Pilot Study: Initial findings on effectiveness of invest in play parent groups
The study compared measurements before and after the intervention from 4 invest in play (iiP) groups in Denmark. The outcomes were compared to control and intervention groups derived from a meta-analysis of 14 European trials of a well-established evidence-based behavioural parent training programme.
The results show that:
- iiP effectively reduced child behaviour problems with effects comparable to the well-established intervention.
- iiP effectively reduced parenting stress with considerably larger effects compared to the well-established intervention.
- Parents in the iiP groups were more satisfied with the programme materials.
- Fewer sessions were needed.
- Costs were 48% lower at a specific clinic in Denmark.
The present findings are meant as a first building block while establishing larger and more rigorous studies of iiP effects. In addition, it is meant to illustrate how integrated assessment and evaluation in iiP may contribute to a continuous loop of learning and improvement as the programme is further developed.
Parent training interventions for children with conduct problems
Over the past 60 years, research on parent training has produced a wealth of information about effective prevention and treatment for reducing children’s challenging behaviours and increasing social emotional resilience. A review (Gatti, 2018) of evidence-based practice for children’s conduct problems identifies some of the most well researched programs for preventing and treating conduct problems. These include: Parent Management Training: PMTO (Forgatch, 2010), The Incredible Years ®: IY (Menting, 2013) (Webster-Stratton, 2001), Helping the Noncompliant child: NCCP (McMahon, 2003), Parent-Child Interaction Therapy – PCIT (Eyberg, Boggs, & Algina, 1995) (Thomas, Abell, Webb, Avdagic, & Zimmer-Gembeck, 2017), Triple-P (Sanders, Markie-Dadds, & Turner, 1999), Helping Defiant Children (Barkley, 2013), Treatment Foster Care Oregon (TFCO) (Fisher & Chamberlain, 2000), Parenting Plus (Carr, Hartnett, Brosnan, & Sharry, 2016), and Komet and iKomet (Enebrink, Forster, & Ghaderi, 2012). These interventions show reliable and clinically meaningful reductions in children’s oppositional and aggressive behaviors with parents.
Theoretical framework and mechanism of change
Present day evidence-based interventions for children ages 3-12 have their roots in the 1960’s with a recognition of the importance of intervening with parents to change children’s behaviour (Reitman & McMahon, 2013). Gerald Patterson and colleagues at the Oregon Social Learning Center, Robert Wahler at the University of Tennessee, and Sydney Bijou at the University of Oregon all contributed to this approach. Patterson and colleagues developed a social learning theory model to describe how coercive parent-child interaction patterns led to and maintained children’s negative behaviours (Patterson, 1976) (Patterson, 2005). Around the same time, Constance Hanf, at the University of Oregon Medical school, developed an intervention to coach parents during structured interactions with their children via bug-in-the ear and video feedback (Reitman & McMahon, 2013). These intervention models were different from prior interventions for children in that they focused on changing parent behaviour, used behavioural principles, and were concerned with documenting meaningful and measurable change in children’s behaviour. The focus of interventions developed by Patterson, Bijou, and Wahler were on operant principles of behaviour management. Hanf’s model placed more emphasis on the parent-child relationship as a key intervention target and focused more on social re-inforcement than tangible re-inforcement. Below we describe in more detail how current day interventions incorporate core principles developed and expanded from this early work.
Patterson’s social learning theory model is core to all evidence-based parent practices; see a review by Scott and Yale (2008). Social learning theory posts that children’s life-experiences shape their learning and behaviour, forming interaction patterns that are both modeled and re-inforced by their caregivers. Interventions that stem from this theory focus on understanding and changing the pattern of interactions between the caregiver and child so that parents are modeling effective interaction styles, re-inforcing children’s positive behaviours, and giving little attention to undesirable behaviours.
While social-learning provides the core theory for effective parent interventions for disruptive child-behavior problems, researchers and clinicians have examined the ways in which different theoretical approaches such as those that focus on attachment, cognitive processes, and attributions may be combined to produce more effective interventions (Fisher & Skowron, 2017) (Scott & Dadds, 2009). These may be particularly important in circumstances where children have been mistreated or where parents or children have experienced other trauma or adverse life circumstances.
Research shows that maltreatment or other severe, early life stress can result in measurable changes in children’s brains with lasting impact on their ability to learn, form positive relationships, and regulate their emotions (Child Welfare Information, 2015). Translational neuroscience research shows that increasing parental responsiveness and positive parenting and decreasing critical parenting can ameliorate some of these detrimental neurological outcomes for maltreated children (Fisher & Skowron, 2017). Social-learning interventions can have a direct impact on the quality of parent-child attachment (Fisher & Kim, 2007) (O’Connor, 2012). Approaches that combine social-learning theory with a specific focus on improving parent-child attachment are also effective (Van Zeijl, et al., 2006). Toth (2013) suggests that the field is moving towards a more relational, rather than single-theory, approach to interventions. An examination of the core components of several of the most effective social-learning parent interventions supports this view. For example, The Incredible Years, Triple P, and PCIT borrow from Hanf’s early work (Hanf & Kling, 1973) and begin with a focus on parent-child relationships in the context of responsive, child-directed play interactions. During these interactions parents are taught to focus their positive attention on their child, to be child-directed and responsive to their child’s overtures (serve and return), and to validate and support their child’s emotional states. This focus on the parent-child relationship and attachment goes beyond a purely behavioral social-learning model.
A potential barrier to the effectiveness of social-learning interventions is that while parents may know and understand how they should respond to their child, their attributions about their child or the situation may lead to emotional dysregulation that hinders their ability to respond effectively (Scott & Dadds, 2009). For many parents, standard behavioural parent training leads to positive change in parent attributions without an explicit intervention focus on changing attributions (Sawrikar & Dadds, 2018). For some higher risk parents, who find it more difficult to change negative attributions about their child’s behaviour, standard behavioural parenting interventions are less effective (Sawrikar, Hawes, Moul, & Dadds, 2020). Chacko et al. (2012) found that for high-risk parents, an enhanced intervention that included a focus on parents’ maladaptive cognitions led to more treatment engagement, more homework completion, and lower rates of drop out than traditional behavioural parent training.
Scott (2009) and Sawrikar (2018) both suggest that for high risk families with initial negative attributions, it may be helpful to integrate cognitive behavioural therapy (CBT) strategies into the intervention model. CBT focuses on the relationship between thoughts, feelings, and behaviors, with the goal of challenging or changing the negative thought processes, or attributions, that lead to dysregulation and ineffective behavioural responses. There is a robust research base for the use of cognitive behavioural interventions for a wide variety of mental health challenges including anxiety and depression in both adults and children and adult stress management and addiction (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). In the area of child externalising disorders, a meta-analysis (Battagliese, et al., 2015) of 21 studies that incorporated CBT strategies into social learning parent interventions showed effectiveness in reducing children’s oppositional and ADHD symptoms, improving children’s social competence, improving parenting skills, and reducing parent stress and depression. The Incredible Years and PCIT are two well established parent interventions, included in the Battagliese review, that include a focus on the role that parent cognitions and emotions play in effectively utilising social-learning strategies to support children’s positive behaviours. Triple P also has a training module focused on changing maladaptive attributions and cognitions for high-risk parents.
Model for invest in play mechanisms of change
In summary, there remains strong evidence for the effectiveness of parent interventions that are firmly grounded in pioneering behavioural parent training interventions. Research also supports the benefits of expanding these interventions to include content on creating strong parent-child attachments and addressing parental attributions and cognitions. Some parents will be able to implement parenting strategies more effectively if they receive intervention that targets the thoughts, feelings, behaviour cycle with the goal of changing negative attributions and increasing emotion regulation. In addition, the negative impact of adverse early childhood experiences on children’s developing brains, highlights the importance of early relationship-focused intervention for families that have experienced trauma or child maltreatment.
What content should be covered in parent interventions?
Meta-analyses, examining the core content of the most effective parent training programs for children, have helped to discern which programme elements are most effective. Leijten et al. (2019) reported that positive reinforcement, praise, and logical consequences produced the largest reductions in disruptive child behaviour, whereas focus on rules and parental problem solving were associated with weaker effects. (Kaminski, 2008) found similar results: focus on positive parent–child interactions, emotional communication skills, use of time out, and parenting consistency were associated with better outcomes, while focus on problem solving and children’s cognitive, academic, or social skills were associated with poorer outcomes.
Leijten, Melendez-Torres, & Gardner (2022) reported that, in treatment populations, programmes with a primary focus on core behaviour management techniques were more effective than programmes that added additional components. For higher risk prevention populations, core behaviour management strategies plus parental self-regulation was the most effective. Leijten hypothesised that in prevention settings, parents may experience high levels of environmental and mental health stressors that impair parental-self management and may need additional support to effectively implement the behavioural strategies. In treatment settings, on the other hand, parents are often seeking services specifically to address their child’s challenging behaviour. They may be ready to implement the behaviour management strategies with fewer barriers.
The importance of play for young children’s development and for the parent-child relationship is a cornerstone of several effective programmes: for example, The Incredible Years, Triple P, and PCIT all begin with parent-child playtime, as first developed in Hanf’s intervention model (Hanf & Kling, 1973). The LEGO Foundation has studied and funded research exploring the benefits of play for children (The LEGO Foundation, 2019) (The LEGO Foundation). Their findings highlight that caregiver-child play that is actively responsive, engaging, socially interactive, meaningful, and iterative leads to optimal child physical, social, emotional, and cognitive development. This kind of play involves giving the child freedom to explore, problem-solve, and imagine, with adults participating as a supportive partner, appreciative audience, or offering gentle guidance while letting children explore and create. Research also supports the role of play in parent-child attachment in healthy brain development (Schonkoff, Phillipe, & eds., 2000) Responsive caregiver-child play supports children to feel safe and secure in their first relationships, which then extend to their pattern of relationships with others. As noted above, this content is particularly relevant for families where there is a history of child maltreatment.
A focus on emotion competence, emotion regulation, and the development of empathy are another research-based components of interventions for parents of young children. Difficulties in reading and understanding others’ emotions is a well-established deficit for children with conduct problems and social skills difficulties. Parents’ ability to acknowledge children’s emotions, label them, and provide support around regulating negative emotions has been linked to positive outcomes such as improved self-regulation, self-esteem, and social skills. In contrast, parental dismissiveness of children’s negative emotions is associated with increased externalising and internalising behaviour problems and inability to self-regulate (Katz, Maliken, & Stettler, 20212). Tuning Into Kids (Havighurst, et al., 2012) evaluated emotion coaching as the primary focus of intervention for children with externalising behaviour problems and showed reduced behaviour problems and increased emotional understanding. Emotion coaching has also been included as one component of several comprehensive behavioural parent training interventions, such as The Incredible Years ® (Webster-Stratton & Reid, 2009), PMTO (Forgatch, 2010) and Triple P (Salmon, Dittman, Saunders, Burson, & Hammington, 2014). These programmes have not evaluated the independent impact of the emotion focused parts of their intervention but have reported changes in children’s emotion regulation skills as a result of the comprehensive intervention.
In summary, research supports teaching a set of core behavioural parenting strategies to reduce children’s disruptive behaviour disorders and increase co-operative and pro-social behaviours and emotion regulation. These programmes begin with positive strategies focusing on the parent-child relationship, praise, selective attention, and incentives, and then proceed to positive discipline, setting clear limits, follow-through, ignoring, and Time Out. A focus on building strong parent- child relationships through play interactions (informed by attachment theory) and addressing parent self-regulation and self-efficacy (informed by cognitive and attributional theory) are also indicated, particularly for higher-risk families.
Interventions for parents of neuro-diverse children
Neurodiverse children, specifically those with ADHD or autism, are frequently reported by their parents and teachers to display high rates of emotional or behavioural difficulties. For example, 50% of children with an ADHD diagnosis have behavioural or conduct problems, 30% have a co- morbid anxiety diagnosis, and 14% have autism (The Center for Disease Control and Prevention, 2022). For autistic children, rates of co-morbid diagnoses are similarly high. Seventy-nine percent of autistic children show clinical levels of anxiety, 59% meet criteria for ADHD, and 29% for Oppositional Defiant Disorder (ODD) (Stringer, et al., 2020). Given this high incidence of emotional and behavioural problems for neurodiverse children, it is not surprising that parent training interventions have been a treatment of choice for these children and their parents.
Many of the effective programmes for children with conduct problems, reviewed above, also have been tested as treatments for children with ADHD; for example, Incredible Years, (Webster- Stratton, Reid, & Beauchaine, 2011) and Patterson’s PMTO program (Bjørnebekk, Kjøbli, & Ogden, 2015). Other programmes such as the New Forest Parenting (Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001) have been specifically developed for parents of children with ADHD. This research shows clinically important improvements in the disruptive and oppositional behaviours that are often co-morbid with ADHD (Barkley, 2016) but shows more limited effects in reduction of core ADHD symptoms.
Review of the content for programmes targeting ADHD generally concurs with that for conduct problems and highlights the importance of the parent-child relationship along with core parent management strategies. Hornstra, (2022) found that for children with ADHD, content on logical consequences for problem behaviours was particularly important. However, they also noted that in all programmes, logical consequence strategies were proceeded by a strong focus on parental attention and reinforcement of positive opposite behaviour. It is likely that the positive framework is an important pre-requisite to the use of negative consequences. There is evidence that a reduction in negative parenting as well as an increase in parent self-efficacy is associated with greater reduction in children’s ADHD symptoms (Rimestad, O’Toole, & & Hougaard, 2020). Several studies have found limited effects of psycho-education as an addition to parent-training for children with conduct problems (Leijten, Melendez‐Torres, & Gardner, 2022) or ADHD (Hornstra, 2022).
Preliminary research indicates that skills-based parent training is also effective at reducing disruptive behaviors for autistic children. An RCT with parents of autistic children found an adaptation of Triple P (Stepping Stones) reduced child behaviour problems and dysfunctional parenting compared to a control group (Whittingham, Sofronoff, Sheffield, & Sanders, 2009). Several preliminary studies using the IY program for families of autistic children show high parent satisfaction, reduced parental stress, (Dababnah & Parish, 2016) and significant pre-post change in parenting and disruptive child behaviours (Pierce & Lyons, 2019).
Behavioural parent training interventions developed specifically for children with autism also show promising results. Tonge and colleagues (2014) conducted an RCT comparing parent education, parent education plus behavioural skills training, and a usual services control condition for parents of autistic pre-schoolers. Results showed that education plus behavioural skills training produced more improvement in children’s social and communication skills than education alone or usual treatment. An RCT by Bearss, et al. (2015) comparing parent education to behavioural parent training for autistic children found stronger results for behavioural parent training on measures of disruptive and oppositional child behavior. Another promising behavioural parent training program for autistic children, Riding the Rapids, showed significant intervention effects on children’s behaviour problems and parents’ feelings of competence in a non-randomised comparison of intervention and waitlist control families (Stuttard, et al., 2014).
It is notable that parent training treatment effects for children with ADHD and autism are strongest for outcomes related to effective parent skills, parent stress, and challenging behaviours rather than core ADHD (Barkley, 2016) and core autism symptoms (Oono, Honey, & McConachie, 2013). Barkley (2016) suggests that, in some cases, behavioural parent training for children with ADHD may be counter-indicated because it sets parents up to confront disruptive behavior that may be out of the child’s voluntary control. It may be that an important focus of parent training for families of children with ADHD and autism should be to help parents accept, value, and work with their child’s neurodiverse characteristics, rather than trying to eliminate these core symptoms. Interventions that focus on teaching strategies to reduce parent-child conflict and to provide scaffolding and support to help the child to be successful in home and school environments will improve quality of life for both parents and children.
What should parent programme delivery look like?
Group versus Individual Treatment: the evidence-based programmes listed above include both group, for example, The Incredible Years®, (Webster-Stratton, 2001); Helping Defiant-Children (Barkley, 2013); Triple P, (Sanders, Markie-Dadds, & Turner, 1999) and individual treatment models (Helping the Non- Compliant Child, (McMahon, 2003); Parent Management Training, (Forgatch, 2010); Parent- Child Interaction Therapy (Eyberg, Boggs, & Algina, 1995), Triple P, (Sanders, Markie-Dadds, & Turner, 1999); and the New Forest Program, (Sonuga-Barke, Daley, Thompson, Laver- Bradbury, & Weeks, 2001). Both group and individual treatment models are effective and have not been found to differ significantly from each other in terms of most parent or child outcomes (Webster-Stratton, 1984) although Hornstrat (2022) reported some benefit to individual therapy over group therapy for reducing children’s ADHD symptoms.
Parent preference and programme costs are also key factors to consider when delivering parent training. Initially parents of children with ADHD reported they would prefer individual to group treatment (Wymbs, et al., 2016); however, 85% said that they would be willing to participate in group treatment if individual treatment were not available. An RCT by Gross (2018) compared group treatment (IY) to individual sessions (PCIT) and found no difference between attendance rates and effectiveness for the two formats. However, parents who received the group parent training reported higher satisfaction post-treatment. In terms of cost, while group therapy would seem to be more cost-effective, that is not always the case. Sonuga-Barke, et al. (2018) found that individually administered treatment using the New Forest Model was less expensive than group treatment using the Incredible Years ® model, likely because of the small size of the groups and agency factors related to therapist turn-over. This research indicates that in some situations, individual therapy may be less expensive than group therapy.
In summary, individual and group parent interventions are both effective and have different advantages based on the situation. Parent preference and characteristics, numbers of families who need treatment, proximity of families to treatment location, and parents’ schedules and availability should be considered. Flexible programmes that can deliver treatment using a combination of group and individual sessions may be most effective.
How should content be delivered?
In terms of content delivery, research from the wider treatment and training literature with both adults and children sheds light on intervention components that lead to behaviour change. Several elements of CBT interventions are linked to intervention effectiveness: behavioural modelling, role play practice, (Taylor, Russ-Eft, & Chan, 2005) (Bellini & Akullian, 2007) (Rønning & Bjørkly, 2019) and homework practice activities (Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010).
All the evidence-based programmes listed above use these components (modelling, role play, and homework) to some degree. Hornstra’s review (2022) of 32 parent programmes found that role play was used in 40%, homework assignments in 47%, and live or video-modelling in 76% of programmes. The extent to which each of these elements contributes significantly and uniquely to parent outcomes is not well-researched, but research supports the inclusion of each element. Kling (2010) found that homework completion was related to positive parent intervention outcomes. Becker et al., (2015) reported that homework assignment and modelling were associated with improved adherence to parent training. Kaminski (2008) reported that role play between the parent and their own child predicted positive change.
Several evidence-based parent training programmes utilise standardised video clips to illustrate examples of both positive and negative parent-child interactions for parent learning and discussion, for example: The Incredible Years, (Webster-Stratton, 2001), Tuning Into Kids, (Havighurst, et al., 2012), Parenting Plus (Carr, Hartnett, Brosnan, & Sharry, 2016), and Triple P (Sanders, Markie-Dadds, & Turner, 1999). Webster-Stratton (1989) compared two parent interventions, one using standardised video modelling and one using group discussion. Video modelling and group discussion were both more effective than a control condition, and video modelling was more effective than group discussion on material stress, increased parent praise, parent satisfaction, and attendance. Taken together, these data, provide support for the continued use of homework, role play (particularly with own child), and therapist and video modelling as important elements of a parent training programme.
Treatment research attests to the importance of a supportive and collaborative therapist-client relationship in positive therapy outcomes (Tyron & Winograd, 2011). Motivational Interviewing (MI) techniques, originally developed for treatment of alcoholism, have also informed knowledge of effective ways to enhance behaviour change (Miller & Rollnick, 2013). Therapists using an MI approach are collaborative, empathic, affirming, ask open-ended questions, and encourage client self-reflection. In the parent-training literature, incorporating MI techniques with behavioural parent training improved parent outcomes and engagement compared to behavioural approaches without MI (Nock & Kazdin, 2005) (Sibley, et al., 2016) (Stormshack, DeGarmo, Garbacz, & McIntyre, 2021). Other parent training programmes describe and incorporate the collaborative approach as a core component of working with parents of children who have disruptive behaviour disorders (Webster-Stratton, 2012) and autism (Fettig & Ostrosky, 2013).
If families do not access or participate in evidence-based treatments for children’s conduct problems, then the positive outcomes outlined above cannot be realised. A review of parent engagement in behavioural parent training (Chacko, et al., 2016) reports that 25% of parents who are referred to receive behavioural parent training do not pursue the referral and an additional 26% of those who initiate treatment dropout before completing. Research has examined factors that improve parent attendance and engagement in treatment. Becker, et al., (2015) reported that providing information about the treatment, assessing barriers, and increasing accessibility to treatment (e.g., childcare and transportation) were factors most strongly related to parental attendance. Ingoldsby (2010) examined successful engagement strategies across 17 intervention studies and found that several elements were associated with better engagement: individually addressing each family’s barriers and concerns early in the intervention process and revisiting these barriers throughout treatment, having a strong theoretical intervention framework, utilising motivational interviewing strategies, and engaging multiple family members in the intervention. McCabe and colleagues (McCabe, Yeh, & Zerr, 2010) describe a process using standardised interviews that provide therapists with information to tailor evidence-based treatments to fit the values and goals of culturally diverse families.
Interventions are more effective when they are culturally sensitive and specific (Griner & Smith, 2006), and cultural adaptations should cover a wide range of areas including language, context, metaphors, concepts, content, goals, and presenting problems (Bernal, Bonilla, & Bellido, 1995). A meta-analysis examining the impact of culturally adapted mental health interventions found moderately strong effects of cultural adaptations to traditional interventions on mental health outcomes for diverse populations (Griner & Smith, 2006).
Interventions targeting adaptations for one cultural group were four times more effective than adaptations provided to mixed cultural groups. Research by Wang and colleagues (Wang, 2008) shows that cultural adaption of existing evidence-based interventions that maintains the core elements of the intervention while fitting the needs of a different cultural context, is an effective approach (Wang, 2008). While it is more typical to think of cultural adaptations in the context of ethnicity, race, nationality, language, or culture, the same need for adaptation exists for interventions that target neurodiversity such as autism or ADHD (Dickson, et al., 2021). Lee and colleagues (2022) developed a Cultural Adaptation Checklist that provides a helpful framework for outlining and measuring the key elements that are necessary when making cultural adaptations to an existing intervention. These include:
1. language that is translated for both meaning and understanding, with a feedback loop from consumers
2. involving key stakeholders in the creation process
3. content adapted for cultural significance, appropriate metaphors, and examples
4. goals aligned with cultural values, methods, and context
5. process to provide continued discussion and feedback loops that align the goals and needs of the community with those of the programme developers
This checklist provides a tool to guide the development of culturally relevant evidence-based programmes and to measure the extent to which existing programmes address important cultural elements.
invest in play and the Six Bricks for Kids model
The development of the invest in play (iiP) parent intervention is informed by the above research in programme theory, content, cultural relevance, and delivery format. The core parent programme includes the same key content and theoretical background that has been found to be effective across prior research studies. These key content areas are represented in the Six Bricks for Kids model below.
The program is structured to include home practice feedback, standardised videos that represent parents own language and cultural setting, parent practice, interactive teaching, and parent discussion. Therapists use motivational interviewing strategies to assess family’s individual goals, beliefs, cultural identity, and attributions about their child’s behaviour. The intervention is delivered in group format to strengthen support systems for families but provides flexibility to deliver sessions to individual families in some contexts. Additional modules will be used alongside the core program to address other child or family characteristics, for example: ADHD, autism, anxiety, or family involvement in the child welfare system.
To provide a culturally relevant programme across diverse audiences, invest in play co-creates cultural adaptations of the core parent programme with communities who wish to adopt the programme. These adaptations are created in response to community need and may be based on language, nationality, racial, ethnic, and cultural context. The same co-creation process is used to develop supplementary modules for neurodiverse audiences such as autistic people or people with ADHD. Each culturally relevant version of the programme will be made available to all users. This allows providers who work with diverse clients to provide culturally relevant intervention to a broader range of families.
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