Amelioration of Child Depression Through Behavioral Parent Training: A Preliminary Study

Child depression is an impairing condition for which tested treatments have shown relatively modest mean effects. One possible explanation is that the treatments have generally adopted an individual child focus, without addressing the dysfunctional parent–child interactions that often accompany child depression. The present study provides preliminary evidence bearing on this hypothesis, using data from a treatment outcome study in which clinically referred children with a depression diagnosis could receive individual cognitive behavioral therapy (CBT) focusing on the depression or behavioral parent training (BPT) focusing on comorbid conduct problems. Among children in the study who met criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed.) depressive disorders, we identified two groups, matched on gender and age: 15 who received only CBT focused on child depression and 15 who received only BPT focused on child conduct problems. Children were 7 to 13, 20 of whom were male, and race included Caucasian (17), Latino (5), African American (2), and multirace (6). Measures assessed depressive diagnoses and symptoms, as well as parenting stress. Analyses focused on whether BPT alone might lead to reduced depression, and if so how that reduction would compare to the depression reduction achieved through CBT that focused on depression. Both groups showed significant reductions from pre- to post-treatment in depressive diagnoses and depression symptoms, and there were no BPT versus CBT group differences at post-treatment. BPT that focuses on child conduct problems, with no emphasis on depression treatment, may produce significant depression reduction in comorbid children who meet criteria for depressive disorders.     

Face-to-Face Versus Online Behavioral Parent Training for Young Children at Risk for ADHD: Treatment Engagement and Outcomes

Attention deficit/hyperactivity disorder (ADHD) is associated with significant challenges in child functioning. Although behavioral parent training (BPT) can reduce ADHD symptoms, factors associated with traditional face-to-face (F2F) delivery results in only about half of families receiving BPT. The purpose of this pilot randomized controlled trial was to examine parent engagement and program acceptability of F2F and online BPT, as well as the efficacy of both formats relative to a waitlist control (WLC) group. Participants were 47 families with preschool children (30 boys, 17 girls) who were between the ages of 3 years 0 months (3;0) and 5 years 11 months (5;11) old who were identified at risk for ADHD. Children were randomly assigned to F2F or online BPT or to WLC; parents in the two treatment conditions received 10 sessions of BPT. Assessment data for all groups were collected at pre-, mid-, and posttreatment. Both intervention formats resulted in high attendance (M = 80%) and significantly improved parent knowledge of interventions, treatment implementation fidelity, and child behavior (reduced restlessness and impulsivity, improved self-control, affect, and mood) compared with WLC. However, parents in the F2F group reported significantly higher acceptability ratings than parents in the online group. Findings indicate a streamlined BPT delivered online or F2F results in high levels of engagement, acceptability, as well as parent treatment knowledge and fidelity. Online BPT is associated with similar efficacious outcomes with F2F BPT, suggesting the need for further research to determine variables that predict greater acceptability for and adoption of this format.     

A meta-analysis of parent training: moderators and follow-up effects

A meta-analysis of 63 peer-reviewed studies evaluated the ability of parent training programs to modify disruptive child behaviors and parental behavior and perceptions. This analysis extends previous work by directly comparing behavioral and nonbehavioral programs, evaluating follow-up effects, isolating dependent variables expressly targeted by parent training, and examining moderators. Effects immediately following treatment for behavioral and nonbehavioral programs were small to moderate. For nonbehavioral programs, insufficient studies precluded examining follow-up effects. For behavioral programs, follow-up effects were small in magnitude. Parent training was least effective for economically disadvantaged families; importantly, such families benefited significantly more from individually delivered parent training compared to group delivery. Including children in their own therapy, separate from parent training, did not enhance outcomes.     

Cognitive-behavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior

The present study evaluated alternative treatments for children (N = 112, ages 7-13) referred for severe antisocial behavior. Children were randomly assigned to one of three treatments: problem-solving skills training (PSST), problem-solving skills training with in vivo practice (PSST-P), which included therapeutically planned activities to extend training to settings outside of treatment, or client-centered relationship therapy (RT). PSST and PSST-P children showed significantly greater reductions in antisocial behavior and overall behavior problems, and greater increases in prosocial behavior than RT children. These effects were evident on measures obtained immediately after treatment and at a 1-year follow-up, and on measures of child performance at home and at school. PSST-P children showed greater changes than PSST children on measures of functioning at school at posttreatment, but these differences were no longer evident at follow-up. Children in both PSST conditions showed significant reductions in deviant behavior and improvements in prosocial behavior from pretreatment to follow-up, whereas RT children tended to remain at their pretreatment level of functioning. Notwithstanding the significant improvements, comparisons with nonclinic (normative) samples revealed that the majority of youth remained outside of the normal range of deviant behavior. Possible directions for improving treatment for antisocial youth are highlighted.     

Therapies for hyperactive children: comparisons, combinations, and compromises

Comparative treatment studies of attention-deficit hyperactivity disorder (ADHD) are impeded by methodological quandaries, constricted focus, and the heterogeneity of ADHD children, research designs, measures, and treatment responsiveness. Comparisons are drawn among three major treatment modalities for ADHD: stimulant treatments, primarily methylphenidate; behavioral treatments, including contingency management and parent training; and cognitive-behavioral or self-regulation therapies. We identify a dozen "...abilities," such as communicability, controllability, and constrainability, that compel consideration and that convert either-or questions about the single best treatment into more comprehensive assessment and intervention strategies. The profusion of problems called ADHD mandates multimodal approaches not only to optimize therapeutic impact but also to inform theories of developmental psychopathology and therapeutic change.     

Preschool children with disruptive behavior: three-year outcome as a function of adaptive disability

A significant discrepancy between intelligence and daily adaptive functioning, or adaptive disability (AD), has been previously found to be a associated with significant psychological morbidity in preschool children with disruptive behavior (DB). The utility of AD as a predictor of later developmental risks was examined in a 3-year longitudinal study of normal (N = 43) and DB preschool children. The DB children were grouped into those with AD (DB+AD; N = 28) and those without AD (DB-only; N = 98). All children were followed with annual evaluations to the end of second grade. Both DB groups demonstrated substantial and pervasive psychological and educational morbidity at 3-year follow-up. In comparison to DB-only children, DB+AD children had more symptoms of attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD), more severe and pervasive behavior problems at home, more parent-rated externalizing and internalizing, and lower academic competence and more behavioral problems at school. Parents of DB+AD children also reported greater parenting stress than did parents in the other groups. A significant contribution of AD to adverse outcomes in the DB group remained on some measures even after controlling for initial severity of DB. AD also contributed significantly to CD symptoms at follow-up after controlling for initial DB severity and initial CD symptoms. The results corroborate and extend earlier findings of the utility of AD as a risk indicator above severity of DB alone. They also imply that AD in the context of normal intellectual development may arise from both the deficient self-regulation associated with ADHD and from disrupted parenting. with exposure to kindergarten moderating these adverse effects.     

Predicting successful weight loss after treatment

Conducted two 8-week behavioral self-control weight reduction groups to investigate the relationship between locus of control and success at weight reduction (N = 49 female Ss). Mean weight losses were significant at post-treatment and after a 3-month and 18-month follow-up. There was no significant difference in weight loss between internals and externals at post-treatment, but internals maintained a significantly greater weight loss than externals at the follow-ups. These results are discussed with regard to self-control behavior.     

Predictors of Response to Behavioral Treatments Among Children With ADHD-Inattentive Type

The goal of the study was to examine baseline characteristics—child gender, IQ, age, internalizing problems, symptoms of hyperactivity/impulsivity (HI), oppositional defiant disorder, and sluggish cognitive tempo, and parent income, education, attention deficit/hyperactivity disorder (ADHD) severity, and anxiety/depression (A/D)—associated with response to behavioral treatments for ADHD, predominantly inattentive type. We employed data from 148 children (M = 8.7 years), 58% male, and 57% Caucasian in a randomized clinical trial. Positive treatment response was defined as (a) 5 or fewer inattentive symptoms and (b) a decrease of at least 3 inattentive symptoms from baseline to posttreatment. Child HI, parental A/D, and child IQ were associated with positive response, as follows: Child HI had a main effect in which it was negatively associated with treatment response (36% with 2 or more HI symptoms were positive responders vs. 59% of those with 1 or no symptoms) that was qualified by parental A/D and child IQ. When children had 2 or more symptoms of HI and higher parental A/D, positive response rate was low at 25%; when children had 2 or more symptoms of HI, low parental A/D, and an IQ of 105 or higher, positive response rate was 85%. Furthermore, the group with the poorest response rate (25%) had parents who self-reported greater ADHD severity, and the group with a relatively good rate of positive response (59%) had the lowest number of oppositional defiant disorder symptoms. Likelihood of positive response to our behavioral treatment for ADHD-I is dependent on child and parent factors.     

Community interventions in children's injury prevention: Differing costs and differing benefits

Three studies focused upon implementation issues in children's injury prevention programs. Study One used a small group design to examine the parent as a cost-effective safety skills instructor and to assess the possibility of crossproblem generalization of training. The results suggested that with hourlong instruction sessions, volunteer parents who received once-weekly professional instruction could effectively teach their children home safety skills across a variety of areas. There were also some indications of generalization of two of the three untrained areas-Study Two attempted to replicate these effects with a larger group of parents whose children volunteered for instruction. This study showed very weak and inconsistent effects for home safety skills instruction, with the primary reason for the lack of replication appearing to be inadequate instruction by the parent. The demands of training with no enhancing motivation through contact with a professional appeared to limit the amount and rigor of instruction for most community participants. A third study examined the influence of a one-time, hospitalbased workshop on home safety, and the same low-level gains were discovered. The similarities and differences in these three methods of delivering home safety instruction are considered, and future challenges to implementation are discussed.     

Couple and individual adjustment for 2 years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy

Follow-up data across 2 years were obtained on 130 of 134 couples who were originally part of a randomized clinical trial comparing traditional versus integrative behavioral couple therapy (TBCT vs. IBCT; A. Christensen et al., 2004). Both treatments produced similar levels of clinically significant improvement at 2 years posttreatment (69% of IBCT couples and 60% of TBCT couples). Both treatments showed a "hockey-stick" pattern of change in which satisfaction dropped immediately after treatment termination but then increased for most of follow-up. The break point when couples reversed courses and gained in satisfaction occurred sooner for IBCT than TBCT couples, and those couples who stayed together generally fared better in IBCT than in TBCT. Finally, there was evidence of greater stability during follow-up in IBCT than in TBCT couples. There was little change in individual functioning over follow-up, but when change occurred it was strongly related to change in marital satisfaction. Given that this sample was selected for its significant and chronic distress, the data are encouraging about the long-term impact of behavioral couple therapy.     

Marital Discord and Child Behavior Problems: A Description of Family Interactions During Treatment

We conducted systematic observations of parent-parent interactions for 4 families undergoing behavioral parent training. The families all presented with an oppositional child and showed evidence of concurrent marital discord. Families underwent baseline, child management training (CMT), partner support training (PST), and follow-up in a multiple-baseline-across-families design. Measures of parent and child behavior were obtained by independent observers, who recorded the family interaction in the home during the evening meal and in other settings. Results showed that at baseline and CMT, parents engaged in aversive interchanges with their spouses, especially concurrently with child misbehavior. For most parents, successful implementation of the child management techniques was observed despite the aversive parental interchanges. Low rates of supportive interchanges were observed. During PST, aversive behavior decreased and problem solving increased for the majority of parents. Little change was noted for supportive behaviors. The results support the theories of Patterson and Reid (1984) and others, which emphasize the functional relationship of aggressive child behaviors to marital and other family interactional systems.     

Personality, body image, and eating pattern changes in overweight persons after weight loss.

A group of overweight persons who achieved a substantial weight loss over a 6-month period were compared with a group of overweight persons who showed an unsubstantial weight change and a normal weight control group. All groups were evaluated before the weight program began and at a 6-month follow-up. The substantial weight loss group showed a number of significant changes after weight reduction. Body image rating shifted in the direction of evaluating onself as less heavy, eating was rated as less good and more heavy, and a greater feeling of self-control was indicated. Over time, the change group learned to limit the number of emotional and environmental cues that were discriminative stimuli for eating behavior. There also were more frequent reports of eating in response to cues of hunger after substantial weight loss.     

Preschool children's response to behavioural parent training and parental predictors of outcome in routine clinical care

Objective

To investigate the effectiveness of behavioral parent training (BPT) for preschool children with disruptive behaviours and to explore parental predictors of response.

Methods

Parents of 68 preschool children, aged between 2.7 and 5.9 years, participated in BPT. We evaluated the changes in children's behaviour after BPT with a one group pretest–posttest design, using a waiting period for a double pretest. Outcome was based on parents' reports of the intensity and number of behaviour problems on the Eyberg Child Behavior Inventory. Predictor variables included parents' attention‐deficit/hyperactivity disorder symptoms, antisocial behaviours, and alcohol use, and maternal parenting self‐efficacy and disciplining.

Results

Mother‐reported child behaviour problems did not change in the waiting period but improved significantly after BPT (d = 0.63). High levels of alcohol use by fathers and low levels of maternal ineffective disciplining were each associated with somewhat worse outcome.

Conclusions

BPT under routine care conditions clearly improves disruptive behaviours in preschool children. Mothers who consider themselves as inadequate in disciplining and mothers whose partners do not consume high levels of alcohol report the largest improvements.     

Digit Span components as predictors of attention problems and executive functioning in children.

This study examined the extent to which digits forward (DF) or digits backward (DB) account for variance in parent ratings of attention and executive function in children. The sample (n=90) included children with no diagnosis and children with a range of clinical problems, including attention deficit hyperactivity disorder (ADHD). Clinical groups differed from the No Diagnosis group on cognitive ability as well as achievement. Once cognitive ability was controlled, no group differences emerged for Digit Span or digits forward; notably, the ADHD-Predominantly Inattentive group was able to recall significantly more digits backward than the ADHD-Combined Type group. Regression analyses indicated that Full Scale IQ explained significant variance in parent ratings of attention and executive function; DF emerged as a significant predictor only for one measure of attention. When only children with ADHD were considered, DF no longer was a significant predictor. Results support the notion that DF and DB are differing constructs, as well as highlighting the importance of controlling for cognitive ability in consideration of group differences on behavioral measures.     

The Effects of Stimulant Medication and Training on Sports Competence Among Children With ADHD

The current study examined the relative efficacy of behavioral sports training, medication, and their combination in improving sports competence among youth with attention deficit/hyperactivity disorder (ADHD). Participants were 73 youth (74% male; 81% Hispanic) between the ages of 5 and 12 diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) ADHD enrolled in a Summer Treatment Program (STP). The study consisted of a 2 (medication: methylphenidate, placebo) × 2 (sports training: instruction and practice, recreational play) between-groups design and was conducted over a 3-week period during the STP. Sports training was conducted with a novel sport, badminton, to limit previous sport knowledge and to differentiate it from concurrent sports training that occurred within the STP. Objective and subjective measures of sports skills, knowledge, and behavior were collected. Results indicated that, relative to recreational play, brief sports training improved observed and counselor-rated measures of sports competence including sports skills, knowledge, game awareness, effort, frustration, and enjoyment. During sports training, medication incrementally improved children’s observed rule following behavior and counselor-rated sportsmanship relative to placebo. In the absence of sports training, medication improved behavior, effort, and sport knowledge. Training in sports skills and rules produced the largest magnitude effects on sports-related outcomes. Therefore, skills training, rather than medication alone, should be used in conjunction with behavioral intervention to teach sports to youth with ADHD. It is recommended that medication be used only as an adjunct to highly structured sports skills training for youth who display high rates of negative behavior during sports activities.     

Biofeedback vs. video games: effects on impulsivity, locus of control and self-concept with incarcerated juveniles

Research has found hyperactivity, poor impulse control, impaired sustained attention and low self-concept to be behavioral deficits common to juvenile delinquents. Limited opportunities for exercising self-control while incarcerated may encourage helplessness. If biofeedback training enhances self-regulation skills, then perhaps these behaviors can be taught in confinement. A sample of 12 felonious juvenile residents (aged 15-18) from a highly restricted environment were assigned randomly to a biofeedback or video game group and trained for 10 half-hour sessions. Results indicated virtually no significant differences between biofeedback and video game training. However, pre and post differences for both groups combined demonstrated significant gains in impulsivity, EMG, and self-concept. Both groups rated themselves equally on self-control ability, regardless of training. Further comparisons between other institutionalized residents (N = 14) and staff counselors (N = 10) as non-treatment controls were made. On each measure, both training groups improved consistently and became more like their less restricted counterparts.     

Training parents as therapists: A comparison between individual parent-child interaction training and parent group didactic training

Children with home behavior problems frequently are treated via training their parents to become behavior therapists for their own children. One well-established approach has been to use didactic group training. Another approach involves parent training in specific parent-child interaction patterns through the use of modeling, in vivo practice, and immediate feedback. In this study, the effectiveness of these two methods was compared via multiple outcome measures, which included both direct therapist observation and parent report. Twenty-nine children between the ages of 4 and 9 were divided into didactic group-treatment, individual mother-child interaction training, and controls. After five training sessions, therapist observation revealed improvement in the facilitative behavior of the mothers who received individual, in-vivo instruction, as well as improvement in the children's behavior. No significant changes were observed in the group treatment or control conditions. Specific home management behaviors were improved in all three groups according to mothers' reports. The individually trained mothers expressed significantly more satisfaction with the program. It is suggested that direct observation of mother-child behavior, with immediate feedback, reinforcement, and further practice, may be related to the superiority of the individual training method.     

Modifying Problematic Mealtime Interactions of Children with Cystic Fibrosis and Their Parents Via Behavioral Parent Training

Implemented behavioral parent training targeting maladaptivemealtime behavior with two children with cystic fibrosis (CF)and their parents. Treatment was implemented in multiple baseline fashion across the two families. Primary dependent measurewas coding of parent and child behaviors from videotaped dinners.Data were also collected on the children's daily calorie intakeand weight. During treatment and at the posttreatment follow-ups,parents' attention to disruptive behavior decreased, attentionto appropriate eating increased, and parental control at mealsincreased. The children showed an increase in appropriate behaviorand a decrease in disruptive behavior; caloric intake and weightalso improved. Results are discussed in terms of the applicabilityof behavioral intervention with feeding problems in childrenwith CF.     

Teaching Parents to Modify Child Behavior Problems: An Examination of Some Follow-Up Data

The maintenance of treatment effects associated with the useof a standardized parent training program was examined. Thirty-sixmother-child pairs, who had completed parent training, werecontacted to participate in an 8-month follow-up; 18 agreedto participate. Treatment effects were assessed by home observationaldata and parent perceptions of child adjustment at pretreatment,posttreatment, and follow-up. The results indicated that childbehavior change and parent perceptions of change in child adjustmentwere maintained at follow-up. Positive parent behavior changedwith treatment and occurred at a significantly higher rate atfollow-up than at pretreatment. No differences were detectedat pre- or posttreatment between mother-child pairs who participatedin follow-up and those who refused to participate.