Treatment Effects of a Modular Intervention for Early-Onset Child Behavior Problems on Family Contextual Outcomes

Abstract

The overall aim of this multi-informant study was to examine pre–post treatment changes, and maintenance at 3-year follow-up, for multiple dimensions of the family context, for a modular intervention that has previously demonstrated significant clinical improvements in child behavior and maintenance of these effects. Family outcomes included parenting practices (i.e., positive parenting, harsh/inconsistent parenting, psychological/physical aggression), parent functioning (i.e., symptoms of psychopathology, self-efficacy), and family functioning (i.e., family adaptability/cohesion, social support, negative life events). The sample comprised 139 families with children ages 6 to11 who participated in a modular treatment protocol for early-onset oppositional-defiant disorder or conduct disorder that has already been associated with improved child behavior outcomes, delivered in a nonrandomized comparison of research clinic and community settings. Improvement from pre- to post-treatment included indicators of maternal psychological distress and negative parenting practices (e.g., corporal punishment, inconsistent discipline, psychological aggression). Psychological aggression significantly increased following treatment termination; corporal punishment continued to decrease during the 3-year follow-up period. Results are discussed in the context of treatment effects in the broader family context and potential needs for continued intervention research and development.

Keywords

parenting intervention parenting maternal psychopathology family functioning

Treatments for childhood behavior disorders, particularly those treatments that target parenting, cannot be studied without attention to the contexts in which they occur, and children are embedded within multiple systems, most proximally the family system (Cox & Paley, 1997; Parke, 2004). Developers of treatments for child behavior problems have become increasingly attentive to these systems in the delivery and assessment of treatments, and the identification of the processes by which parenting interventions exert their effects on child functioning (Sandler, Schoenfelder, Wolchik, & MacKinnon, 2011). Few studies specifically examine contextual factors in child and family treatment studies, except as static control variables. Yet, these domains are dynamic and open to change—Furthermore, as aspects of the family context are also indicators of parent and family functioning, these factors may also improve over the course of clinical intervention. The purpose of this study is to evaluate the effectiveness of a behavioral intervention for child behavior problems on family contextual variables that are likely to be related to child functioning. To this end, we focus on an intervention that has already been associated with significant posttreatment improvements in child behavior (Kolko et al., 2009) and seek to extend these findings to posttreatment changes in other aspects of family functioning.

Childhood Behavior Problems and Associated Family Contextual Variables

The study of risk and resilience has focused on family contextual factors that are associated with child functioning over time (Masten & Shaffer, 2006; Morris, Silk, Steinberg, Myers, & Robinson, 2007). However, when risk factors are subject to change over time, there are attendant implications for change in child behavior and adaptation (Luthar & Cicchetti, 2000), and also for potential targets for intervention and prevention. This is relevant to many factors in the family context, such as parent psychopathology or family cohesion, that have previously been shown to distinguish children with disruptive behavior disorders (DBDs) from their healthy peers. For example, symptoms of parental psychopathology may wax and wane over time, with relative changes in the risks for child behavior problems (e.g., Jaffee & Poulton, 2006). More pertinent to the present study, these family factors may also improve as a result of treatment targeting child behavior problems. The sections below identify family factors that relate to child behavior problems and subsequently review how these aspects of the family context might be affected by treatment targeting child DBDs.

Parenting Practices

While child behavior problems are the eventual targets of parenting interventions, the effects of these interventions are generally understood to be influenced through parenting behaviors (Kaminski, Valle, Filene, & Boyle, 2008), although less treatment outcome research directly assesses intermediate changes in parenting behaviors as a variable of interest. Accumulated evidence indicates that harsh or unsupportive parenting practices, including punitive or critical responses to child behavior or emotional expression, psychological aggression, and corporal punishment, are related to child problems such as emotion dysregulation and behavior problems (Gershoff, 2002; Morris et al., 2007; Vissing, Straus, Gelles, & Harrop, 1991).

Parental Psychopathology

One of the most well-studied factors in the family context is maternal psychopathology and dysregulated affect, which can include features of depression, anxiety, and hostility. Research has consistently found that maternal psychopathology is related to poorer outcomes for children, as presented in multiple reviews of the literature (Downey & Coyne, 1990; Goodman & Gotlib, 1999), and that improvements in maternal depression are associated with improvements in child functioning (Gunlicks & Weissman, 2008). Relatedly, the amount of social support that children experience, particularly in the family context, shows a positive correlation with child adaptation (Compas, 1987). In addition, relevant to parent functioning and its influence on child functioning, parental self-efficacy (Jones & Prinz, 2005) has been implicated as either a direct predictor of child functioning or an indirect predictor through its impact on parenting behaviors.

Family Functioning

The family environment itself represents a “whole greater than the sum of its parts,” and the health of the family system has also been implicated in the development and maintenance of child behavior problems (Parke, 2004). To this end, aspects of family functioning, such as adaptability and cohesion, have been related to behavior problems in children and adolescents (i.e., Lucia & Breslau, 2006; Smets & Hartup, 1988); parent and adolescent reports of low family cohesion related to higher rates of conduct disorder (CD) and externalizing symptoms in youth (Prange et al., 1992). The accumulation of negative life events in the family context has also been associated with increased risk for child maladaptation (Appleyard, Egeland, van Dulmen, & Sroufe, 2005; Sameroff, 2006) and with higher levels of oppositional-defiant disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD) symptoms in children (Deault, 2010).

Relations of Family Contextual Variables to Child Functioning and Treatment Outcomes

Many of the contextual family factors noted above are likely to be indirect predictors of child adaptation, through their effects either supporting or undermining positive parenting (Eyberg, Nelson, & Boggs, 2008), and a preponderance of evidence suggests that these factors are likely to be mutually influential. For example, maternal depression has been shown to relate to escalating harsh discipline, mediated by maternal anger (Shay & Knutson, 2008), and maternal psychopathology in general has been associated with less sensitive responses to child emotions (Morris et al., 2007). The relation of parental self-efficacy to child behavior problems through indirect effects on discipline styles has been identified in treatment outcome studies of parenting interventions targeting child conduct problems (Sanders & Woolley, 2005). Perceptions of social support may be related to better adjustment either directly or as a buffer against other sources of risk or adversity (Compas, 1987; Dubow, Tisak, Causey, Hryshko, & Reid, 1991). Negative life events tend to exert a cumulative effect on adaptation, and they are frequently nonindependent of parent, child, and family functioning (Masten & Powell, 2003).

Family Factors as Moderators of Treatment Outcomes

Many of the above-named factors have been associated with less effective treatment outcomes for children with DBDs. For example, treatment outcomes for parent–child interaction therapy were poorer for families with higher levels of self-reported parenting stress at baseline and higher frequencies of maternal “inappropriate behavior” (i.e., sarcasm, hostility) observed during parent–child interactions over the course of treatment (Werba, Eyberg, Boggs, & Algina, 2006). Beauchaine, Webster-Stratton, and Reid (2005) reported, using data combined across six randomized controlled trials (RCTs) of the Incredible Years treatment, that marital adjustment and maternal depression moderated treatment outcomes for children with ODD and CD. Reyno and McGrath’s (2006) meta-analysis of parenting intervention studies revealed that maternal psychopathology was consistently associated with poorer treatment outcome, with effect sizes in the moderate range. In the same meta-analysis, negative life events within the family were also associated with poorer treatment outcomes, albeit with a small overall effect size (Reyno & McGrath, 2006).

Effects of Psychosocial Treatment on Contextual Variables

At this point, the degree to which contextual factors in the family system can be addressed as part of family-based intervention, to prevent these factors from undermining or negatively relating to treatment outcomes, is unclear. In fact, most treatments for DBDs attempt to address or acknowledge these contextual factors to some degree, most especially through the support and improvement of parenting behaviors. Still, there is room for expansion of these treatment targets (Kolko et al., 2009), and previous research that addresses changes in parenting or family processes has had mixed findings. Multimodal treatment efforts can be more effective than more specifically or individually focused interventions (Burke, Loeber, & Birmaher, 2002).

There are often efforts to target multiple domains of functioning in the treatment of families affected by child DBDs (Kaminski et al., 2008; Reyno & McGrath, 2006), presumably to address these contextual factors that have already been identified as differing between families with children diagnosed with ODD and/or CD, as compared with healthy controls (Kolko, Dorn, Bukstein, & Burke, 2008). A few empirical studies and meta-analyses have investigated changes in the family context as a result of interventions for child behavior problems. Many empirical studies have focused on maternal depression, documenting improvements in maternal mental health following parenting interventions for child disruptive behavior (e.g., DeGarmo, Patterson, & Forgatch, 2004; Griest et al., 1982; Hutchings, Appleton, Smith, Lane, & Nash, 2002; Jouriles et al., 2009; Scholes, Zimmer-Gembeck, & Thomas, 2009). Less research has focused on other aspects of maternal mental health, such as symptoms of anxiety.

Other studies have focused on improvements in positive parenting behaviors as mediators of child behavior improvement or problem prevention (e.g., Dishion et al., 2008; Eddy & Chamberlain, 2000; Jouriles et al., 2009; Stemmler, Beelmann, Jaursch, & Lösel, 2007). Serketich and Dumas (1996) conducted a meta-analysis of short-term outcomes of behavioral interventions for DBDs that primarily targeted improving parenting practices and found a significant effect size, indicating improvement, in parental psychological adjustment (i.e., an average across depression, stress, irritability, anxiety, and marital satisfaction). Barlow, Coren, and Stewart-Brown (2002) utilized meta-analytic techniques to investigate data obtained from 15 RCTs of parenting interventions and found significant improvements in maternal depression, anxiety/stress, self-esteem, and relationships with partners at post-treatment. More recently, Shaw, Connell, Dishion, Wilson, and Gardner (2009) reported that improvements in maternal depression, following a brief behavioral intervention for families with preschool-aged children, have mediated subsequent improvements in child behavior, underscoring the potential for broad and spreading effects of parenting interventions on the family system.

Aims and Hypotheses

The overall aim of this study is to examine pre–post treatment changes, and maintenance of posttreatment change at 3-year follow-up, for multiple aspects of the family context, including specific parenting practices (i.e., positive parenting, harsh or inconsistent parenting, psychological and physical aggression), parent functioning (i.e., symptoms of psychopathology, hostility, parental self-efficacy), and family functioning (i.e., family adaptability and cohesion, social support, and negative life events). These research questions will be addressed in a sample of families who participated in a modular treatment protocol developed for early-onset ODD or CD and was delivered in either research clinic or community settings. Although the present study design does not include a no-treatment control group (due to concerns regarding withholding treatment when the treatment components already have an extensive history of empirical support in the DBD treatment literature), the protocol consisted of seven brief treatment modules targeted directly to parents and to children (Kolko, 1995; Kolko & Swenson, 2002). This treatment has been found to be efficacious in prior outcome studies for behavior disorders (Kolko et al., 2009; Kolko, Loar, & Sturnick, 1990), child firesetters (Kolko, 2001) and aggressive/abusive families (Kolko, 1996a, 1996b; Kolko, Iselin, & Gully, 2011), many of which have now been integrated in Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT, see www.afcbt.org). This study takes advantage of multiple sources of data in obtaining reports from participating parents and children participating in the intervention across a 3-year follow-up period, and follows a previous study (Kolko et al., 2009) that documented the treatment effects of this intervention on child disruptive behaviors, with effect sizes ranging from 0.35 to 2.44 at post-treatment and 0.31 to 2.61 at follow-up for a variety of behavioral and emotional indicators.

To this end, this study represents a novel contribution to the literature on treatment outcomes for parenting interventions for a number of reasons. Parenting and family factors are the primary contributors to the development and maintenance of DBDs and, accordingly, are the most frequent targets in the treatment of DBDs. However, few studies report outcomes for these factors, and among those studies, results are mixed. Thus, the question remains: When child behaviors change as a result of treatment, what change (if any) occurred in the parenting and family context? Changes in parenting and family-related outcomes may, in turn, highlight possible mechanisms of action or additional areas benefited by these treatments. The present study addresses these questions using multiple reporters of parenting and family factors in multiple domains, and capitalizes on a follow-up period that spans 3 years subsequent to interventions delivered in clinical and community settings.

It is hypothesized that significant improvements in parenting and parent and family functioning will be evidenced from pre-treatment to post-treatment, and maintained through the 3-year follow-up period. Given previous findings that the clinic and community samples showed comparable rates of improvement in child symptomatology (Kolko et al., 2009), group differences based on treatment site are not anticipated in this study. We will also include follow-up data obtained over the course of 3 years to explore trajectories of change and determine which of these variables maintain improvements over time.

Method

Participants

Study participants were 139 child–parent dyads who were referred for treatment due to child disruptive behavior problems. Families were referred by program sites affiliated with the University of Pittsburgh Medical Center (UPMC). Eligibility requirements included child age (6–11 years) and a current diagnosis of ODD or CD. Exclusion criteria included concurrent treatment for a DBD, IQ below 70, suicidality with a plan, homicidality, substance abuse, and presence of an eating disorder or major psychiatric condition. Children who were receiving current medication management for DBDs were not excluded from the study. Of a total 704 families who were screened, 470 (67%) were ruled out during the screen. Reasons for exclusion included the following categories: “age” (7%), “no ODD/CD diagnosis” (13%), “distance” (13%), “disinterest” (34%), “concurrent treatment” (13%), “clinical/medical exclusion” (5%), “IQ ≤ 70” (1%), and “other” (14%). An additional 53 (8%) did not complete the initial assessment, and 42 (6%) were deemed ineligible during the initial assessment.

In summary, 118 (85%) of the final study sample were male and 21 (15%) were female; 115 (83%) children met diagnostic criteria for ODD and 29 (21%) met diagnostic criteria for CD (5 children met criteria for both ODD and CD); 106 children (76%) met diagnostic criteria for comorbid ADHD. A total of 64 children were identified by their parent as African American, not of Hispanic origin (46%); 66 were identified as White, not of Hispanic origin (47%); 8 were identified as biracial (6%); and 1 was identified as Hispanic (1%). Child age at initial assessment ranged from 6 to 11 years (M = 8.8; SD = 1.6). In all, 85 (61%) of the parents were unmarried and mean family income was low to modest. The majority of parents had completed high school (n = 125, 90%), and 24% (n = 34) had a college degree or higher.

Procedure

All outcome measures were completed during the following standard assessments: pre-treatment (n = 139), post-treatment (n = 137), 6-month follow-up (n = 135), 1-year follow-up (n = 135), 2-year follow-up (n = 134), and 3-year follow-up (n = 129). Attrition was very low (7%) during the follow-up phase of the study, and attrition did not differ based on treatment setting or any demographic variables (e.g., child race, sex, age). All assessments were completed by full-time research specialists who were blind to treatment condition and all other study data.

Enrolled families were randomized to either the “clinic” condition (n = 70) or “community” condition (n = 69). The two conditions were identical other than the treatment delivery setting. Families in the clinic condition received treatment at a university clinic, whereas those in the community condition received treatment in a community setting (most often the family’s home). Treatment content included the following modules: (a) parent management training, (b) child CBT/skills training, (c) parent–child family sessions, (d) teacher consultation, (e) peer relations/community activities development, (f) medication consult for comorbid ADHD cases, and (g) crisis management. All modules except for the medication consult were administered by female therapists with a masters-level education, training in cognitive-behavioral therapy, and at least 2 years’ experience treating childhood externalizing problems. Treatment fidelity ratings were based on 107 audiotaped or videotaped treatment sessions sampled from all modules except Module 7 (crisis management). The ratings were calculated as the percentage of correctly administered techniques in each content area and ranged from 89% to 100%.

Psychosocial treatment sessions were scheduled weekly and therapists were encouraged to complete treatment within 6 months. Families participated in 0 to 41 treatment sessions (M = 17.7, SD = 8.2) for more than 0 to 8 months (M = 4.3, SD = 1.7). The diverse range in the number of treatment sessions is due to a few participants who dropped out of treatment early (11% of the sample participated in fewer than 8 sessions) and an even smaller minority who received more than 30 sessions (4%); 85% of participants completed 8 to 28 treatment sessions.

The medication consult was conducted by a board-certified child and adolescent psychiatrist. Of the 106 children who were diagnosed with comorbid ADHD at intake, only 29 (27%) were already on psychotropic (generally stimulant) medication. A total of 26 (90%) of these children continued to take medication during the treatment phase of the study. Of the 77 ADHD children who were not already taking medication at the beginning of the study, 41 (53%) initiated medication management via participation in the medication consult module. Overall, only 29% of the total sample (41/139) initiated medication management during the active phase of treatment. A separate article documents the clinical correlates and outcomes associated with the medication management module (see Demidovich, Kolko, Bukstein, & Hart, 2011). In summary, medication was associated with some reduction in ADHD symptoms but did not contribute to reduction in ODD or CD symptoms.

Measures

Parent psychopathology/functioning

Parent psychopathology was assessed using the Global Severity Index, Anxiety scale, Depression scale, and Hostility scale of the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983). In terms of reliability, the BSI has good internal consistency (αs ranging from .71 to .83 on subscales) and test–retest reliability (ranging from .68 to .91 on subscales). The BSI also has well-established construct validity and convergent validity with measures of similar constructs. Depression was further assessed using the 21-item Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988). The BDI has well-established reliability (α = .88 in the current sample) and validity. Parents’ self-efficacy was assessed using an aggregate of five subscales (Emotional Support, Behavior Management, Advocacy, Provider Issues, and School Issues) from the Parental Self-Efficacy Scale (PSES; Evans, Boothroyd, & Armstrong, 1997). The aggregate scale has adequate reliability (α = .75 in the current sample), and items have adequate face validity.

Parenting practices

Parents completed the Alabama Parenting Questionnaire (APQ; Shelton, Frick, & Wootton, 1996) and the Conflict Tactics Scale (CTS; Straus, Hamby, Finkelhor, Moore, & Runyan, 1998). Internal consistency of the APQ ranges from .80 (Involvement and Positive Parenting scales) to .46 (Corporal Punishment scale). In terms of validity, the APQ discriminates well between families of children with DBD diagnoses and normal controls. Internal consistencies are modest for the Physical Assault scale (α = .55) and the Psychological Aggression scale (α = .60) of the CTS. The CTS also evidences good discriminant and construct validity. Children completed the child version of the CTS and the Parent Perception Inventory (PPI; Hazzard, Christensen, & Margolin, 1983). The summary score on the PPI reflects the amount of positive behavior minus the amount of negative behavior. Higher scores indicated more positive parenting behavior relative to negative parenting behavior. The PPI has good internal consistency (α = .80 in the current sample) and evidence of convergent validity (Glaser, Horne, & Myers, 1995).

Family functioning/stress

Parents completed the Family Adaptability and Cohesion Evaluation Scale (FACES-II; Olson, Porter, & Bell, 1982) and the Life Events Checklist (LECL; Brand & Johnson, 1982). The FACES-II Adaptation Scale consists of 23 items (α = .76), and the Cohesion Scale consists of 27 items (α = .76). The FACES-II also has evidence of good construct validity (Hampson, Hulgus, & Beavers, 1991). Test–retest reliability for the Negative Events Scale of the LECL is .72 (Brand & Johnson, 1982). Children completed the Family Support Scale of the Survey of Children’s Support Interview (SOCCS; Dubow & Ullman, 1989). The scale consists of 11-items for which children rate their perceived level of family support. The SOCCS has adequate reliability (α = .70 in the current sample), an evidence of convergent validity.

Data Analyses

We examined treatment effects using hierarchical linear modeling (HLM; Raudenbush & Bryk, 2002) with time nested within participants. Piecewise growth curve models were used to assess change during the two distinct phases (i.e., treatment phase and follow-up phase) of the study. The Level 1 equations for the unconditional models were Y_ti = π_0i + π₁_i (treatment) + π_2i (follow-up) + e_ti, where Y_ti is the observed outcome score at time t for participant i. The “treatment” variable was coded 0, 1, 1, 1, 1, and 1 for each on the six time points. The slope of this variable can be interpreted as the rate of change from the pre- to post-assessment or the initial treatment effect. The “follow-up” variable was coded 0, 0, 1, 2, 4, and 6 for each of the six time points. The slope of this variable can be interpreted as the rate of change from the post-assessment to the final (3-year follow-up) assessment. A nonsignificant slope would suggest that there are no significant changes or “decays” over the follow-up period. To examine setting differences, setting was entered as a Level 2 variable (Clinic = “1”; Community = “−1”). To reduce the likelihood of type I errors resulting from multiple outcome variables, we used the Bonferroni correction to set our alpha level at .0026 (α = .05 divided by 19 outcome variables) for interpreting the statistical significance of the HLM results. These analyses followed the same approach as in Kolko et al. (2009).

Results

Descriptive Statistics

Means and standard deviations of all outcome variables at the pretreatment assessment, posttreatment assessment, and 3-year follow-up assessment are presented in Table 1. At the pretreatment assessment, group mean scores on all the BSI scales were in the average range. Only 3 parents (2%) scored in the clinical range (≥63) on the BSI Global Severity Index. In all, 4 parents (3%) scored in the clinical range on either the BSI Anxiety scale (n = 2, 1.5%) or BSI Hostility scale (n = 2, 1.5%). On the BDI, 46 parents (33%) scored in mild (n = 32, 23%), moderate (n = 14, 10%), and severe (n = 2, 1.5%) ranges for depression.

Table 1.

Descriptive Statistics.

	Pre-treatment (n = 139)	Post-treatment (n = 137)	6-month follow-up (n = 135)	1-year follow-up (n = 135)	2-year follow-up (n = 134)	3-year follow-up (n = 129)
Measure	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)
BSI Global Severity Index (T-score)	39.47 (7.95)	36.94 (7.50)	37.51 (7.38)	37.62 (8.05)	37.03 (6.84)	36.35 (7.21)
BSI Hostility (T-score)	45.72 (8.07)	42.48 (7.94)	43.14 (7.43)	42.93 (7.98)	42.50 (7.45)	42.16 (7.90)
BSI Anxiety (T-score)	38.12 (7.91)	35.46 (6.65)	35.62 (7.11)	35.56 (7.10)	35.47 (6.63)	35.20 (6.47)
BSI Depression (T-score)	39.53 (8.20)	37.69 (7.85)	38.12 (7.46)	37.93 (7.91)	37.45 (7.91)	37.01 (7.02)
Beck Depression Inventory (raw)	8.41 (7.36)	6.47 (6.97)	6.55 (6.89)	7.04 (7.48)	6.31 (6.42)	7.51 (7.68)
Parental Self-Efficacy Scale (raw)	82.83 (8.11)	87.47 (8.43)	87.84 (8.12)	88.31 (8.70)	86.97 (9.24)	86.25 (10.50)
APQ Corporal Punishment (raw)	6.24 (2.14)	5.17 (1.92)	5.33 (2.08)	5.11 (1.97)	5.03 (2.08)	4.74 (1.91)
APQ Inconsistent Discipline (raw)	16.02 (3.74)	14.39 (4.07)	14.40 (4.06)	14.69 (3.65)	14.47 (4.00)	14.42 (3.64)
APQ Involvement (raw)	37.03 (5.74)	38.22 (5.62)	38.07 (5.95)	37.90 (6.03)	37.74 (5.89)	37.18 (6.26)
APQ Positive Parenting (raw)	25.19 (3.81)	25.52 (3.78)	25.08 (3.68)	24.77 (3.82)	24.79 (3.87)	24.41 (4.00)
CTS Minor Assault (child report, raw)	12.47 (19.19)	5.13 (10.01)	5.13 (11.12)	3.88 (10.75)	4.03 (6.81)	2.92 (7.04)
CTS Minor Assault (parent report, raw)	16.41 (17.58)	6.40 (10.82)	5.67 (7.77)	5.13 (7.00)	6.31 (9.92)	5.02 (8.51)
CTS Psychological Aggression (child report, raw)	21.10 (21.18)	16.88 (21.48)	13.01 (18.07)	14.91 (20.20)	17.20 (19.74)	19.95 (23.07)
CTS Psychological Aggression (parent report, raw)	45.60 (23.46)	30.24 (20.55)	29.35 (20.56)	29.93 (19.51)	34.99 (20.95)	36.49 (25.22)
Parent Perception Inventory (raw)	11.86 (10.40)	14.74 (10.55)	16.51 (10.33)	16.23 (10.20)	16.04 (9.84)	14.49 (10.52)
Survey of Children’s Social Support (raw)	47.53 (5.76)	49.21 (5.84)	49.58 (5.32)	50.45 (4.94)	49.47 (5.31)	48.24 (6.64)
LECL Negative Events (raw)	4.74 (2.57)	2.87 (2.19)	2.82 (2.08)	2.99 (2.35)	3.39 (2.66)	3.68 (3.26)
FACES Adaptability (raw)	49.22 (7.25)	48.94 (7.55)	49.79 (7.08)	49.51 (7.31)	50.00 (6.43)	49.97 (6.49)
FACES Cohesion (raw)	62.56 (9.09)	63.34 (9.43)	63.32 (8.89)	63.53 (9.73)	63.83 (9.67)	62.83 (8.88)

Note. BSI = Brief Symptom Inventory; APQ = Alabama Parenting Questionnaire; CTS = Conflict Tactics Scale; LECL = Life Events Checklist; FACES = Family Adaptability and Cohesion Evaluation Scale.

Treatment Effects

The results of the unconditional HLM models are summarized in Table 2. In summary, there were significant (p < .0026) pre–post treatment effects for nearly all the outcome variables, including measures of maternal psychopathology, harsh/inconsistent parenting, parental physical and psychological aggression, parental self-efficacy, and child social support. Variables that did not evidence significant improvement from pre–post treatment were the BSI Depression scale, APQ Positive Parenting scale, and the Adaptability and Cohesion Scales of the FACES. There were only two significant changes during the follow-up phase, indicating that treatment gains were generally maintained. Only the CTS Psychological Aggression scale (parent report) and the APQ Corporal Punishment scale evidenced significant changes during the follow-up phase of the study. Specifically, scores on the APQ Corporal Punishment scale continued to decline, whereas scores on the CTS Psychological Aggression scale (parent report) reversed and increased during the follow-up phase.

Table 2.

Summary of Unconditional HLM Models Examining Parenting and Family Outcomes, and Effect Sizes.

	Unconditional pre–post slope				Unconditional follow-up slope				Effect size
Outcome variable	B	SE	t	p	B	SE	t	p	d _{pre post}	d _{pre 3-year}
BSI Global Severity Index	−2.03	0.51	−3.98	.000	−0.16	0.10	−1.61	.109	0.33**	0.41**
BSI Hostility	−2.73	0.58	−4.74	.000	−0.13	0.12	−1.06	.293	0.40**	0.45**
BSI Anxiety	−2.40	0.53	−4.52	.000	−0.05	0.10	−0.52	.602	0.37**	0.41**
BSI Depression	−1.44	0.59	−2.44	.016	−0.17	0.11	−1.48	.142	0.23**	0.33**
Beck Depression Inventory	−1.94	0.50	−3.89	.000	0.09	0.10	0.88	.381	0.27**	0.12
Parental Self-Efficacy Scale	5.22	0.67	7.80	.000	−0.23	0.14	−1.60	.113	0.56**	0.37**
APQ Corporal Punishment	−0.94	0.16	−6.02	.000	−0.09	0.03	−3.63	.001	0.53**	0.74**
APQ Inconsistent Discipline	−1.58	0.28	−5.72	.000	0.01	0.05	0.12	.907	0.42**	0.44**
APQ Involvement	1.28	0.34	3.73	.000	−0.16	0.08	−2.08	.039	0.21**	0.02
APQ Positive Parenting	0.15	0.22	0.65	.514	−0.16	0.05	−3.10	.003	0.09	−0.20*
CTS Minor Assault (child)	−7.39	1.38	−5.34	.000	−0.35	0.16	−2.25	.026	0.50**	0.73**
CTS Minor Assault (parent)	−10.44	1.36	−7.70	.000	−0.14	0.14	−0.97	.337	0.70**	0.87**
CTS Psychological Aggression (child)	−6.73	1.55	−4.33	.000	0.80	0.36	2.19	.030	0.20*	0.05
CTS Psychological Aggression (parent)	−16.91	1.81	−9.36	.000	1.31	0.36	3.59	.001	0.70**	0.37**
Parent Perception Inventory	4.00	0.84	4.75	.000	−0.11	0.16	−0.67	.502	0.27**	0.25*
Survey of Children’s Social Support	2.35	0.44	5.35	.000	−0.20	0.10	−2.13	.035	0.29**	0.11
LECL Negative Events	−1.96	0.22	−8.91	.000	0.14	0.05	2.86	.005	0.79**	0.36**
FACES Adaptability	0.07	0.53	0.12	.903	0.12	0.11	1.06	.291	−0.04	0.11
FACES Cohesion	0.97	0.65	1.50	.135	−0. 06	0.16	−0.38	.705	0.08	0.03

Note. HLM = hierarchical linear modeling; BSI = Brief Symptom Inventory; APQ = Alabama Parenting Questionnaire; CTS = Conflict Tactics Scale; LECL = Life Events Checklist; FACES = Family Adaptability and Cohesion Evaluation Scale.

p < .05. **p < .01.

Table 2 also summarizes effect sizes for each outcome variable at the posttreatment assessment and the 3-year follow-up assessment. All the effect sizes have been calculated so that a positive number indicates improvement. Most effect sizes were in the “small” (0.2) to “medium” (0.5) range. The two negative effect sizes, indicating deteriorating scores, are not statistically significant (p > .05). The largest and most durable treatment effects were for measures of physical punishment. The APQ Corporal Punishment scale and the CTS Minor Assault Scale (both parent and child report forms) were the only measures with effect sizes in the medium range or higher at both the posttreatment assessment and the 3-year follow-up assessment.

Treatment Setting

Results from the conditional models, with treatment setting included as a Level 2 predictor variable, indicated that the slopes of the treatment phase and follow-up phase did not differ significantly between the two treatment settings (p < .0026). In other words, families in the clinic and community conditions benefited equally from the treatment. Furthermore, there were no differences in the maintenance of these benefits during the follow-up phase of the study.

Discussion

Summary of Findings

Outcomes at post-treatment

Most family context variables, including parent-reported psychological distress (i.e., BSI Anxiety, Hostility, and Overall Severity scales; BDI total depression scores) and negative parenting practices (e.g., corporal punishment, inconsistent discipline, psychological aggression) improved modestly but significantly from pre-treatment to assessments at the conclusion of the intervention. Of note, the reductions in negative parenting practices reflect skills that were directly addressed in the parent-oriented part of the intervention. These results are also consistent with previous research that has documented improvements in maternal mental health following behavioral parenting interventions (e.g., DeGarmo et al., 2004; Hutchings et al., 2002). However, the BSI Depression scale, the APQ Positive Parenting scale, and the Adaptability and Cohesion Scales of the FACES did not evidence significant change from pre- to post-treatment.

Outcomes at 3-year follow-up

Nearly all treatment gains were maintained by the 3-year follow-up assessment. These findings indicate the relatively robust effects of a modular treatment for child DBDs that includes child, parent, family, and school/community components. Furthermore, this study extends the findings of Kolko and colleagues (2009), who reported on the effects of this treatment on child behavior problems, by documenting the additional beneficial effects that this treatment has (both immediately and over a relatively lengthy follow-up period) on the broader family context. However, two contextual variables did evidence significant change from post-treatment to 3-year follow-up. Parental psychological aggression actually increased over the follow-up period, despite initial decreases over the pre- to posttreatment period. In contrast, corporal punishment continued to decrease across the 3-year follow-up period.

Implications of Current Findings

Posttreatment outcomes

Among the family variables that evidenced statistically significant change at post-treatment, the effect sizes of treatment effects in the present study are generally consistent with previously published effect sizes for behavioral parenting interventions (Barlow et al., 2002; Serketich & Dumas, 1996), although the effects on parent psychopathology (i.e., no significant reduction in parental depressive symptoms) were not as strong as effect sizes for interventions that specifically include modules to address maternal depression in addition to parenting (e.g., Sanders & McFarland, 2000). Thus, it may be that adjunctive treatments are still needed to address depressive problems. In addition, a lack of significant changes in positive parenting or family adaptability/cohesion suggest that the current treatment may be more effective at reducing or minimizing negative parenting and family factors, rather than supporting or bolstering indicators of positive family functioning.

Three-year follow-up outcomes

Overall, the maintenance of most treatment effects over the course of a 3-year follow-up period is notable as a strength of the current treatment under investigation. The findings regarding the increase in psychological aggression from post-treatment to 3-year follow-up require additional consideration. Although the magnitude of change was somewhat modest (i.e., psychological aggression approached, but did not reach, pretreatment levels over the course of follow-up), these findings raise questions about how best to address psychological aggression in the context of parenting interventions. For example, a recent meta-analysis found that emotional communication skills (e.g., relationship-building communication skills such as active listening, helping children identify and appropriately express emotions) is one of the treatment components most strongly associated with behavioral parent training treatment outcome effects on parenting behaviors (Kaminski et al., 2008); yet these skills are less frequently targeted and less clearly defined in the extant parenting intervention literature. Of note, the manualized treatment that is utilized in the present study does include two modules for teaching parents emotion communication skills. This includes specific education for parents on psychological aggression and recommendations on emotion communication (i.e., “Words That Can and Do Hurt”) for one session, and later instruction on assisting a child in emotional identification and understanding, with an emphasis on helping a child feel listened to and valued within the family. Drawing from the current results, it may be the case that more intensive intervention in this domain is needed to produce lasting change in these parenting behaviors. Of note, some promising new interventions have been recently developed to specifically support and educate parents in improving positive emotion coaching and support skills, while decreasing emotionally unsupportive communication (e.g., Havighurst, Wilson, Harley, & Prior, 2009; Shipman & Fitzgerald, 2009).

Parents’ use of corporal punishment continued to decrease over the follow-up period. Although it is possible that treatment effects continued to strengthen over time, the confounding effect of child age cannot be ruled out. Researchers have previously reported that corporal punishment tends to decrease developmentally as children get older, and this has been demonstrated using the same measures as in the present study (Shelton et al., 1996; Straus et al., 1998). Thus, maturation effects are a potential concern when interpreting the magnitude of the effect sizes at the 3-year follow-up assessment, and we cannot rule out that the effect sizes for the indices of corporal punishment might be slight overestimates of treatment effects at this assessment. However, as the slopes representing pre- to posttreatment change were of greater magnitude than the slopes over the follow-up period, it is possible that the treatment effects likely outweighed any potential maturation effect. Of note, the Positive Parenting scale of the APQ also decreased during the follow-up phase of the study. Although this effect was not statistically significant, it may also reflect a similar developmental trend in which parents become less actively engaged in parenting as their children age, which may have resulted in a slight underestimate of treatment effects with respect to positive parenting practices at the 3-year follow-up assessment.

Limitations and Future Directions

The findings of the present study must be interpreted in light of its limitations, which point to directions for future research. The treatment was multidimensional, with multiple modules, so it is not possible to identify the “active ingredients” of the intervention (Kazdin, 2005; Kolko et al., 2009). This is particularly relevant given the differential improvement across factors in the family context, as noted above with respect to psychological aggression. Relatedly, we are not able to interpret possible differential response to treatment based on number of sessions completed, or other measures of “dose,” as these are likely confounded by baseline problem severity or a host of other factors. Although other researchers have not detected dose–response relations in studies of similar treatments (Bickman, Andrade, & Lambert, 2002; Salzer, Bickman, & Lambert, 1999), future studies are needed to clarify specific predictors of differential response to treatment.

The current treatment outcome study does not include a control group with random assignment, as its initial study design was intended to examine differences in treatment settings (i.e., clinic vs. community) with 3-year follow-up to track improvements in child behavior, as previously documented (Kolko et al., 2009), and improvements in the broader family context, as in the present study. Although the lack of control group may limit the conclusions about posttreatment change that can be drawn, it is worth noting that whereas effect sizes of treatment-related change are typically greater in pre–post studies as compared with RCTs (and thus perhaps overestimates), the magnitude of change in uncontrolled studies is still greater than can be accounted for by regression to the mean, as Lipsey and Wilson (1993) documented in their meta-analysis. The current findings are also quite similar to the effect sizes reported by Lundahl, Risser, and Lovejoy (2006) in their meta-analysis of parenting intervention effects of parent behaviors (d = 0.45) and perceptions of parenting (d = 0.53); current effect sizes are similar or greater in magnitude to those reported in Jouriles et al. (2009) regarding reports of parent psychiatric symptoms and physical and psychological aggression. These findings, when considered in tandem with decades of research on the effectiveness of parent management and CBT interventions for child behavior problems, lend support to the conclusions of the present study. Furthermore, the comparability of effects across the clinic and community settings can serve to reflect a replication of treatment outcomes within the present study, thus bolstering confidence in the significance of the outcomes. Nevertheless, without a true no-treatment control group, we cannot conclusively state that postintervention changes are entirely accounted for by treatment effects.

Regarding the generalizability of findings, it is important to note that 67% of families who presented to the clinic for the present study were found to be ineligible at the screening phase. Therefore, it is not possible to draw firm conclusions about the potential effects of this intervention for families who may present to a treatment setting with subclinical child behavior problems or lower motivation for treatment, although previous prevention-oriented research would support that similar treatment procedures would be effective for subclinical or developing child behavior disorders (e.g., Dishion et al., 2008; Patterson, DeGarmo, & Forgatch, 2004; Stemmler et al., 2007). In addition, measures of internal consistency were lower than is typically desirable for subscales measuring physical punishment and physical aggression, although this is often observed among measures of low-frequency behaviors such as physical assault. Finally, reports of treatment outcomes are limited to the family members who participated in the intervention. Although more objective reports of outcomes (e.g., teacher reports) could be advantageous to minimize the possible demand characteristics that could lead to biased reporting of treatment-related improvements, it is notable that reports were consistent across parents and child reports. Future research in this area may benefit from extending to a broader range of outcomes, including marital functioning or social support.

Summary and Conclusion

The present study presents evidence for the potential impact of well-designed interventions on the broader family context, utilizing multidimensional, multireporter data that span 3 years of posttreatment follow-up. We have highlighted the positive treatment outcomes of a modular intervention that extended beyond reductions in child disruptive behaviors to improvements to the broader family context. These findings are relatively rare in the literature, and few if any studies have utilized such comprehensive measures of family context over a significant span of time to more fully explore how interventions work in context. Future studies of this nature can continue to capitalize on consideration of child-oriented treatments as they affect family systems, bolstered by evidence presented in this study that such systemic effects are broad, significant, and lasting.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grants to the third author from the National Institute of Mental Health (MH 57727).

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