The role of parental attributions in predicting parenting intervention outcomes in the treatment of child conduct problems

Objective Linguistic Markers Associated with Callous-Unemotional Traits in Early Childhood

BACKGROUND

Callous-unemotional (CU) traits are associated with interpersonal difficulties and risk for severe conduct problems (CP). The ability to communicate thoughts and feelings is critical to social success, with language a promising treatment target. However, no prior studies have examined objective linguistic correlates of childhood CU traits in early childhood, which could give insight into underlying risk mechanisms and novel target treatments.

METHODS

We computed lexical (positive emotion, sad, and anger words) and conversational (interruptions and speech rate) markers produced by 131 children aged 5-6 years (M = 5.98; SD = 0.54, 58.8% female) and their parents while narrating wordless storybooks during two online visits separated by 6-8 weeks (M = 6.56, SD = 1.11; two books, order counterbalanced). Audio recordings were diarized, time-aligned, and orthographically transcribed using WebTrans. Conversational markers were calculated using R and word frequencies were calculated using Linguistic Inquiry and Word Count (LIWC) software. We examined links between child CU traits and linguistic markers, and explored whether relationships were moderated by child sex.

RESULTS

Higher CU traits were associated with fewer positive emotion words produced by parents and children. Higher CU traits were also associated with greater concordance in the degree of interruptions and expression of anger emotion words by parents and children.

CONCLUSIONS

Results suggest that objective linguistic correlates of CU traits are detectable during early childhood, which could inform adjunctive treatment modules that improve outcomes by precisely tracking and targeting subtle communication patterns.

Validation and psychometric properties of a brief measure of parental attributions in a sample from Spain

The parental attribution measure (PAM) is an instrument that assesses the attributions made by parents regarding their children's behavior, for both clinical and community samples. This research has aimed at evaluating the psychometric properties of the PAM in a community sample in Spain. Data were analyzed from several samples of fathers and mothers (N1 = 253; N2 = 458, N3 = 711) who reported on their attributions and level of parental stress on the one hand and on their children's emotional insensitivity traits and behavioral problems on the other. The results did not support the original structure proposed but a unidimensional structure consisting of nine items with good psychometric properties and factorial invariance. The 9-item PAM exhibited a positive relationship with callous unemotional traits and behavioral problems in children and with parental stress. This study provides important new insights into the psychometric properties of the PAM in a Spanish sample. It represents a significant advance, since so far there have been no other instruments to use in assessing parental attributions about their children's behavioral problems in Spanish. In short, this research is intended to evaluate the psychometric properties of the PAM in a sample of a community in Spain. The results supported a unidimensional structure composed of a 9-item instrument with good psychometric properties and factorial invariance.

Caregiver Attributions of Toddlers' Behaviors: A Comparison Between Groups of Children with Differing Developmental Concerns

Little is known about the attributional patterns of caregivers of autistic children, particularly in relation to caregivers of children with other developmental or behavioral disorders. This study examined differences in caregiver attributions of child behavior between three groups: toddlers with (1) Autism spectrum disorder (ASD) or ASD concerns; (2) Other developmental concerns; and (3) No concerns. Qualitative descriptions of actual child behaviors were coded using a three-stage content analysis. Regression analyses were utilized to determine if group membership predicted types of positive and challenging behaviors caregivers endorsed, as well as their attributions of these behaviors. Caregivers of children with ASD or ASD concerns endorsed similar types of behaviors, but rated their child's positive behaviors as less characteristic of their child and more a function of the particular situation, less stable or permanent, and less controllable as compared to caregivers of toddlers with other developmental or no concerns. Additionally, they rated their child's challenging behaviors as more stable or permanent and less controllable as compared to caregivers of toddlers with other developmental concerns or no concerns. These findings suggest that caregivers of children with ASD and ASD related concerns may be vulnerable to a negative attributional pattern, which can have important implications for child and family functioning and overall quality of life.

Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses

BACKGROUND

Children with callous-unemotional (CU) traits are at high lifetime risk of antisocial behavior. It is unknown if treatments for disruptive behavior disorders are as effective for children with CU traits (DBD+CU) as those without (DBD-only), nor if treatments directly reduce CU traits. Separate multilevel meta-analyses were conducted to compare treatment effects on DBD symptoms for DBD+CU versus DBD-only children and evaluate direct treatment-related reductions in CU traits, as well as to examine moderating factors for both questions.

METHODS

We systematically searched PsycINFO, PubMed, Cochran Library (Trials), EMBASE, MEDLINE, APA PsycNet, Scopus, and Web of Science. Eligible studies were randomized controlled trials, controlled trials, and uncontrolled studies evaluating child-focused, parenting-focused, pharmacological, family-focused, or multimodal treatments.

RESULTS

Sixty studies with 9,405 participants were included (Mage  = 10.04, SDage  = 3.89 years, 25.09% female, 44.10% racial/ethnic minority). First, treatment was associated with similar reductions in DBD symptoms for DBD+CU (SMD = 1.08, 95% CI = 0.45, 1.72) and DBD-only (SMD = 1.01, 95% CI = 0.38, 1.64). However, DBD+CU started (SMD = 1.18, 95% CI = 0.57, 1.80) and ended (SMD = 0.73, p < .001; 95% CI = 0.43, 1.04) treatment with more DBD symptoms. Second, although there was no overall direct effect of treatment on CU traits (SMD = .09, 95% CI = -0.02, 0.20), there were moderating factors. Significant treatment-related reductions in CU traits were found for studies testing parenting-focused components (SMD = 0.21, 95% CI = 0.06, 0.35), using parent-reported measures (SMD = 0.16, 95% CI = 0.04, 0.28), rated as higher quality (SMD = 0.26, 95% CI = 0.13, 0.39), conducted outside the United States (SMD = 0.19, 95% CI = 0.05, 0.32), and with less than half the sample from a racial/ethnic minority group (SMD = 0.15, 95% CI = 0.002, 0.30).

CONCLUSIONS

DBD+CU children improve with treatment, but their greater DBD symptom severity requires specialized treatment modules that could be implemented alongside parenting programs. Conclusions are tempered by heterogeneity across studies and scant evidence from randomized controlled trials.

Mental Health Literacy for Supporting Children: A Systematic Review of Teacher and Parent/Carer Knowledge and Recognition of Mental Health Problems in Childhood

The level of mental health literacy (MHL) in adults who work with or care for children is likely to influence the timeliness and adequacy of support that children receive for mental health problems. The aim of this study was to systematically review the literature on mental health literacy for supporting children (MHLSC, recognition/knowledge) among parents and teachers of school aged children (5 to 12 years old). A systematic search was conducted for quantitative studies published between 2000 and June 2021 using three databases (MEDLINE, PsycINFO and ERIC) and relevant citations reviewed in Scopus. To be included, studies needed to measure at least either 'mental health knowledge' or 'recognition'. Synthesis proceeded according to study design, adult population, child MHP, then MHL outcome. Study quality was assessed using AXIS. 3322 documents were screened, 39 studies met inclusion criteria. 49% of studies examined teachers' knowledge or recognition of ADHD; only five studies reported on parent samples. Synthesis found a nascent field that was disparate in definitions, methods and measures. Little research focussed on knowledge and recognition for internalizing problems, or on parents. Methods used for measuring knowledge/recognition (vignette vs screening) were associated with different outcomes and the quality of studies was most often low to moderate. Adults appear to have good recognition of childhood ADHD but their knowledge of internalizing disorders is less clear. Further research is required to develop standard definitions and validated measures so gaps in MHLSC can be better identified across populations who have a role in supporting children with their mental health.

Predictors and Moderators Two Treatments of Oppositional Defiant Disorder in Children

OBJECTIVE

The aim of this study was to examine predictors and moderators of behavioral improvement in children with Oppositional Defiant Disorder (ODD) following treatment with Parent Management Training (PMT) and Collaborative and Proactive Solutions (CPS). Initial problem severity, inconsistent discipline, parental attributions of child misbehavior, and child lagging cognitive skills were examined.

METHOD

One hundred and forty-five children aged between 7 and 14 (103 males, M = 8.88 years, ethnicity representative of the wider Australian population) were randomly assigned to PMT and CPS. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semi-structured diagnostic interviews and parent-ratings of ODD symptoms. Using an intent-to-treat sample in this secondary analysis (Murrihy et al., 2022), linear regressions and PROCESS (Hayes, 2017) were used to examine these predictors and possible moderators of treatment.

RESULTS

Higher pre-treatment levels of conduct problems, lagging skills, and inconsistent discipline predicted poorer behavioral outcomes following both treatments. The only characteristic that moderated treatment outcome was child-responsible attributions - mothers who were more likely to attribute their child's problematic behaviors to factors in the child had significantly poorer outcomes in PMT than CPS at 6-month follow-up.

CONCLUSIONS

CPS may be a more beneficial treatment than PMT for families who have been identified as having higher levels of child-responsible attributions before commencing treatment for ODD. While tentative, this provides promising insights as to how treatment outcomes for children with ODD may be improved.

Parental Attributions—Mothers’ Voices in Economically and Socially Disadvantaged Contexts

In the present study, the attributions of socially and economically disadvantaged mothers for their own negative parenting behavior and for their children’s undesirable behaviors as perceived by parents—understood as misbehavior—were analyzed. To this end, an exploratory study with a qualitative design was developed, in which 24 socially and economically disadvantaged mothers were individually interviewed. The data were analyzed following a thematic analysis approach, using software suited to qualitative analysis, namely NVIVO 12. The children’s undesirable behaviors as perceived by parents and some characteristics associated with parental performance (particularly the appraisal of the effectiveness of their negative practices) emerged respectively as external and internal factors, explaining mothers’ inadaptive behaviors—difficulties in behavior regulation, physical coercion, psychological control and paraverbal hostility. The parental subsystem and school emerged as the main external factors, and the psychological characteristics as the most relevant internal factors, explaining the children’s undesirable behaviors—challenge, immaturity, hostility, emotionally-based, school behavior/absenteeism and danger. The results also indicate weak self-critical reflexivity regarding some of the inadaptive behaviors. The comprehensive analysis of the results, based on the literature review, gave rise to an explanatory hypothesis on the dysfunctional circular process regarding the maintenance of inadaptive practices and children’s undesirable behaviors, considering the role played by parental attributions and by insufficient parental reflexivity.

Bridging the gap between child mental health need and professional service utilisation: Examining the influence of mothers' parental attributions on professional help-seeking intentions

There is a significant gap between the need for child mental health services and use of these services by families. Parental attributions may play a role in this. This study examined whether mothers' attributions about their child's problems influence professional help-seeking intentions in a general sample of community mothers. Secondary analysis re-examined this hypothesis in a subgroup of mothers of children with clinically elevated mental health symptoms. Cross-sectional survey data were collected from mothers (N = 184) of children aged between 2 and 12 years recruited from the community. Mothers completed self-report questionnaires measuring parental attributions: child-responsible attributions and parental self-efficacy; professional help-seeking intentions; and psychosocial covariates: child mental health, mothers' anxiety and depression, child age, gender, marital status, education, and professional help-seeking experience. Hierarchical regression modelling indicated that parental attributions explained professional help-seeking intentions after controlling for covariates in both the general sample (ΔF = 6.07; p = .003) and subgroup analysis (ΔF = 10.22, p = .000). Professional help-seeking intentions were positively associated with child-responsible attributions (β = .19, p = .002) but not parental self-efficacy (β =  - .01, p = .865) in the general sample, while positively associated with child-responsible attributions (β = .20, p = .009) and negatively associated with parental self-efficacy (β =  - .16, p = .034) in the subgroup analysis. Findings were independent of the presence of clinically elevated symptoms, problem type, and severity. Overall, the findings support models suggesting that parental attributions have a role in professional help-seeking for child mental health problems.

Time-Out with Young Children: A Parent-Child Interaction Therapy (PCIT) Practitioner Review

Time-out is a component of many evidence-based parent training programmes for the treatment of childhood conduct problems. Existing comprehensive reviews suggest that time-out is both safe and effective when used predictably, infrequently, calmly and as one component of a collection of parenting strategies-i.e., when utilised in the manner advocated by most parent training programmes. However, this research evidence has been largely oriented towards the academic community and is often in conflict with the widespread misinformation about time-out within communities of parents, and within groups of treatment practitioners. This dissonance has the potential to undermine the dissemination and implementation of an effective suite of treatments for common and disabling childhood conditions. The parent-practitioner relationship is integral to the success of Parent-Child Interaction Therapy (PCIT), an evidence-based treatment which involves live coaching of parent(s) with their young child(ren). Yet this relationship, and practitioner perspectives, attitudes and values as they relate to time-out, are often overlooked. This practitioner review explores the dynamics of the parent-practitioner relationship as they apply to the teaching and coaching of time-out to parents. It also acknowledges factors within the clinical setting that impact on time-out's use, such as the views of administrators and professional colleagues. The paper is oriented toward practitioners of PCIT but is of relevance to all providers of parent training interventions for young children.

Mind-Mindedness and Stress in Parents of Children with Developmental Disorders

Relations between mind-mindedness (assessed using the describe-your-child interview) and stress were investigated in parents of children with developmental disorders (ADHD, n = 51, ASD, n = 23, Down's Syndrome, n = 38, and 22q11.2 Deletion Syndrome, 22q11.2DS, n = 32) and typically-developing children (n = 89). Mind-mindedness did not differ across diagnostic groups, and mind-mindedness predicted parenting stress across groups. Parenting stress was lowest in the typically-developing and Down's Syndrome groups. Across all groups, mind-minded and positive descriptions predicted lower parenting stress, and negative descriptions predicted higher stress. In the developmental disorder groups, describing the children with reference to their disorder was negatively correlated with mind-mindedness. Results are discussed with regard to interventions for families where children have developmental disorders.

Transdiagnostic Associations Among Parental Causal Locus Attributions, Child Behavior and Psychosocial Treatment Outcomes: A Systematic Review

Parents' interpretations of the cause of their children's behavior, i.e., parental attributions, are linked to parenting behavior and child development. However, it is not yet known whether parental attributions are systematically associated with children's internalizing and externalizing symptoms and behavior or psychosocial treatment engagement and outcomes across diagnostic categories. This systematic review aimed to fill this knowledge gap using a transdiagnostic perspective to synthesize the literature on the associations between parent-causal and child-responsible attributions and children's internalizing and externalizing behavior, treatment engagement, and treatment outcomes for parents and children. A total of 67 studies were identified. Overall, biased child-responsible attributions were associated with elevated child internalizing and externalizing symptoms and behavior across diagnoses, while findings on the association between parent-causal attributions and child behavior were inconsistent. The link between parental attributions and treatment engagement was also mixed, varying across treatment type, child diagnosis, and focus of attributions. Regarding treatment outcomes, less biased parent-causal and child-responsible attributions were linked to post-treatment improvements in children's behaviors, while mixed findings were reported on post-treatment improvements in parental attributions. Findings are discussed with a focus on approaches to enhance the effectiveness of assessment and psychosocial treatment approaches across diagnostic categories with consideration of parental attributions.

Psychometric Properties of the Parent Cognition Scale in a Clinical Sample of Parents of Children With Disruptive Behavior

The Parent Cognition Scale (PCS; Snarr, Slep, & Grande, 2009) is a self-report measure of parental attributions of child behavior that has demonstrated validity in community samples. However, its psychometric properties have not been examined in a clinical sample of parents of children with disruptive behavior. Examining the psychometric properties of the PCS in this population is important given research linking parent attribution with childhood disruptive behavior. The present study aimed to: (a) examine the psychometric properties of the PCS in a sample of parents whose children were clinic-referred for disruptive behavior problems; and (b) investigate the concurrent validity of the PCS and its factors using correlations with parent reports of children's emotional and behavioral difficulties, and parenting skills (i.e., discipline, supervision). A confirmatory factor analysis was run on 225 parents' responses on the PCS, and revealed that a two-factor structure of the PCS fit the data well. Significant correlations were found between Parent Causal Attributions (Factor 1) and parent-reported parenting difficulties. Child Responsible Attributions (Factor 2) were correlated with elevations in children's emotion, attention, and conduct difficulties. The results provide information on the utility of the PCS for parents of children with disruptive behavior and its potential clinical relevance.

Parental and Familial Predictors and Moderators of Parent Management Treatment Programs for Conduct Problems in Youth

Despite the established efficacy of Parent Management Training (PMT) for conduct problems in youth, evidence suggests that up to half of all treated youth still display clinical levels of disruptive behavior post-treatment. The reasons for these unsatisfactory outcomes are poorly understood. The aim of the present review was to provide an updated analysis of studies from the past 15 years that examined parental and familial predictors and moderators of improvement in PMT for conduct problems. A systematic literature review of indicated prevention (children with conduct problem symptoms) and intervention (children with clinical diagnoses) studies published between 2004 and 2019 was conducted. This 15-year time period was examined since the last systematic reviews were reported in 2006 and summarized studies completed through mid-2004 (see Lundahl et al. in Clin Psychol Rev 26(1):86-104, 2006; Reyno and McGrath in J Child Psychol Psychiatry 47(1):99-111, 2006). Risk of bias indices was also computed (see Higgins et al. in Revised Cochrane risk of bias tool for randomized trials (RoB 2.0), University of Bristol, Bristol, 2016) in our review. A total of 21 studies met inclusion criteria. Results indicated that a positive parent-child relationship was most strongly associated with better outcomes; however, little additional consistency in findings was evident. Future PMT research should routinely examine predictors and moderators that are both conceptually and empirically associated with treatment outcomes. This would further our understanding of factors that are associated with poorer treatment outcome and inform the development of treatment components or modes of delivery that might likely enhance evidence-based treatments and our clinical science. Protocol Registration Number: PROSPERO CRD42017058996.

How Do Mothers' Parental Attributions Affect Child Outcomes from a Positive Parenting Intervention? A Mediation Study

Problematic parental attributions refer to negative causal explanations for child problem behaviour and are known to predict parenting intervention outcomes. This study examines alternative accounts of how mothers' problematic parental attributions, operationalised as negative pre-treatment and change resistant parental attributions during treatment, may affect child behaviour outcomes from a parenting intervention program. Putative mediators included parental feelings about the child and use of harsh discipline. Participants were 163 families with children aged from 3 to 16 referred to specialist clinics for the treatment of conduct problems. Measures were collected as part of pre-treatment, post-treatment, and 3-month follow-up assessments. Mothers' pre-treatment and change resistant parental attributions were associated with smaller improvements in parental feelings at the end of treatment which in turn were associated with greater use of harsh discipline. Greater use of harsh discipline was associated with greater conduct problems overall. Smaller improvements in parental feelings mediated the effects of pre-treatment and change resistant parental attributions on outcomes in mothers' use of harsh discipline and mediated the effects of change resistant parental attributions on outcomes in child conduct problems. Smaller improvements in parental feelings about the child may act as a mechanism that explains the impact of problematic parental attributions on treatment outcomes.

Co-occurring change in children's conduct problems and maternal depression: Latent class individual participant data meta-analysis of the Incredible Years parenting program

Children vary in the extent to which they benefit from parenting programs for conduct problems. How does parental mental health change if children benefit less or more? We assessed whether changes in conduct problems and maternal depressive symptoms co-occur following participation in the Incredible Years parenting program. We integrated individual participant data from 10 randomized trials (N = 1280; children aged 2–10 years) and distinguished latent classes based on families' baseline and post-test conduct problems and maternal depressive symptoms, using repeated measures latent class analysis (RMLCA) and latent transition analysis (LTA). Classes differed mainly in severity of conduct problems and depression (RMLCA; 4 classes). Conduct problems reduced in all classes. Depressive symptoms did not change in most classes, except in a class of families where conduct problems and depression were particularly severe. Incredible Years led to a greater likelihood of families with particularly severe conduct problems and depression moving to a class with mild problems (LTA; 3 classes). Our findings suggest that for the majority of families, children's conduct problems reduce, but maternal depressive symptoms do not, suggesting relative independence, with the exception of families with severe depression and severe conduct problems where changes for the better do co-occur.

Parents' Spontaneous Attributions about their Problem Child: Associations with Parental Mental Health and Child Conduct Problems

Parents' attributions about their child's personality and behaviour are known to predict the quality of parent-child interactions and outcomes for the child, including those from parenting interventions. Nothing is known, however, about the quantity and quality of attributions parents use during free speech about their children referred for treatment of behavioural and emotional problems. We tested hypotheses about the types of attributions and associations among parental attributions, parental psychopathology and child conduct problems, using 504 five-minute speech samples (FMSS) coded using the Parent Attribution Speech Sample (PASS) coding system. Both mothers and fathers talked about their thoughts and feelings regarding their children with disruptive behaviour problems (N = 295; 74% male; 3-8 years old). The assessment of spontaneous parental attributions via the PASS coding system was shown to be valid and reliable. Mothers made more negative, dispositional attributions than fathers, however, parents of either gender made, on average, more positive than negative attributions about their children. Parents' natural attributions about these children with emotional and behavioural problems were rather independent from parents' own mental health, but were consistently related to child factors. Specifically, across parent gender and across all attribution dimensions, levels of callous-unemotional traits were associated with spontaneous parental attributions above and beyond other child and parent factors. Overall, the results show that parents' spontaneous speech about referred children contains important information about their causal attributions, and that these are associated with child temperament rather than specific referral symptoms.