The Effectiveness of a Parenting Skills Program for ...

Journal of Consulting and Clinical Psychology 1999, Vol. 67, No. 6, 811-825

Copyright 1999 by the American Psychological Association, Inc. 0022-006X/99/$3.00

The Effectiveness of a Parenting Skills Program for Parents of Middle School Students in Small Communities A. Blair Irvine, Anthony Biglan, Keith Smolkowski, Carol W. Metzler, and Dennis V. Ary Oregon Research Institute This study provides evidence of the effectiveness of behaviorally based parenting skills classes provided by carefully trained and supervised group leaders who were not mental health clinicians. A program for parents of at-risk middle school students was evaluated in a randomized controlled trial in 8 small Oregon communities. Parents (N = 303) were randomly assigned to immediate treatment or a wait-list condition. Data were analyzed using latent growth modeling. Participation in the program led to significant improvements in problem-solving interactions as indicated by parent reports and a Taped Situations Test. Parents' overreactivity and laxness toward their children's behavior were reduced and their feelings toward their children improved significantly as a function of treatment. Parent-reported child antisocial behavior was also reduced.

This article describes the evaluation of a behavioral parenting skills program for parents of at-risk middle school children. The program, entitled the Adolescent Transition Program (ATP; Dishion, Kavanagh, & Kiesner, in press), produced significant effects on parents' skill and on youth behavior in a prior randomized controlled trial (Dishion & Andrews, 1995). That study can be thought of as an efficacy trial because group leaders were highly trained, experienced research staff who provided the program under optimal conditions (Flay, 1986). In the present study, the effectiveness of the program was evaluated in a randomized trial in which persons who were not mental health professionals delivered the program in eight small Oregon communities. Middle schools pose particular challenges to the development of early adolescents. Eccles et al. (1993) have described a "downward

spiral" that begins in early adolescence for some young people. The spiral consists of initial academic and social difficulties that lead to increasing emotional, behavioral, and academic difficulties. This spiral is particularly likely to occur in junior high and middle school settings. Compared with elementary school teachers, teachers in middle and junior high schools exercise greater control and discipline and have less personal and positive contact with students. Moreover, with departmentalized instruction with multiple classes for each student the norm, whole-group instruction is more common and small group instruction is less likely. Eccles et al. argued that these conditions make it particularly likely that students will fail academically and develop behavior problems. It is in this context that effective parenting practices may be particularly important. Increasing evidence suggests that certain parenting practices are critical to the development of adolescents both at school and at home. Patterson, Dishion, and colleagues (Dishion, Patterson, & Kavanagh, 1992; Patterson, 1995, 1996; Patterson, Reid, & Dishion, 1992) have shown that inadequate parental monitoring and discipline marked by high levels of coercive interaction predict the development of antisocial behavior both in childhood and adolescence. Dishion, Patterson, and Reid (1988) have shown that these parenting practices also predict the development of substance use. In a study of adolescents, Ary et al. (1999) found that parent-child conflict, inadequate monitoring, and poor family relationships contributed to the development of general problem behavior. This model was replicated in a study of 355 young people who were assessed in seventh or ninth grade and assessed again 2 years later (Biglan et al., 1996), as well as in a study of 204 adolescents who were assessed annually over 3 years (Ary, Duncan, Duncan, & Hops, 1997). Skills training programs for parents have been shown to bring about improvements in these parenting practices and to lead to reductions in youth problem behaviors (Taylor & Biglan, 1998). However, most studies have focused on parents of children, not adolescents (e.g., Webster-Stratton, 1997), or have targeted a mixture of children and adolescents (e.g., Kumpfer, 1988, 1996). Two programs that were designed especially for parents of middle school children have been shown to be efficacious. Pre-

A. Blair Irvine, Anthony Biglan, Keith Smolkowski, Carol W. Metzler, and Dennis V. Ary, Center for Community Interventions on Childrearing, Oregon Research Institute, Eugene, Oregon. This article was supported by Grant DA07389 from the National Institute on Drug Abuse (NIDA). Additional support was provided by Grant CA38273 from the National Cancer Institute and NIDA Grants DA09306 and DA09678. We thank Kate Kavanagh and Tom Dishion for their consultation and guidance. We are also indebted to the group leaders from each community whose dedication to the program often went well beyond the job description. They include Lois Azumano, Cathy Barr, Stevie Blakely, Phil Brady, Christine Campbell, Victoria Fuller, Karen Garibay, Linda Garrison, Pam Gerhardt, Gordon Gillespie, Michael Hammond, Tom Jacquemin, Ellen Johnson, Debby Jordan, Renee Kenna, Karen Kramer, Raven Muska, Brent Nichols, Kathy Peinhardt, Alex Quinoveva, Cathy Ward, Mike Wellborn, and Michelle Whitcomb. We thank Cathy Milchak for her dogged efforts to coordinate and track the data collection process and Wanda Ballentine for her help with preparation of this article. Constructive comments on earlier versions of this article were provided by Manuel Barrera, Carol Black, Tom Dishion, Barbara Gunn, Ted Taylor, and Lisa Strycker. Correspondence concerning this article should be addressed to A. Blair Irvine, who is now at the Oregon Center for Applied Science, 1839 Garden Avenue, Eugene, Oregon 97403. Electronic mail may be sent to birvine @orcasinc.com.

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812

IRVINE, BIGLAN, SMOLKOWSKI, METZLER, AND ARY Table 1 Communities Included in Each Year of the Study Year

Florence

1 2 3 4

A D(2)

Reedsport

Willamina

A

A

D(l)

C( 1)

Prineville

Creswell

Hood River

Sutherlin

Sherwood

B(6) D (1) D(l)

D(l)

B (8) E(l)

B (4) E(l)

B (4) D(l)

Note. Numbers in parentheses indicate the number of times that a PhD-level supervisor observed the group sessions. A = each intervention group was coled by a PhD-level supervisor from the Oregon Research Institute and an inexperienced group leader from that community. B = neither group leader had previously led a behaviorally based parenting skills class. C = one intervention coleader had extensive experience leading parenting groups and was completing a doctorate in clinical psychology. D = for the intervention group, one coleader had previously coled an Adolescent Transition Program (ATP) group. E = for the intervention group, both coleaders had previously led ATP groups. paring for the Drug-Free Years (Hawkins, Catalano, & Kent, 1991) is a five-session program designed as a universal intervention to assist parents in increasing their involvement, monitoring, and rule enforcement. It has been shown to have beneficial effects on parents' reports of their use of rewards, communication of rules, and punishment of alcohol use and to improve parents' communications with each other and with the target child (Catalano, Kosterman, Haggerty, Hawkins, & Spoth, 1998; Kosterman, Hawkins, Spoth, Haggerty, & Zhu, 1997). The ATP parenting program (Dishion et al., in press) is designed for parents whose children are at risk for substance use, academic failure, and antisocial behavior. Rooted in the evidence about the role of coercive family interactions in the development of youth problem behaviors (Patterson et al., 1992), the program focuses on helping parents develop consistent, nonharsh methods of setting limits on children's behavior while increasing their positive reinforcement of appropriate social behavior. The specific parenting skills covered include (a) making neutral requests, (b) using rewards, (c) monitoring, (d) making rules, (e) providing reasonable consequences for rule violations, (f) problem solving, and (g) active listening. As a result of the program, Dishion and Andrews (1995) found that parent and child negative behavior in problemsolving interactions was significantly reduced and teacher ratings of the focal child improved on the Externalizing scale of the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1991b). A critical issue for the development of parenting programs is how well they will achieve their intended effects when they are no longer being provided by researchers (Taylor & Biglan, 1998). Although there is substantial evidence that parenting programs can have a significant impact on parents' and children's behavior, few studies have shown that these effects can be obtained when the program is offered by someone other than a research team (Weisz, Donenberg, Han, & Weiss, 1995). This issue has typically been discussed in terms of a distinction between efficacy and effectiveness trials (Flay, 1986; Hoagwood, Hibbs, Brent, & Jensen, 1995). An efficacy trial consists of a controlled randomized experiment in which the effect of an intervention is evaluated under optimal circumstances. For example, the program is provided by a research team consisting of professionals with advanced degrees, there is extensive training, and implementation of the program is tightly monitored. Effectiveness trials involve tests of an efficacious intervention under more realworld conditions. For example, in an effectiveness trial, one might

test whether an intervention that has been validated using professionals continues to have an effect when it is delivered by less experienced interventionists.' The distinction is relevant to the present study because group leaders who are mental health professionals are unlikely to be available in most small communities (Irvine, Biglan, Duncan, & Metzler, 1996). In the Dishion and Andrews (1995) study of ATP, the research team from the Oregon Social Learning Center (OSLC) included two PhD-level clinical psychologists and experienced master' s-level therapists from psychology, education, and school psychology. In the present work, we tested whether effects could be achieved when the ATP was conducted in small communities by providers who were not professional mental health workers.

Method Research Design Families in eight small Oregon communities were assigned at random to receive immediate treatment (IT) or to participate as wait-list (WL) controls who received classes 3 months after the IT group had completed the program. The populations of the communities ranged from 1,717 to 5,355 residents. The study was conducted over 4 years, with two to six communities active in a given year (see Table 1 for further information).1 Parents provided baseline assessment data before the 1st intervention class (Time 1 [Tl]) and were assessed again just after completion of the 12th and final session (T2). Three months later, and prior to the first classes for WL families, all the parents again provided data (T3). They were again assessed at the end of the WL group classes (T4; 6 months postintervention for IT families) and again 6 months after that (T5).

Participating Families Table 2 provides descriptive information about families that participated in the study. The sample consisted of 303 families. The target children were 61% boys and 39% girls. Their average age was 12.2 years (SD = 1.1). One parent from each family provided data; that parent was the mother in 94% of the cases. The average age of the responding parent was 37.2 years (SD = 6.19). Most of the families were Caucasian I 1

During 2 recruiting years in one community and 1 recruiting year in two other communities, insufficient numbers of families were recruited; consequently, they were not included in the randomized trial during that year.

PARENTING SKILLS

813

Table 2 Demographic Information for Participating Families

Variable Age (years) Target child Target parent Mother" Father6 Target parent's gender Female Male Target child's gender Female Male Highest level of school completed (target parent) Grades 0-1 1 High school Some college College graduate or postgraduate No. unspecified Family annual income

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PARENTING SKILLS

Table 5

Means, Standard Deviations, and t-Test Values for the Taped Situation Test of Parent Problem Solving T2: WL vs. IT

Variable Tracking and reinforcing behavior M SD Setting expectations and defining problems M SD Remaining calm in a stressful situation M SD Monitoring and listening M SD Limit setting M SD Problem solving M SD

WL

IT

t

df

3.27

3.64 0.95

-3.07

170

3.26 0.65

-3.64

3.21

-3.68

0.75 2.94 0.59

2.83 0.77

WL: T2 vs. T4 d

12

T4

'(71)

P

d

.002

0.47

3.28 0.74

3.80 0.96

-3.43

60) or clinical (T score > 70) range at Tl and T3 (Achenbach, 199la). The IT and WL conditions had virtually identical proportions above these levels at Tl (for >60, 54% for WL and 56% for IT; for >70, 22% for WL and 20% for IT). They did not differ in the proportion of adolescents who were above these cutoffs at T3 (for >60, 41% for WL and 40% for IT; for >70, 12% for WL and 11% for IT). Secondary analysis of treated cases. All of the analyses presented thus far involved all of the families, whether they participated in classes or not. To further explore the effects of the ATP, we analyzed treatment effects on measures of adolescent behavior for a subset of 138 families that attended four or more sessions.

For Parent Report of Problematic Interactions, the model fit the data for IT cases, CFI = .960, NNFI = .969, ^(13, N = 138) = 16.18, p = .24. However, the model did not fit for WL cases. The difference factor was significantly different from zero for the IT condition (Z = -2.59, p < .005, d = 0.58). The result indicated that parents who received four or more sessions reported that their adolescents decreased the level of negative behavior in problematic interactions following treatment. For the PDR Antisocial Behavior scale, the multisample model for IT and WL conditions fit the data, CFI = .949, NNFI = .956, X*(23, N = 138) = 34.56, p = .058. The difference factor was significantly different from zero (Z = -3.85, p < .001, d = 0.66). Thus, for parents receiving more than four sessions, there was a clear and moderate-sized effect of treatment on parent-reported antisocial behavior. Analyses of effects for the PDR Child Adjustment scale and the CBCL total score did not yield significant results.

Discussion The results of this study suggest that a behaviorally based parenting program for parents of at-risk middle school students can be of value even when it is provided by persons who are not mental health professionals. The ATP led to less coercive parental behavior, as indicated by reductions in parents' reports of harsh behavior in problematic encounters with their adolescent and self-reports of reductions in overreactivity during disciplinary interactions with the adolescent. Evidence from the TST indicated that parents improved in their skill in tracking and reinforcing appropriate behavior, setting expectations and defining problems, remaining calm in distressing situations, setting limits, and problem solving. Parents' improvement in limit-setting ability was also indicated by the apparent effects that the ATP had in reducing PSA Laxness scale scores. These findings suggest that reductions in aversive behavior reported by parents were not due to them simply giving up efforts to set limits on their adolescents' behavior. The changes in parenting practices were accompanied by changes in adolescents' behavior, although these results were not as strong or as consistent. The IT condition produced a significant posttreatment improvement in adolescents' total problem score on the CBCL compared with the WL condition, although this effect was not replicated when the WL group received the intervention and the conditions did not differ in the proportion of children who were in the clinical range. The program led to reductions for IT parents in the coercive behavior of the adolescents in problematic interactions with parents. These effects were maintained through follow-up, but similar effects were not found for WL adolescents. PDRs indicated that the ATP affected antisocial behavior. The effect was maintained through follow-up for the IT condition, and there was an apparent delayed effect for WL families. PDRs of child adjustment improved as a function of the IT condition, but the failure of the model to fit the data across posttreatment time points indicated that this effect was not maintained at follow-up. Finally, when effects of the intervention were assessed only for families that attended four or more class sessions, there were two significant treatment effects. Parent reports of adolescent antisocial behavior showed significant treatment effects for both treatment conditions, which were maintained dirough follow-up. For IT families, a significant reduction in parent-reported negative behav-

PARENTING SKILLS ior of the child in problematic interactions with the parent was maintained through follow-up. These changes in parent and child behavior were accompanied by improvements in parental feelings toward their adolescents and, for the IT condition, by a posttreatment improvement in parental depression. The present results are consistent with those of Dishion and Andrews (1995), who found that the program decreased family conflict and improved CBCL teacher-rated child behavior at school. An analysis of attendance data provided additional support for the effectiveness of the program. The number of sessions parents participated in was positively related to improvements in parents' behavior. The more parents participated, the less they overreacted to their children and the better they were at problem solving in difficult situations with their children. One limitation of the present study was the substantial attrition, especially at T4 and T5. To some extent, the rate of attrition differed between conditions, with greater dropout at T2 and T3 in the IT condition than in the WL condition. However, there was no evidence on any dependent variable of an interaction between experimental condition and attrition status. This indicates that the differences obtained between experimental conditions were not due to differential attrition. With respect to the external validity of the study, dropouts from the study differed from those who remained in the program on four variables: parental laxness, parental overreactivity, parental depression, and PDR on peer relations. In addition to being a methodological concern, the attrition in this study has clinical implications. Although much of the attrition occurred after the program had been provided and before subsequent assessments, a sizable number of parents dropped out during the program or missed sessions. Nearly 14% of the parents in the IT condition and 38% in the WL condition did not attend a single session, with IT parents attending an average of 6.29 sessions and WL parents attending 4.33 sessions. The fact that more parents dropped out of the WL condition suggests that the immediate availability of treatment following a parent's agreement to participate may foster participation. Among the variables that have been shown to predict parent attrition from parenting intervention are family socioeconomic advantage, adverse child-rearing practices, parent stress, parental history of antisocial behavior, and severity of child functioning (Kazdin & Mazurick, 1994). Prinz and Miller (1994) found that treatment dropout can be reduced if the intervention attends to adult issues. Although this study provides evidence to support use of nonclinically trained group leaders to deliver a behavioral parenting program, it is only a modest step beyond an efficacy trial. Three of the 16 IT classes were coled by PhD-level clinicians. Eight IT classes had at least one group leader with previous ATP experience conducting the classes, and group leaders received considerable training and support along with regular supervision. One could argue that a purer test of effectiveness would have had wholly inexperienced group leaders, after initial training, implement the program with little ongoing supervision. This is undoubtedly the way that many treatment programs are disseminated to many social service professionals, but we question whether it is the optimal approach for dissemination to nonclinicians. We believe that empirically supported parenting programs in the hands of nonclinicians will be found to be most effective when the model for transferring the program involves substantial training and the involvement of experienced coleaders. This is indeed the model

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that Webster-Stratton has used in her dissemination of the Parents and Children Videotape Series (Webster-Stratton, 1992; WebsterStratton, personal communication, May 1997). We did not have an adequate sample size to compare effects of experienced versus inexperienced group leaders on participating parents, but this is an important area for further research. It might also be argued that the present study falls short of an effectiveness trial because the parents were paid for their homevisit recruitment visit. They received cash incentives for attendance at class sessions, plus snacks, sodas, and door prizes. Child care was also made available, and sometimes group leaders encouraged car pooling to minimize transportation problems. It may be, however, that only through the use of incentives will at-risk parents be motivated to participate. Concerning the issue of how to get empirically supported practices into communities (Biglan, 1998; Chambless & Hollon, 1998), we should not try to force efficacious programs into the procrustean bed of existing community conditions. If home recruitment and incentives enhance participation in parenting programs for at-risk parents, then we must study how these or similar strategies might best be used by communities. For example, in a current community intervention project, community leaders have decided to fund the ATP entirely with local and state funds. Although they decided to drop the cash incentive for class attendance, they added more costly child care and the provision of dinner to all family members at each session. The research results presented here also demonstrate that it is feasible to implement a parenting program in small communities that are far from a research center. Three of the communities in this study were more than a 2-hr drive from ORI; only one was less than an hour drive. The system for training and supervising therapists consisted of initial and follow-up training sessions, a preference toward use of experienced coleaders, and biweekly supervisory sessions involving the group leaders. Such a system would be feasible for an extension service or other such agency to provide. Two additional limitations of this study should be noted. First, the measures of children's functioning were limited to three parent rating measures—parent reports of the child's behavior in problematic interactions, the PDR, and the CBCL. Results for these measures suggested that the program led to some improvement in children's behavior. However, it is possible that change on these parent-report measures was as much a function of the social demands of being in the program as it was a function of change in the adolescent's behavior. In a current assessment of the program, we are also using archival school records and adolescents' selfreports as metrics of child behavior. Second, the study did not use direct observation measures of parents' behavior. Parent reports and analogue TSTs provided two different methods of assessment; but as advocated by Patterson (1982) and others, evidence of parent behavior changes that was directly observed would have increased our confidence in the effectiveness of the intervention. Taken together, the results from this study support the potential value of the ATP parenting skills classes first reported by Dishion and Andrews (1995). This research demonstrated a dissemination approach that resulted in reports of measurable changes at 1 year, when the intervention was delivered by trained and supported non-mental health professionals. These results may have broad and positive implications for communities that want to develop

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IRVINE, BIGLAN, SMOLKOWSKI, METZLER, AND ARY

programs for local residents who may benefit from improved parenting skills. Further study is recommended to learn about the mix of group leader experience and outside support that provides the most cost-effective programs for real-world applications.

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Received October 10, 1997 Revision received March 22, 1999 Accepted March 22, 1999