Regarding the Behavioural Treatment of Infant Sleep Disturbance

Infant sleep disturbance (ISD) is widespread and troublesome. Although effective management techniques have been established, some lay and professional authors have expressed concern about these interventions. These concerns are sometimes shared by parents who seek professional advice while feeling ambivalent about undertaking treatment. These concerns include (a) that ISD is normal and inevitable, (b) that it results from unnatural or artificial cultural practices, (c) the belief that ISD expresses a need state, and (d) the belief that the use of extinction is harmful. These concerns are examined and the management of ISD by extinction and its alternatives are considered in the light of the ethics of professional practice. It is concluded that these concerns are best answered within the context of a professional relationship based on a partnership and the sharing of expertise with parents.

Reciprocal Skills Training in the Treatment of Externalising Behaviour Disorders in Childhood: A Preliminary Investigation

This study reported on the efficacy of Reciprocal Skills Training (RST), a family-based treatment modality for childhood externalising disorders. Children (N= 57) ranging from 7 to 12 years old who fulfilled diagnostic criteria for oppositional defiant disorder were randomly allocated to RST (in either a hospital or clinical setting) or a waiting-list control group. At posttreatment, no significant differences were observed across the two treatment settings. Results indicated that 95.5% of children in the hospital setting and 72.2% of children in the clinical setting no longer met criteria for oppositional defiant disorder, compared to 30% of children on the waiting list. Children in the treatment groups also obtained significantly lower scores on the Externalising scale of the Child Behaviour Checklist, compared to the waiting-list group. In addition, mothers' levels of stress and depression were significantly reduced at posttreatment, compared to mothers of children on the waiting list. These findings suggest that RST is an effective treatment modality for children displaying externalising behaviours, as well as for their mothers. The results are discussed in terms of limitations of the current study and future directions for research and clinical practice.

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.

ECT, Infants, Children and Adolescents: Shocking Abuse of Power, or Valuable Treatment Medium?

ECT has been administered to infants, children and teenagers between the ages of two and eighteen, in Europe, North America and Australasia. There are several alternate forms of effective behavioural and cognitive interventions for the range of problems experienced by minors. In this paper, some of the reasons for the contemporary popularity of ECT administration with children and teenagers are explored, via a critical evaluation of the published literature.

Testing the Oregon delinquency model with 9-year follow-up of the Oregon Divorce Study

This paper presents experimental tests of the Oregon delinquency model applied within a randomized design of an at-risk sample of single mothers and their elementary school-aged sons. In the theoretical model, ineffective parenting practices and deviant peer association serve as the primary mechanisms for growth in adolescent delinquent behavior and early arrests. Multiple-method assessments of 238 mothers and sons include delinquency as measured by teacher reports and official arrest records, parenting skills measured by observations of parent–child interactions, and deviant peer association as reported by focal boys. Analyses of the 9-year follow-up data indicate that the Oregon model of parent management training significantly reduced teacher-reported delinquency and police arrests for focal boys. As hypothesized, the experiments demonstrated that improving parenting practices and reducing contacts with deviant peers served as mediating mechanisms for reducing rates of adolescent delinquency. As predicted, there was also a significant delay in the timing of police arrests for youth in the experimental as compared to the control group.

Treatment of conduct disorder: Progress and directions in psychotherapy research

The present paper charts the course for future research on the treatment of conduct disorder. The course builds on current advances both in understanding conduct disorder and its treatment and in the clinical care provided to youth and their families. The paper highlights substantive and methodological advances in contemporary research on both treatment and developmental psychopathology more generally. In light of the current status of treatment research, several priorities are identified, which include expanding the criteria used to evaluate outcome, expanding the range of research questions asked about treatment, testing a broader range of treatments and treatment combinations, evaluating long-term treatment effects, and expanding the models to develop and to evaluate treatment. A plan is presented to guide the progression of research to identify and to develop effective interventions. The special opportunities that a developmental perspective provides for designing treatments for youth of different ages and stages of development are also discussed.

Effectiveness of the Triple P Positive Parenting Program on behavioral problems in children: a meta-analysis

The Triple P Positive Parenting Program is a multilevel parenting program to prevent and offer treatment for severe behavioral, emotional, and developmental problems in children. The aim of this meta-analysis is to assess the effectiveness of Triple P Level 4 interventions in the management of behavioral problems in children by pooling the evidence from relevant literature that included Level 4 Triple P interventions. Level 4 intervention is indicated if the child has multiple behavior problems in a variety of settings and there are clear deficits in parenting skills. Results indicate that Level 4 of Triple P interventions reduced disruptive behaviors in children. These improvements were maintained well over time, with further improvements in long-term follow-up. These effects support the widespread adoption and implementation of Triple P that is taking place in an increasing number of countries in quite diverse cultural contexts around the world.

Self-administered behavioral family intervention for parents of toddlers: Part I. Efficacy

This study examined the efficacy of a self-administered behavioral family intervention for 126 parents of toddlers. The effects of 2 different levels of intensity of the self-administered intervention were contrasted (self-administered alone or self-administered plus brief therapist telephone assistance). The results provide support for the efficacy of the self-administered form of behavioral family intervention. There were significant short-term reductions in reported child behavior problems and improvements in maternal parenting style, parenting confidence, and anger. Families who received minimal therapist assistance made more clinically significant gains compared with families who completed the program with no therapist assistance. The intervention effects were maintained at 6-month follow-up. The implications of the findings for the population-level delivery of behavioral family interventions are discussed.

Developing a family-based depression prevention program in urban community mental health clinics: a qualitative investigation

Extensive research documents that children of depressed mothers are at a significantly higher risk for developing a variety of socioemotional difficulties than children of nondepressed mothers. Yet, little prevention research has been conducted for this population, and low-income, minority, and urban families are rarely included. To address this deficit, we are developing the Protecting Families Program (PFP), a family-based multicomponent depression prevention program for mothers in treatment at urban community mental health agencies and their school-aged children. To inform intervention development and begin relationship building with the agencies, patient and staff focus groups were conducted in the participating agencies. Eighteen mothers with depression participated, and eight major themes were identified: (1) depression symptoms, (2) generational legacy, (3) parenting difficulties, (4) child problems, (5) social support, (6) stressful life events, (7) therapy and other helpful activities, and (8) desired treatment. In the focus groups with 10 mental health providers, the five major themes identified were parenting difficulties, lack of social support, life stress, current mental health practices, and intervention development. The findings support the multicomponent design of PFP, which focuses on increasing knowledge of depression, enhancing social support, and improving parenting skills. The study helped clarify many of the challenges of conducting research in a community mental health system.

Closing the Research-Practice Gap: Factors Affecting Adoption and Implementation of a Children's Mental Health Program

Despite the availability of effective interventions, they are not widely used in community mental health centers. This study examined the adoption and implementation of The Arson Prevention Program for Children (TAPP-C), a program for juvenile firesetters developed at a teaching hospital and disseminated to community settings. Questionnaire data from mental health professionals were used to evaluate the roles of adopter, innovation, and dissemination characteristics in TAPP-C adoption and implementation. Results indicate that different factors are important at different diffusion stages. Moreover, they suggest that innovation characteristics may be particularly important to adoption, whereas adopter and dissemination characteristics may be more influential in implementation.

Empirical support for a treatment program for families of young children with externalizing problems

We evaluated the efficacy of a manualized multimodal treatment program for young externalizing children. Families were assigned randomly to an immediate 12-week parent and child treatment condition (n = 24) or to a delayed-treatment condition (n = 23). Parents had high attendance, high satisfaction with treatment, and increased knowledge of behavior management principles. Relative to the waitlist condition, treatment parents reported statistically and clinically significant reductions in child behavior problems, improved parenting practices (i.e., increased consistency, decreased power assertive techniques), an increased sense of efficacy, and reduced parenting stress. There was a trend toward parents improving their attitudes toward their children. In considering the process of change, we found evidence that improved parenting practices mediated reductions in child behavior problems and that child improvements mediated changes in parent attitudes and stress. Five months following treatment, teachers reported significant improvements in child behaviors, whereas parents reported that reductions in child behavior problems and parenting stress were maintained.

Childhood behavioral and emotional disorders

We reviewed the literature on family treatment for childhood behavioral and emotional disorders and found an increase in the number of studies since 1995; however there was significant variation by disorder and therapy model. There is substantially more research on externalizing disorders (i.e., conduct disorder, attention deficit hyperactivity disorder, oppositional defiant disorder) then internalizing disorders, depression and anxiety disorders. The data support the conclusion that family-based interventions produce results comparable to individually oriented interventions, and in some cases family-based interventions are superior to individual treatments. To date, cognitive behavioral family therapy and parent management have been the two models studied, almost exclusively. Implications for family therapy and future research are considered.

Parenting interventions and the prevention of serious mental health problems in children

The reduction of coercive or inadequate parenting is essential if the mental health status of Australian children and adolescents is to be improved. Of the available approaches that address parenting practices, behavioural family interventions have the strongest empirical support and are effective in reducing parenting practices that contribute to the development of behavioural and emotional problems in children. However, only a small proportion of parents access such interventions. A comprehensive multilevel, evidence-based parenting and family support strategy needs to be implemented on a wide scale to reduce the prevalence of mental health problems in children and youth. The Triple P - Positive Parenting Program is an example of a population-level strategy that can be used to improve the mental health status of children and their parents.

Verhaltenstherapie bei Kindern mit aggressiv-dissozialen Störungen

Zusammenfassung: Aggressiv-dissoziale Störungen bei Kindern und Jugendlichen kommen häufig vor und haben eine schlechte Prognose; sie werden stets mehr als chronische Störung aufgefasst, die sowohl Behandlung als lebenslange Betreuung erfordert. Verhaltenstherapie gilt als effektivste Behandlung, wobei unterschieden wird zwischen Elterntrainings und sozial-kognitiven Problemlösetrainings. Bei jüngeren Kindern ist ein Elterntraining indiziert, bei älteren Kindern zusätzlich ein Problemlösetraining. Die Effekte von Elterntrainings wurden in zahlreichen Studien nachgewiesen; Elterntrainings gelten als «empirically supported treatment», das strengste Kriterium, dem psychologische Behandlungen entsprechen müssen. Auch mit sozial-kognitiven Problemlösetrainings wurden bei klinischen Gruppen signifikante Veränderungen erzielt; sie entsprechen dem etwas weniger strengen Kriterium «probably efficacious». Probleme von Elterntrainings und Problemlösetrainings sind die hohe Abbruchrate bei den Eltern mit den meisten Risikofaktoren und die Tatsache, dass viele Kinder nach einem Problemlösetraining zwar signifikante Verbesserungen erreicht haben, aber immer noch im klinischen Bereich für aggressives Verhalten bleiben. Zur Optimierung des Behandlungserfolgs wurden in den letzten Jahren komplexe Präventionsprogramme entwickelt, die die Entwicklung von delinquentem Verhalten und einer antisozialen Persönlichkeit verhindern sollen. Die bisherigen Ergebnisse sind widersprüchlich; die ersten Resultate zweier noch laufender Studien (FAST- und LIFT-Studie) sind jedoch positiv. Ein höherer Stellenwert von Dissozialität in der kinderpsychiatrisch-psychotherapeutischen Versorgung wäre angesichts der Prävalenz und Folgenschwere der Störung angezeigt.

Evaluation of a short-term group therapy program for children with behavior problems and their parents

The current study investigated the effectiveness of a short-term, cognitive behavioral program for 106 primary school-aged children referred with externalizing behavior problems and their parents, compared with 39 children and their parents on a waiting-list to be treated. Exploring Together' comprised a children's group (anger management, problem-solving and social skills training), a parents' group (parenting skills training and dealing with parents' own issues), and a combined children's and parents' group (to target parent-child interactions). The program reduced children's behavior problems and improved their social skills at home. Changes in children's behaviors and social skills at home were generally maintained at 6- and 12-month follow-up. Implications of the findings for improving interventions for childhood externalizing behavior problems are discussed.

Community-based parenting and family support interventions and the prevention of drug abuse

This paper presents a model for the development of a comprehensive, multilevel, preventively-oriented parenting and family support strategy to reduce family risk factors associated with drug abuse in young people. If parenting interventions are to make a significant impact at a population level on the prevalence of dysfunctional parenting practices, there is a need for an ecological approach to parenting support. Such an approach needs to target a variety of social contexts that are in a position to provide parents with access to evidence-based parenting interventions. The Triple P-Positive Parenting Program is discussed as an example of such an approach to illustrate the distinguishing features of a population level strategy. The core constructs underpinning the Triple P system include the promotion of parental self-regulation (self-sufficiency, self-efficacy, self-management, personal agency, and problem solving), through making parenting programs of adequate intensity widely available in the community through flexible delivery modalities (individual, group, telephone assisted and self-directed). The system comprises a tiered continuum of increasingly intensive parenting interventions ranging from media interventions with wide reach, to intensive behavioural family interventions with narrow reach for high-risk families where parenting problems are complicated by other factors including marital conflict, parental mood disturbance, and lack of social support. The scientific basis of the system of intervention and possible directions for future research is discussed.

Socialization, personality development, and the child's environments: comment on Vandell (2000)

Although many socialization agents influence children's behavior (D. L. Vandell, 2000), the evidence (e.g., from intervention studies) indicates that each exerts its influence only within its own domain. Context effects and genetic effects are among the confounding factors that make it impossible, given current data, to reject the null hypothesis of zero long-term effects of parenting on child outcomes. Problems with the prevailing view of development cannot be solved by invoking within-home environmental differences or gene- environment interactions. Group socialization theory can account for findings that do not fit the prevailing view. The theory attributes outside-the-home socialization to identification with a peer group and assimilation of group norms, but attributes nongenetic variation in personality to differentiation within the group. The latter proposition is still largely untested but other aspects of the theory are well supported by evidence.

Parent management training in a Chinese population: application and outcome

OBJECTIVE

To examine the applicability and outcome of parent management training in a group of Chinese children referred for aggressive and defiant behaviors.

METHOD

Twenty-five children (aged 4-10 years) were assigned to a standardized 8 to 12 sessions of parent management training. Trained child and adolescent psychiatric nurses conducted the treatment. Measures taken at pretreatment, posttreatment, and 4-month follow-up period included the Child Behavior Checklist, direct observation of parent-child interactions, and a parent perception inventory.

RESULTS

Significant therapeutic gains occurred in parent-child interactions, externalizing behaviors, and parents' perception of their parenting behaviors. These were maintained at 4-month follow-up. Fifty-two percent of cases improved to a level below clinical cutoffs. Poor parent-child interactions had stronger correlation with externalizing disturbances than internalizing disturbances. The changes in parent-child interactions had low correlation with the changes in the symptom profiles.

CONCLUSIONS

The data provide preliminary evidence for the efficacy of parent management training for Chinese children with conduct problems. The rationale for its success and modifications to improve its cultural sensitivity are discussed.

Self-directed behavioral family intervention for parents of oppositional children in rural and remote areas

Twenty-four parents of oppositional preschoolers were randomly assigned to either a self-directed behavioral family intervention condition (SD) or to a waitlist control group (WL). The self-directed parent training program, based on self-regulation principles, consisted of a written information package and weekly telephone consultations for 10 weeks. At posttest, in comparison to the WL group, children in the SD group had lower levels of behavior problems on parent report measures of child behavior. At posttreatment, parents in the SD condition reported increased levels of parenting competence and lower levels of dysfunctional parenting practices as compared to parents in the WL condition. In addition, mothers reported lower levels of anxiety, depression, and stress as compared to mothers in the WL condition at posttreatment. Using mother's reports, gains in child behavior and parenting practices achieved at posttreatment were maintained at 4-month follow-up.

The treatment of conduct disorder: perspectives from across Canada

OBJECTIVE

To provide a synopsis of treatment programs for conduct-disordered children in Canada.

METHOD

Five groups of authors from British Columbia, Ontario, Quebec, and New Brunswick describe their approaches to the treatment of children with conduct disorder.

RESULTS

All programs emphasize the needs to use multimodal treatment schemes, including day and short-term residential care, and to base programs on identified factors associated with the development of conduct disorder.

CONCLUSION

Specific forms of treatment of conduct disorder are promising but are often hampered by social and political agendas.

Practitioner review: psychosocial treatments for conduct disorder in children

The present paper reviews promising treatments for conduct disorder among children and adolescents. The treatments include problem-solving skills training, parent management training, functional family therapy and multisystemic therapy. For each treatment, conceptual underpinnings, characteristics and outcome evidence are highlighted. Limitations associated with these treatments (e.g. paucity of long-term follow-up evidence and of evidence for the clinical significance of the change) are also presented. Broader issues that affect treatment and clinical work with conduct-disordered youths are also addressed, including retaining cases in treatment, what treatments do not work, who responds well to treatment, comorbidity, the use of combined treatments and the need for new models of treatment delivery.

Does parent training with young noncompliant children have long-term effects?

The current study was a long-term follow-up (approx. 14 yr following treatment) of 26 late adolescents/young adults (17 yr and older) who had participated in parent training with their mothers when they were young (2-7 yr old) noncompliant children. Parent training, consisting of teaching mothers to use attends and rewards for appropriate behavior, clear commands and time-out, had reduced deviant behavior and increased compliance immediately following treatment. At this follow-up, these individuals were compared to a matched community sample on various measures of delinquency, emotional adjustment, academic progress and relationship with parents. No differences emerged between the two groups on any of the measures, suggesting that noncompliant children who participated in parent training during their early years are functioning as well as nonclinic individuals as they move into adulthood.

Bibliotherapy as an adjunct to stimulant medication in the treatment of attention-deficit hyperactivity disorder

The effectiveness of bibliotherapy as an adjunct to stimulant medication in the treatment of children with attention-deficit hyperactivity disorder was investigated. Subjects were randomly assigned to the experimental group, or the control group. Parents in the experimental group received a written protocol (bibliotherapy) outlining behavioral techniques for managing oppositional child behavior. Results indicated significant differences favoring the experimental group on standardized measures of the intensity of behavior problems in the home, parental knowledge of behavioral principles, and teacher ratings of behavior. This bibliotherapy approach appears to offer an inexpensive adjunct to stimulant medication in the treatment of attention-deficit hyperactivity disorder when individual or group behavior management training is not feasible.