ddparenttrainmetaanalysis

PRIMARY AND SECONDARY EFFECTS OFPARENTING AND STRESS MANAGEMENT

INTERVENTIONS FOR PARENTS OFCHILDREN WITH DEVELOPMENTALDISABILITIES: A META-ANALYSIS

George H.S. Singer,* Brandy L. Ethridge, and Sandra I. AldanaGevirtz Graduate School of Education, Department of Education, University of California, Santa Barbara,

Santa Barbara, California

A meta-analysis of the group intervention research for parents ofchildren with developmental disabilities was conducted in order to charac-terize the efficacy of treatments in reducing depressive symptoms andother forms of psychological distress associated with stress in parents ofchildren with developmental disabilities. An extensive search led to theidentification of 17 studies which were divided into three categories forcomparative purposes: parenting education studies usually based on be-havioral parent training, coping skills education studies based primarily oncognitive behavioral training, and studies that combined these methodsalong with other support services. Studies were rated for the quality ofthe research designs and of the reports. Consistent positive benefits werefound in the form of reductions in parents’ distress, and these effectswere comparable to those reported in other syntheses of parenting inter-ventions for parents of children without disabilities. The studies were eval-uated in order to assess whether or not they met standards for estab-lished evidence-based practices. On the basis of the quality and numberof the randomized trials, we present evidence to support the claim thatthere are established evidence-based interventions for reducing psycho-logical distress at least in middle-class mothers in the short term. Theinterventions for fathers are promising as are the data on somewhatlonger-term effects. The need for replications with a more diverse groupof parents and longer-term follow-up were discussed. Multiple compo-nent interventions addressing both parent well-being and behavioral par-ent training were significantly more effective than either behavioral parenttraining or cognitive behavioral training along. ' 2007 Wiley-Liss, Inc.MRDD Research Reviews 2007;13:357–369.

Key Words: meta-analysis; developmental disability; treatment efficacy;parent training; stress management; evidence-based treatment

Contemporary scholarship on families of children withdevelopmental disabilities has identified a wide rangeof variability in parent adaptation to family life with

children with developmental disabilities [Glidden and School-craft, 2003; Singer, 2006]. Formerly, researchers held the beliefthat there were inevitable and severe negative impacts onparents, including chronic sorrow [Olshansky, 1962]; increasedmental and physical health problems [Wolfensberger, 1969;Witt et al., 2003]; increased divorce rates [Gath, 1977]; andelevated levels of psychosocial problems in siblings [Hannah

and Midlarsky, 1999]. However, recent meta-analyses and lon-gitudinal studies show that these negative impacts are neithercommon nor as severe as once thought [Seltzer et al., 2001;Risdall and Singer, 2004; Glidden and Jobe, 2006; Singer,2006]. Singer [2006] conducted a meta-analysis of 19 compar-ative studies of depressive symptoms in mothers of childrenwith and without developmental disabilities. Roughly 70% ofthe mothers of children with disabilities did not have elevatedsymptoms. In addition, there is emerging evidence that manyparents perceive long-term benefits and families are resilientover the long term. Data from the Wisconsin LongitudinalStudy spanning a 35-year period found no significant differ-ences between parents of adult children with and withoutmental retardation on measures of psychological well-being,depression, physical health, and divorce [Seltzer et al., 2001].Further, an emerging literature indicates that many parentsperceive benefits and positive contributions associated withloving and raising their children with developmental disabil-ities [Hastings and Taunt, 2002].

The accumulation of evidence suggesting family resil-ience, rather than family catastrophe, best characterizes thesefamilies and suggests that efforts to support and assist familiesshould be designed to foster attitudes, skills, and resources thatnot only reduce distress but also buffer it as well, augment resil-ience, and promote positive outcomes. The cumulative weightof the more sanguine research indicates that it is realistic to aimfor promotional as well as preventive and ameliorative outcomes.

Despite long-term resilience, many parents of childrenwith developmental disabilities experience unusual levels ofstress along the way. Researchers have particularly focused on

*Correspondence to: George Singer, University of California, Santa Barbara,Department of Education, Gevirtz Graduate School of Education, Santa Barbara,California 93106-9490. E-mail: [email protected] 20 August 2007; Accepted 22 August 2007Published online in Wiley InterScience (www.interscience.wiley.com).DOI: 10.1002/mrdd.20175

MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIESRESEARCH REVIEWS 13: 357 – 369 (2007)

' 2007Wiley -Liss, Inc.

parents’ depressive symptoms as indica-tors of stress in these families [Singer,2006]. For the sizable minority ofparents who do experience unusual lev-els of psychological distress, there is aneed for interventions leading to earlierresolution of depressive symptoms andfewer lifetime episodes of elevated levelsof depression especially in mothers. Incomparing studies of parents with andwithout children with developmentaldisabilities, Singer reported a small butconsistent effect size difference in indi-cators of psychological distress in studiesof mothers conducted over the past 25years. He estimated an approximate10% increase in the number of motherswith scores over clinical cutoff scoreson standardized self-report, paper andpencil measures of depressive symptoms.Thus, roughly 30–35% of the mothersof children with developmental disabil-ities in these studies had elevated levelsof depressive symptoms.

In their longitudinal research, Glid-den and Jobe [2006] reported that parentsof birth children with Down syndromehad higher levels of depressive symptomscompared to adoptive parents for the first5 years following the birth with gradualimprovement over this period of time.Over a 17-year period, early high levels ofdepressive symptoms predicted later emo-tional distress. Breslau et al. [1986] alsofound that although there was not a sig-nificant difference in the prevalence ofMajor Depression in this group of moth-ers compared to mothers of typicallydeveloping children, they did have signif-icantly more lifetime episodes of depres-sion, with the first occurrence at the timeof their children’s original diagnoses.

Stresses associated with caregivingfor children with disabilities, particularlyduring periods marked by a pile-up ofstressors from other sources, have thepotential to generate psychological dis-tress in both mothers and fathers[Quine and Pahl, 1987; Singer andIrvin, 1991; Hastings and Beck, 2004].In the general population, twice asmany women experience depression asmen, although men are also vulnerableto psychological distress associated withchronic stress or a pile-up of stressors[Kessler et al., 1997]. Regardless of howit is measured, elevated depressivesymptoms are very common in women,so that it is very likely that !20% of thesemothers would experience psychologicaldistress regardless of their children’s dis-ability [Lin et al., 1986; Kessler et al.,1997; Glidden and Schoolcraft, 2003].The terminology used to describe thispsychological distress is important be-

cause there is some controversy over howto interpret information from writtenself-report measures of depression.

Bailey et al. [2007] discuss the factthat elevated levels of depressive symp-toms as measured with common self-report instruments like the BeckDepression Inventory (BDI) [Becket al., 1988] or the Center for Epidemi-ology Depression Scale (CES-D)[Radloff, 1977] are not accurate indica-tors of prevalence of the clinical condi-tion, major depression, which can onlybe diagnosed by clinical interview witha trained diagnostician. It is for this rea-son that we refer to psychological distressas elevated levels of depression symptoms.

Although self-report measures donot identify cases of clinical depression,there are important reasons for beingconcerned about individuals who ex-press an elevated level of psychologicaldistress on written self-report measures,even though they may not experienceclinical depression. People with elevateddepressive symptoms who do not havemajor depression have shown consider-able limitation and distress in social,work, and physical functioning [Hayset al., 1995]. Hays et al. reported thatsubclinical levels of depressive symptomswere associated with lowered well-being, impaired role function, impairedsocial function, and poor general health.In their longitudinal study of 1,790 per-sons, they found that people withdepressive symptoms but without cur-rent major depression had lower levelsof functioning than individuals withchronic illnesses including diabetes andheart failure. Furthermore, elevateddepressive symptoms have been associ-ated with disrupted parenting interac-tions between mothers and their chil-dren [Downey and Coyne, 1990].

In direct observation studies com-paring mothers with and without highlevels of depressive symptoms, mothersin the former group interacted less withtheir children with disabilities, were lesscontingent in responding to them, weremore irritable, had more negative affect,and were more likely to use explosivediscipline than mothers without ele-vated depressive symptoms [Downeyand Coyne, 1990]. In several of thesestudies, elevated depressive symptomswere measured by using self-reportquestionnaires. Thus, regardless ofwhether or not these measures indicatemajor depression, the psychological dis-tress that they do measure is associatedwith problematic parent–child interac-tions. Further, in studies of parents ofchildren with developmental disabilities,

research indicates that depressive symp-toms are associated with problembehavior in children with developmen-tal disabilities [Floyd and Phillippe,1993; Baker et al., 2003; Hastings et al.,2006; Lecavalier et al., 2006].

The most prevalent theory ofstress in the literature on families ofchildren with developmental disabilitiesis a multivariate model, the doubleABCX theory [McCubbin and Patter-son, 1983; Bristol, 1987; Singer andIrvin, 1991]. It is a broad frameworkpositing that outcomes from familyencounters with stressful events are theproduct of an interaction of the natureof the stressor, the way family membersappraise it, their resources includingsocial support, and their coping skills.The theory recognizes that outcomescan be adaptive and indicative of resil-ience or they can be negative.

Researchers have tested interven-tions aimed at addressing one or more ofthe elements in this model in order tosupport parents who are experiencingstress-related psychological distress. Onespecific stressor has been the focusof extensive research—child problembehavior. Many studies have reportedproblem behavior to be a powerfulpredictor of parental distress. In theiranalysis of the literature on predictors ofdepression, Bailey et al. [2007] foundthat it was a significant correlate ofdepressive symptoms in nine out of ninestudies. Parents have sought help forthese problems and researchers havetested various forms of parenting educa-tion including, most commonly, methodsbased on social learning and appliedbehavior analysis theories [Lucyshynet al., 2002]. Other researchers havefocused on parenting coping skills educa-tion aimed at helping parents managestress by teaching them techniques forboth emotion focused and problem-focused coping [Hastings and Beck,2004]. Most of these stress-managementprocedures are based on cognitive behav-ioral approaches to psychoeducation.The purpose of this meta-analysis is todetermine how effective these behavioraland psychoeducational interventionshave been in helping parents with stressand associated psychological distress, par-ticularly with elevated levels of depressivesymptoms and whether these interven-tions are most effective when deliveredseparately or in a multiple componentmodel combining the two methodsalong with other forms of support. Inaddition, this research synthesis evaluateswhether or not this body of research rea-sonably establishes the interventions as

358 MRDD Research Reviews DOI 10.1002/mrdd " META-ANALYSIS OF PARENT INTERVENTIONS " SINGER ET AL.

effective methods in keeping with recentprofessional and legal imperatives to useproven interventions in social, psycho-logical, and educational services [Sha-velson and Towne, 2001; Levant, 2005].In order to make a claim that an inter-vention is evidence-based, two dimen-sions of the research literature need to beaddressed: the efficacy of an interventionand its clinical utility [Levant, 2005].

In this study we are concernedabout the first dimension—treatmentefficacy. In order to evaluate the efficacyof interventions for reducing distress inparents of children with developmentaldisabilities, we focus on randomized orquasi-randomized trials. Levant [2005]asserted, ‘‘Randomized clinical trials andtheir logical equivalents are the standardfor drawing causal inferences aboutthe effects of interventions . . .’’ (p. 8).In order to go beyond the claim that atreatment method is evidence-based, wealso evaluate whether or not interven-tions can be considered to be well estab-lished, probably efficacious, or unproven.

For a treatment to be considered ‘‘well established,’’two or more studies must show that it is superiorto medication, placebo, or an alternative treatmentor that it is equivalent to an already establishedtreatment, or nine single-subject case studies mustbe conducted to establish its equivalence or superi-ority . . .. For an intervention to be considered‘‘probably efficacious,’’ two or more studies mustshow it to be superior to a wait-list control condi-tion or one experiment must meet the criteria fora well-established treatment, or three single-casestudies must be conducted [Hoagwood et al.,2001, p. 1179].

Additionally, judgments aboutquality of research have been addressedfrom a variety of perspectives, but usu-ally include commonly accepted ele-ments of careful experimentationappearing in widely used graduate text-books in psychology and education[Wortman, 1994; Shavelson and Towne,2001; Levant, 2005].

Meta-analysis is a useful tool forexamining the effectiveness of a varietyof interventions drawn from differingtheories and research traditions, becauseit creates one common metric—theeffect size—indicating the strength ofeach treatment as well as an overall in-dicator of the average efficacy in groupsof research studies [Rosenthal et al.,2000]. Meta-analysis statistics can bereadily compared to other areas ofresearch in order to interpret the rela-tive efficacy of interventions.

This research synthesis also aims tohelp address a prominent debate in thefields of early intervention and familysupport, the question of whether or not

parenting education has generalized ben-efits or contributes to family stress [Bakeret al., 1991; Mahoney et al., 1999]. Par-enting education has been criticized for avariety of reasons, including its demandson parents’ time, possible loss of self-effi-cacy related to professional dominance,and inadequate responsiveness to culturaldifferences [Winton et al., 1999]. In thefollowing analysis, we look for evidenceof increased emotional distress in parentswho participated in different forms ofparenting education.

RESEARCH QUESTIONS ANDHYPOTHESES

In this meta-analysis we asked thefollowing questions:

1. How effective have interven-tions for parents of childrenwith developmental disabilities

been in reducing psychologicaldistress in group comparisonstudies?

2. Are multicomponent training(MCT) interventions signifi-cantly more effective than eitherbehavioral parent training (BPT)or cognitive behavioral, copingskills, training (CBT) alone?

3. Is there evidence to supportthe contention that parentingeducation or other forms ofprofessionally-led psychoeduca-tion increase stress?

4. Using APA guidelines, dothese interventions meet crite-ria for evidence-based treatmentsor are they best considered as

probably efficacious or as yetunproven?

METHODSSearch Procedures

Journals were searched electroni-cally using the databases PsychINFO,PubMed, Social Science Citation Index,Social Science Research Database viaCSA, ERIC, the Dissertation AbstractsInternational databases, the SociologicalAbstracts and Social Services Abstractsdatabases. Articles were also identifiedfrom the Cochran Database [Barlowet al., 2003] and recent reviews of theliterature on interventions for parents ofchildren with developmental disabilities[Singer et al., 2002; Hastings and Beck,2004]. The search was limited to studiespublished in English. Our working defi-nition of developmental disability was amodification of the definition in theDevelopmental Disabilities Assistanceand Bill of Rights Act of 2000 (PL106-42). Developmental disabilitieswere defined as occurring before age22, likely to continue indefinitely,require professional services of lifelongduration, and result in functional limita-tions in at least three major areas of lifeactivities. We narrowed this broad defi-nition by including only those develop-mental disabilities associated with men-tal retardation or other cognitive disabil-ities and children with a combination ofintellectual and physical impairments.That is, we excluded studies in whichthe children had physical disabilities andchronic illnesses that are not associatedwith cognitive disabilities. Thus, weexcluded a group of studies focused oninterventions for parents of childrenwith ADHD and another of childrenwith conduct disorders. Search termsfor all databases included combinationsof the terms disability, developmentaldisability, handicap, autism, mental re-tardation, cerebral palsy, traumatic braininjury and spina bifida with treatment,and intervention, depression, or distresswith parents, mothers, fathers, and fam-ilies. Databases were searched for allyears available.

After screening by reading titlesand abstracts, all promising articles, dis-sertations, and book chapters wereobtained and reviewed. Referencesfrom these studies were searched, inturn, to identify other studies. Refer-ences from reviews of the literaturepublished as chapters in books were alsosearched [Singer and Irvin, 1991; Singeret al., 2002] Authors were contacted byletter or e-mail when further data were

In this study, we areconcerned about . . .treatment efficacy. Inorder to evaluate theefficacy of interventionsfor reducing distress inparents of children with

developmentaldisabilities, we focus onrandomized or quasi-randomized trials.

MRDD Research Reviews DOI 10.1002/mrdd " META-ANALYSIS OF PARENT INTERVENTIONS " SINGER ET AL. 359

needed in order to determine an effectsize or clarify information in theresearch reports.

To be included in the meta-analy-sis, researchers had to have collecteddata on parental mental health usingpublished standardized self-report meas-ures with well-established psychometricproperties. In order to be included,studies had to use random or quasi-random assignment to compare one ormore interventions with a comparisongroup.

Table 1 provides a summary ofthe dependent measures we chose toanalyze in this study. Many of thesestudies included more than one depend-ent measure; however, we deliberatelyfocused on measures of depressivesymptoms or closely related measures ofemotional distress assumed to be associ-ated with caregiving. Table 1 lists thesemeasures and shows that the majority ofstudies included widely used measuresof depressive symptoms or generalmeasures of emotional well-being.

Statistical AnalysisEffect sizes were calculated using

a computer program, DSTAT [Johnson,1993] and checked with another com-puter program, MetaWin [Rosenberget al., 1999]. Hedges and Olkin’s [1985]d was used as the effect size statistic. Itis calculated by subtracting the mean ofthe control or comparison group fromthe mean of the experimental or inter-vention group and dividing by thepooled standard deviation. In keepingwith a common practice in meta-analy-ses, we calculated d based upon posttestmeans [Hedges and Olkin, 1985]. Theseare means at posttest and at follow-up.In the event that the groups had sub-stantially different average scores on thedependent measures at pretest, we usedan adjustment procedure recommendedby Rosenthal [1994], in which changescores are used with adjusted standarddeviations. When sufficient informationabout pre and posttest scores were notprovided, effect sizes were calculatedbased on F or t values. Formulas for allanalyses are available from the firstauthor. Studies with larger samples arelikely to produce more accurate resultsthan those with smaller samples. Thus,individual effect size statistics needed tobe refined by giving more weight tolarger studies [Hedges and Olkin,1985]. Further, as discussed later, studieswith better design features and report-ing of key variables are also likely to bemore trustworthy. Based on a procedurerecommended by Shadish and Haddock

[1994], a weighted effect size was calcu-lated that took into account both sam-ple size and quality. In order to accountfor sample size, each d was multipliedby a weight derived from the reciprocalof the variance. The logic of weightingby the inverse of the variance is thatstudies with larger sample sizes areassumed to more closely approximatethe true effect size for the population ofall similar studies. To analyze quality, wefollowed an approach recommended byWortman [1994].

To determine whether or not allsample effect sizes were drawn from acommon population of effect sizes witha shared mean, a test of homogeneitywas performed. The Q statistic is testedvia traditional inferential methods[Hedges and Olkin, 1985]. If this ho-mogeneity test produces a result that issignificant at the 0.05 level (of v2 at k-1degrees of freedom), the individualstudies are considered to be more vari-able than expected due to samplingerror alone; thus, if the Q is significant(a 5 0.05), the variance associated withthe effect sizes are heterogeneous andcannot be assumed to have been drawnfrom the same population of studies. Ifthe variances are homogenous, then it ispossible to combine studies and treatthem as if they are one large study, pro-vided that the dependent variables sharean underlying construct. In this synthe-sis, we combined measures under thebroad construct of parental distressrelated to environmental stress.

Planned comparisonRosenthal et al. [2000] presented

a procedure for conducting plannedcomparisons in meta-analysis in orderto identify significant moderating varia-bles. It is based on traditional ANOVAwith an adjustment in the calculation ofvariances and the use of weightings forplanned comparisons. We conducted onecomparison based on the ABCX theoryand previous research findings. We investi-gated whether multicomponent traininginterventions, which focused on both par-enting behavior and parent cognitivebehavior coping skills, were more effectivethan either presented alone.

Fail-safe statisticA potential threat to the validity of

a meta-analysis is the possibility that thereare unpublished studies unavailable to theresearchers and that the publishedresearch is biased toward results withhigher effect sizes in order to meet com-mon publication standards for statisticalsignificance. As a way to assess the likeli-

hood of there being enough contradic-tory studies to undermine confidence inan overall effect size, a fail-safe statisticwas calculated [Hedges and Olkin, 1985].The formula used to calculate the fail-safenumber is k0 ¼ kð!d% dcÞ=dc, in which k0is the number of studies with null resultsneeded to render the average effect as neg-ligible, k the number of studies in the syn-thesis, !d the overall average effect size, anddc is the effect size at a negligible level,where in this analysis it was set at 0.01[Hedges and Olkin, 1985].

DSTAT and MetaWin do notinclude the procedure for calculatingthe planned comparison statistics, there-fore quality-weighted effect size, and soan Excel program developed by the firstauthor was used based on formulas pro-vided by Shadish and Haddock [1994].Similarly, an Excel program developedby the first author was used to calculatethe planned comparison statistics usingformulas presented by Rosenthal et al.[2000].

Weighting effect sizes for quality of researchstudies and their reports

To address the variability in thequality of studies and their reports, theywere assigned quality weightings. Theseweightings form an index of the confi-dence that can reasonably be placed inthe findings from each study and fromthe overall synthesis [Orwin, 1994;Wortman, 1994]. Several major designvariables were given the weight of ei-ther 1 or 0 based on (a) whether or notthe study used random assignment totreatment and comparison groups, (b)whether or not the study included fol-low-up data, (c) whether or not thestudy included evidence for fidelity oftreatment, (d) whether demographicdifferences between groups were testedand differences controlled statistically,(e) whether or not the treatment wasbased on a manual, and (f ) whether ornot the psychometric properties of thedependent measures have been estab-lished. All of the studies used psycho-metrically mature instruments and wereassigned a weight of 1 on this dimen-sion. In addition to the design featuresof the studies, we also evaluated theextent of the information included inthe research reports. Parent descriptivedata was coded with a 1 or a 0 for eachof the following bits of information: (a)primary caregivers’ ages, (b) primarycaregivers’ highest levels of educationattained in years, (c) marital status, (d)family income or employment category,and (e) and parents’ ethnicity or race.The following descriptive variables for


Table 1. Summary Data for Meta-Analysis of Group Comparison Studies of Interventions to ReducePsychological Distress in Mothers and Fathers of Children with Developmental Disabilities

Author PublicationDate; PrimaryDisability

InterventionType Measure

N Mean (SD)EffectSizeIntervention Comparison Intervention Comparison

Bristol et al., 1993; Autism MCT CES-DPost 14 14 12.9 (10.5) 16.6 (13.5) 0.30Follow-up 14 14 9.7 (7.1) 16.7 (10.2) 0.77

Chadwick et al., 2001; ID BPT PSIPost 38 24 31.30 (9.8) 33.6 (11.2) 0.47Follow-up 31 18 31.6a (9.3) 31.1 (12.1) 0.05

Drew et al., 2002; Autism BPT PSIPost – – – –Follow-up 10 10 104.3 (20.0) 112.1 (20.1) 0.37

Feldman and Werner, 2002; DD BPT BDIPost – – – –Follow-up 18 18 7.2 (5.9) 8.3 (7.8) 0.16

Gammon and Rose, 1991; DD CBT POMS (Depression-Dejection Scale)Post 24 18 22.2 20.6 0.13Follow-up

Hudson et al., 2003; ID MCT DASS (Stress Subscale)Post 39b 26 9.2 15.1 0.60Follow-up 25 – – 6.8

Kirkham, 1993; DD CBT BDIPost 143 72 6.6 (5.8) 7.8 (7.0) 0.20Follow-up 49 27 7.1 (5.9)* 9.9 (8.5) 0.39

McIntyre, 2007; DD BPT CES-DPost 21 23 14.7 (11.2) 13.4 (7.6) 20.13Follow-up

Niccols and Mohamed, 2000; DD BPT CES-DPost 12 5 – – 0.40c

Follow-up 3 – – –Nixon and Singer, 1993; DD CBT BDI

Post 18 16 10.6 (7.1) 13.6 (8.7) 0.37Follow-up

Pelchat et al., 1999; DS FSI Quebec Health and SocialSurvey EmotionalDistress Indexd

MothersPost 17 14 4.4 (2.7)* 5.1 (2.2) 0.30Follow-up 17 14 3.6 (1.2)* 4.5 (2.5) 0.45

FathersPost 17 14 2.9 (1.6)* 3.5 (2.1) 0.32Follow-up 17 14 2.8 (1.4)* 3.4 (2.7) 0.29

Salt et al., 2002; Autism MCT PSI (Parental Distress Scale)Post 12 5 63.4 (28.8) 52.20 (36.9) 1.97e

Follow-upSchultz et al., 1993; ID CBT General Health Questionnaire

MothersPost 15 39 15.7 (9.2)* 21.3 (13.5) 0.44Follow-up

FathersPost 15 39 16.3 (8.3)* 20.2 (13.0) 0.32Follow-up

Singer et al., 1994; TBI CBT BDIMothersPost 4 6 7.7 (6.8)* 13.88 (10.8) 0.63Follow-up

FathersPost 3f 2 – –Follow-up

Singer et al., 1988; DD CBT BDIPost 18g 18 7.4 (5.9)* 9.0 (6.1) 0.27Follow-up

Singer et al., 1989; DD MCT BDIMothersPost 19 13 5.7 (5.5)*** 12.5 (12.7) 0.72Follow-uph 15 – 6.4 (7.1) –

FathersPost 9 8 5.3 (5.8)** 8.9 (9.9) 0.45Follow-uph 8 – 6.0 (6.9) –


children were also rated with a 1 ifreported and a 0 if not: (a) child’s age,(b) child’s primary diagnosis, and (c) ameasure or indication of the severity ofthe child’s disability. Detailed tablessummarizing the parent and child de-mographic variables are available fromthe first author.

ReliabilityTo determine interobserver agree-

ment on quality weightings, a secondreader coded 100% of the studies. Per-centage of interobserver agreement wascalculated by dividing the total numberof agreements by agreements plus dis-agreements and multiplying by 100. Ininstances of disagreement, the authorand the observer discussed and reviewedthe texts and arrived at an agreed uponcorrect data point.

RESULTSA first order search of the Psych-

Info and PubMed databases using theterms, parent, disability, and interventionyielded a total of 124 and 150 studies,respectively. Review of abstracts andarticles led to inclusion of a total of 22studies retrieved from the databases andpublished literature reviews. Two studieswere dropped because of insufficientdata and three other studies were notincluded because they did not measureparental stress or emotional distress asoutcome variables. Thus, 17 studies metthe inclusion criteria for this synthesis.We sorted the studies into four logicallydetermined categories based on thetreatment methods evaluated: (a) behav-ioral parent training (BPT), (b) cogni-tive behavioral treatment (CBT), (c)multiple component treatment (MCT),and (d) family systems intervention(FSI). Table 1 presents basic information

about the studies. It includes theauthors and years of publication, thetreatment categories, the dependentmeasures, the numbers of subjects ineach group, the means and standarddeviations, and posttest and follow-up(when available) on the dependentmeasures selected for inclusion in theanalysis, and their effect sizes.

Demographic DataMost of the parents in these stud-

ies, with a few exceptions, were Whiteand middle class with high school orsome college as their highest level ofeducational attainment. Several studiesincluded single parents, usually mothers,and small numbers of people with rela-tively low incomes. The numbers ofparents of color or from recent immi-grant populations were very small. Thegreat majority of subjects were mothers,with only three studies reporting out-comes for fathers. The ages of the chil-dren ranged from an average of 6months to !14 years old. Eight of thestudies served parents of children withan average age of 6 months to 6 years,and therefore may be classified as earlyintervention research. Four of the stud-ies targeted parents of children with au-tism, with the other 13 aimed at parentsof children with a variety of develop-mental disabilities as well as autism.Detailed tables summarizing parent andchild characteristics are available fromthe first author.

Dependent Measures andHomogeneity of Variance

It is common in meta-analyses tocombine effects based on a variety oflogically related dependent measures,provided they measure the same generalconstruct and that the data is character-

ized by homogeneity of variance [Hallet al., 1994]. In this meta-analytic syn-thesis, we focused on the impact ofinterventions on parental stress andemotional distress. The most commondependent variables in these studieswere depressive symptoms. Whenever itwas necessary to choose one effect sizefrom others in any given study, we cal-culated effect sizes based on measures ofdepressive symptoms. Eleven of thestudies reported outcomes on com-monly used measures of depressivesymptoms, including the BDI [Becket al., 1988]; the CES-D [Radloff, 1977];and the Depression Anxiety and StressScale [Lovibond and Lovibond, 1995].In one study we analyzed a subscale fordepression from the Depression/Dejec-tion Scale of the Profile of Mood States[McNair et al., 1971].

Three studies employed broadermeasures of stress and emotional dis-tress. Pelchat et al. [1999] used theEmotional Distress Index from theQuebec Health and Social Survey [Pre"-ville et al., 1992], which is a Frenchversion of the Psychiatric SymptomIndex [Ilfeld, 1976], a general measureof psychological distress with scales fordepression, cognitive disturbance, anxi-ety, and anger. Schultz et al. [1993] andTonge et al. [2002] used the GeneralHealth Questionnaire [Goldberg andHillier, 1979], which measures four fac-tors: insomnia, somatic symptoms, anxi-ety, and severe depression. Three studiesused either total or subscale scores fromthe Parent Stress Inventory [Abidin,1995], a widely used measure of per-ceived stress in the family. The underly-ing construct which provides the ration-ale for combining these various measuresis parental psychological responses tostress.

Table 1. (continued)

Author PublicationDate; PrimaryDisability

InterventionType Measure

N Mean (SD)EffectSizeIntervention Comparison Intervention Comparison

Tonge et al., 2006; Autism MCT General Health QuestionnairePosti 35 35 18.0 (13.6) 21.7 (10.2) 0.31Follow-up 35 35 17.1 (7.6) 21.5 (11.9) 0.43

Note. Dashes indicate the data were not available. DD, developmental disabilities; ID, intellectual disability; TBI, traumatic brain injury; BPT, behavioral parent training; CBT, cognitive behavioral training; FSI,family systems intervention; MCT, multiple component treatments; BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies; DASS, Depression Anxiety and Stress Scale; PMI, Perception ofMood Inventory; PSI, Parent Stress Inventory.aMean of two intervention groups: individual and group training.bThree intervention groups combined: group support, telephone support, and self-directed support. Effect size calculated from F value.cNo scores provided, only an average d across three different measures including the CES-D, PSI, and Parenting Sense of Competence Scale.dFrench adaptation of the Psychiatric Symptoms Index [Ilfeld, 1976].eChange score from pre to post with d calculated from N and P value.fMothers and fathers BDI scores were combined for analysis.gMothers and fathers data combined.hFollow-up data for intervention group only.iOnly four fathers participated in the study, thus group assignment was not indicated.*P < 0.05; **P < 0.001; ***P < 0.01.


The Q test for homogeneity ofvariance was nonsignificant, indicatingthat the studies shared a common var-iance, a necessary condition for combin-ing studies with diverse measures andintervention (Q 5 7.41, P 5 0.917).

InterventionsFive studies had a primary focus

on interventions designed to teachparents skills for interacting effectivelywith their children in order to improvechildren’s problem behavior, increasetheir skills, or promote a secure attach-ment, and therefore categorized asbehavioral parent training interventions[Niccols and Mohamed, 2000; Chad-wick et al., 2001; Drew et al., 2002;Feldman and Werner, 2002; McIntyre,submitted for publication, 2007]. Inthese studies, measures of parentaldepressive symptoms were secondarymeasures meant to assess the indirectemanative effects of BPT. The studiestested various forms of BPT, with anemphasis on positive parenting. Thespecific behavioral techniques includedin these studies varied and are reportedin Table 2. One study in the BPT cate-gory used an intervention based onattachment theory, although it focusedon changing parents’ responsiveness totheir infants with disabilities by teachingparents to change their own behavior[Niccols and Mohamed, 2000]. McIn-tryre [2007] implemented a develop-mental and behavioral intervention, anadaptation for parents of children withautism of the Incredible Years ParentTraining Series [Webster-Stratton, 2000].Because our analysis of these studies isfocused on the collateral effects onparents, we do not report on childbehavior change, although in everyinstance there was significant improve-ment in adaptive behavior or decreasesin problem behavior.

Six studies were categorized asusing cognitive behavioral training toteach coping skills to parents to directlyreduce psychological distress associatedwith stress. In these studies, the inter-ventions were directly aimed at support-ing parents to learn and use skills thatwould reduce the impact of daily stress[Singer et al., 1988, 1994; Gammonand Rose, 1991; Kirkham, 1993; Nixonand Singer, 1993; Schultz et al., 1993].Table 2 presents a list of the major cog-nitive behavioral skills that were taughtto parents.

Five studies had interventions thatwere categorized as multiple componenttreatments, which included BPT andeither CBT and/or other support serv-

ices [Singer et al., 1989; Bristol et al.,1993; Salt et al., 2002; Hudson et al.,2003; Tonge et al., 2006]. One inter-vention was based on family systemstheory [Pelchat et al., 1999] and wascategorized as an FSI. Table 2 presentsbrief descriptions of the main treatmentelements, along with information aboutthe number of sessions or amount oftime involved in the group meetings.

How Effective Were TheseInterventions?

The average unweighted effectsize for the participants at posttest forthe 17 studies was d 5 0.49, with a95% confidence interval of þ0.27/þ0.7. A total of 920 parents partici-pated in these studies. When weightedby the inverse of the variances andquality indices, the overall effect sizewas reduced to d 5 0.29. It is theweighted effect size that most accuratelyreflects the overall efficacy in thesestudies.

We made one notable statisticaldecision in calculating these effect sizes.We used follow-up rather than posttestdata for three studies, because there wasevidence of a delayed effect [Bristolet al., 1993; Pelchat et al., 1999; Tongeet al., 2006] with unweighted effectsizes changing from posttest to follow-up from 0.30 to 0.77, 0.30 to 0.45, and0.29 to 0.43, respectively. In these threestudies the number of subjects remainedconstant from posttest to follow-up,whereas the other studies with follow-up data suffered from participant attri-tion. We believe that these data moreaccurately represent the efficacy in thesethree studies than the posttest scoresand so they were used to calculate theireffect sizes.

Data from the three studies thatincluded separate posttest data forfathers [Schultz et al., 1993; Pelchatet al., 1999; Singer et al., 1989] yieldedan average posttest unweighted effectsize of d 5 0.36, with a 95% confi-dence interval of þ0.27/þ0.44 and aweighted effect size of 0.37 for a totalof 102 fathers.

When Grouped by Type ofTreatment What Were the EffectSizes?

The average posttest unweightedeffect sizes for the five BPT studies was0.25. The six studies had an averageunweighted effect size of d 5 0.34. Thefive multiple component interventionstudies, which combined elements of

BPT, CBT, and, in some cases, otherforms of support services, had an aver-age effect size of d 5 0.90 [Singeret al., 1989; Bristol et al., 1993; Saltet al, 2002; Hudson et al., 2003; Tongeet al., 2006]. The single study of theimpact of a FSI [Pelchat et al., 1999]yielded an unweighted average effectsize, with mother and father effect sizesaveraged, of d 5 0.37 at follow-up.

Were MulticomponentInterventions More Effective ThanTreatments Which Focused Solelyon Either BPT or CBT?

There was a significantly higheraverage effect size from the multiple-component studies compared to eitherthe BPT or the CBT interventionsalone (F1,14) 5 6.53, P < 0.025. TheFSI was not included in the analysis,because there was only one study usingthis method.

Quality RatingAll studies were rated for quality

using commonly accepted standards forgroup comparison research methods.The purpose of these ratings was to cre-ate indicators of the overall confidencethat can reasonably be placed in thestudies. The quality ratings ranged froma low rating of 4.7 to a high rating of9.7. The average quality rating was 7.04with a median rating of 6.75 out of apossible score of 10. The most commondesign deficiencies were lack of meth-ods for assuring fidelity of implementa-tion (12 of 16), lack of treatment man-uals (9 of 16 without), and lack of fol-low-up data (9 of 16). Several studiesfailed to report important descriptivedata on the parents and children.

Is There Evidence to Support theContention That ParentingEducation Causes Increased Stress?

The evidence reported here leadsus to reject this contention. Assumingthat depressive symptoms reflect stress,there is little or no evidence that parent-ing education or coping skills educationcauses an increase in distress related tostress in parents. To the contrary, in allbut one study, parents who participatedin these interventions benefited by expe-riencing reductions in distress. Therewas one exception: a study by McIntyre[submitted for publication, 2007] hada negative unweighted effect size ofd 5 20.13, but we believe it should beconsidered an outlier given the out-comes in the other studies. Further,McIntyre [submitted for publication,


Table 2. Descriptions of Interventions for Parents of Children with Developmental Disabilities

Author, Publicationdate; InterventionType Treatment Description Duration of Training

Bristol et al., 1993;MCT

Counseling and Treatment and Education of Autistic and relatedCommunication-Handicapped Children (TEACCH) Parent-as-Cotherapist treatment program services are comprised of (a) childbehavior management, (b) parent attitude adaptation and homeenvironmental management, and (c) implementation and evaluation of‘‘special education procedures and behavior modification techniquesthrough one-to-one modeling, reinforcement, and guided feedback’’ (p.5). Individual coaching and counseling provided as needed.

Total hours of training unknown: in general,biweekly with length of time unknownfor 18 months

Chadwick et al, 2001;BPT

Individual and group parent training is comprised of (a) ‘‘range, causes,consequences and possible functions of their child’s challengingbehavior,’’ (b) ‘‘teaching appropriate behaviors and reducing orweakening unwanted behaviors . . . importance of applying thesetechniques consistently over time and across a range of situations,’’(c)‘‘awareness of more general factors influencing the child’s behavior,’’(d)developing ‘‘focused behavior therapy programmes’’ using the othertraining components, and (e) acknowledgement and addressing‘‘obstacles to implementation of behavior programmes, such asexpectations and beliefs or practical, family, and social factors’’ (p. 155).

7.5–10 hr of training: 1.5–2 hr for 5 weeks

Drew et al., 2002;BPT

Social-pragmatic joint attention focused parent training programme, iscomprised of (a) behavioral management and compliance promotion,(b) ‘‘development of early precursors to social and communicativecompetence. It aimed to promote joint action routines, the explicitteaching of joint attention behavior,’’ (c) shared meaning establishmentin ‘‘joint action routines,’’ and following ‘‘the developmental sequenceof responding to, maintaining and then initiating,’’ (d) ‘‘supportwholistic language learning,’’ and (e) program integration ‘‘intoeveryday routines’’ (p. 268).

24 hr of training: 3 hr every 6 weeks for 12months

Feldman and Werner,2002; BPT

Behavioral parent training is comprised of (a) ‘‘changing/removing settingevents and antecedents,’’ (b) ‘‘replacement skill training . . .noncontingent and differential reinforcement, and errorless procedure. . .,’’ and occasionally (c) ‘‘extinction, response interruption andredirection, or response cost’’ (p. 80).

12–48 hr of training: 1–2 hr for 3–6 months

Gammon and Rose,1991; CBT

Coping skills training program (CSTP) is comprised of ‘‘. . . cognitiverestructuring, interpersonal skills training, problem solving, individualgoal attainment, and group treatment’’ (p. 247).

20 hr of training: 2 hr for 10 weeks

Hudson et al., 2003;MCT

Signposts for building better behavior ‘‘. . . parent materials consist of eightinformation booklets, a videotape and a workbook’’ and is comprisedof (a) child behavior measurement, (b) ‘‘systematic use of everydayinteractions,’’(c) ‘‘replacing difficult behavior with useful behavior,’’ (d)‘‘better behavior’’ planning, (e) ‘‘teaching children ‘‘new skills,’’ (f ) stressmanagement, and (g) ‘‘family as a team’’ (p. 241).

Total hours of intervention varies by modeof intervention: each mode was deliveredover the course of 3 months, where (a)group mode was 12 hr of training: 2 hrsix times on a fortnightly basis, (b)telephone-support mode had no training,but !1.3 hr of contact: !20 min oftherapist contact on a fortnightly basis, (c)self-directed had no training or therapistcontact.

Kirkham, 1993; CBT Life skills-training is comprised of ‘‘. . . coping and communication skills,problem-solving and decision-making techniques, and skills to manageand control their social network. In addition, each group applied thenewly learned skills to resolve a problem in their community that theyshared . . .. Techniques used in the skills-training program includeddidactics, homework assignments, modeling, and peer leadership’’ (pp.510–511).

Hours of training unknown: duration andnumber unknown for 9 weeks

McIntyre (submittedfor publication,2007); BPT

Incredible Years Parent Training (IYPT) program with modifications forchildren with developmental disabilities (IYTP-DD) ‘‘included thetopics of: play, praise, rewards, limit setting, and handling challengingbehavior . . .. [Using the Incredible Years Parent Training manual fortoddlers was used with modifications for children with developmentaldisabilities] this treatment program utilizes group discussion, viewingvideotape vignettes of parent–child interactions, role-playing, didactics,and weekly homework[s]’’ (p. 10).

20 hr of training: 2.5 hr for 12 weeks

Niccols andMohamed, 2000;BPT

Skill building group is comprised of (a) ‘‘attachment security,’’ (b)‘‘parent–child interaction,’’ (c) ‘‘child and parent personality,’’(d)‘‘disengage cues,’’ (e) ‘‘engage cues,’’ and (f) children as leaders where‘‘parents learn how to follow . . . in play’’ (p. 142).


Nixon and Singer,1993; CBT

Cognitive behavioral parent training is comprised of (a) ‘‘cognitive modelof emotions’’ introduction, (b) ‘‘strategies to change cognitivedistortions and automatic thoughts,’’ (c) control-based ‘‘cognitivedistortions,’’ (d) ‘‘misattributions around the explanation of events,’’ and‘‘parental schema-related cognitive distortions and misattributions’’(p. 334).



2007] reported significant reductions inthe primary target of the intervention,problem, and adaptive behavior inyoung children with autism. A notablefinding was that in studies that com-pared skills based educational interven-tions to support groups, the parents inthe noneducational groups did notimprove on measures of psychologicaldistress.

How Many Unpublished StudiesWould Need to Exist to InvalidateThese Findings?

The fail-safe statistic for the 17studies yielded an estimate of 544, sug-gesting that a large number of unpub-lished studies with effect sizes of 0.01 orless would need to be extant, but notretrieved for this synthesis, to reduce theoverall effect size to a negligible level.

How Many Studies Compared anIntervention with Either anAttention-Only Placebo Group oran Alternative Treatment?

Drew et al. [2002] compared anintensive behavioral intervention forchildren with autism with a group thatreceived local services consisting ofhome visiting based on the PortageProject model. They randomly assigned

Table 2. (continued)

Author, Publicationdate; InterventionType Treatment Description Duration of Training

Pelchat et al, 1999;FSI

Programme d’Intervention Familiale (PRIFAM) is comprised of fivefamily subsystems and their associated program objectives: (a)individual, focused on identification of parental ‘‘perceptions and beliefsrelated to the situation; to change those that are detrimental and toreinforce those promoting adaptation,’’ and assisting parents’ gaining of‘‘a realistic understanding of the situation and to help them grieve theirdream of a perfect child,’’ (b) conjugal, focused on helping spouses‘‘understand the experience of each other and support each other inthe grieving process,’’ (c) parental, focused on promotion of ‘‘a trustingrelationship between the parents and the child and to encourage thedevelopment of attachment,’’ (d) family, focused on fostering‘‘exchanges within the family concerning the perception of thesituation and to acknowledge the role of each in the adaptationprocess,’’ and (c) social, focused on helping ‘‘parents keep significantrelationships with others and use in the most efficient way the availableresource and the help from health care professionals’’ (p. 468).

Hours of training unknown: 6–8 meetingsover 6 months, duration unknown

Salt et al., 2002;MCT

Scottish Centre for Autism (SCA) is comprised of (a) ‘‘take the lead fromthe child,’’ (b) ‘‘interpret every behavior as a potential interaction,’’ (c)‘‘shape the child’s interactions,’’ (d) ‘‘introduce adult lead activities withtime,’’ (e) ‘‘maintain balance between intrusion and distress,’’ (f ) ‘‘useimitation to access the child’s world,’’ (g) ‘‘use language contingent onactivities,’’ (h) ‘‘use the child’s ‘objects’ to create exchanges,’’ (i) ‘‘usepausing effectively,’’ (j) ‘‘introduce flexibility,’’ Parent support groupsoffered every 2 weeks.

176 of training: 8 hr fortnightly for 11months

Schultz et al., 1993;CBT

Caring for Parent Caregivers (CPC) is ‘‘a three-tiered approach todeveloping personal coping skills and social supports through awarenessand a problem-solving orientation . . .. Topics covered include familydynamics, loss and grief, communication and conflict-resolution skills,networking and resource utilization, stress management, and relaxationskills’’ (p. 207).


Singer et al., 1994;CBT

Stress management classes are ‘‘designed to combine two approaches tohelping: psychoeducational instruction of coping skills and parent-to-parent self-help and social support’’ (p. 42) where homework‘‘assignments included’’ (a) daily logging of ‘‘stressful events and copingresponses,’’ (b) ‘‘practicing progressive muscle relaxation (PMR) . . .,’’ (c)‘‘practicing short forms of relaxation in stressful events,’’ (d) ‘‘monitoringself-talk in stressful events,’’ and (e) ‘‘keeping track of helpful socialcontacts’’ (p. 43)


Singer et al., 1988;CBT

Stress management training is comprised of (a) stressful event andphysiological reaction self-monitoring, (b) ‘‘muscle relaxation skills,’’ and(c) ‘‘modification of cognitions associated with distress’’ (p. 272).


Singer et al., 1989;MCT

Community-based intensive support is comprised of (a) ‘‘identifyingstressors and stress reactions with self-monitoring,’’ (b) ‘‘progressivemuscle relation’’ long and short forms, (c) ‘‘self-monitoring and briefrelaxation in home and community,’’ (d) ‘‘modification of negativethoughts through self-coaching,’’ (e) covert rehearsal for difficultsituations,’’ (f ) ‘‘techniques for managing worries and obsessivethoughts,’’ and (g) ‘‘strengthening social support networks, utilizingrespite, and advocacy’’ (p. 315)


Tonge et al., 2006;MCT

Parent education and behavior management (PEBM) skills training iscomprised of (a) ‘‘education about autism,’’ (b) ‘‘features ofcommunication, social, play, and behavioral impairments,’’ (c) behaviormanagement and change principles (d) ‘‘teaching new skills,’’ (e) socialinteraction and communication improvement, (f ) ‘‘services available,’’(g) ‘‘managing parental stress, grief and mental health problems,’’ and (h)‘‘sibling, family, and community responses to autism’’ (p. 563).

25 hr of training: ten 90-min small groupsessions alternated with ten 60-minindividual family sessions over 20 weeks

BPT, behavioral parent training; CBT, cognitive behavioral training; FSI, family systems intervention; MCT, multiple component treatments.


parents to the two groups and foundsignificant reduction in parental distressin the BPT group.

Cognitive behavioral traininginterventions were also compared toother forms of parent support. Kirkham[1993] randomly assigned parents toeither a coping skills educational group ora support group, which did not includeskills training. Similarly, Singer et al.[1994] randomly assigned parents to ei-ther a multiple component treatment oran informational support group that metfor the same amount of time as the copingskills group, but received only didacticinformation.

Two multicomponent interven-tions also used alternative treatmentcomparison groups with random assign-ment. Tonge et al. [2006] used a designthat allowed examination of the valueadded through individual coaching ofparents. They compared a group thatreceived emotional group support, andonly the informational content of theircombined BPT and CBT interventionbut without direct coaching of parent-ing skills versus a group that receivedthe full intervention, including not onlydidactic presentations but also coachingof skills in home settings. For parentswho entered the study with elevateddepressive symptoms, both groups werebeneficial compared with the no treat-ment control. Singer et al. [1989] usedrandom assignment to compare a groupreceiving intensive BPT and CBT pluscase management and respite care witha group that received only case manage-ment and respite. The intensive supportgroup had significantly lower depressivesymptom scores at posttest than thecomparison group, and these changesmaintained in the intensive treatmentgroup at a 1-year follow-up.

DISCUSSIONParents of children with develop-

mental disabilities on average experi-ence more stress than comparative fami-lies of typically developing children[Hastings and Beck, 2004]. Elevatedlevels of depressive symptoms in moth-ers are associated with this stress [Singer,2006]. Over the past three decades, sev-eral researchers have studied interven-tions designed either directly or indi-rectly to reduce depressive symptomsand improve well being. When viewedas a whole, these studies consistentlydemonstrated benefits. This evidence isencouraging and is a clear indicator thatthe problems of some parents of chil-dren with developmental disabilities are

responsive to supportive interventions atleast in the short term. The benefitshave primarily been demonstrated withmothers, although the three studiesincluding fathers as participants alsoprovided evidence of efficacy.

Six of the studies reviewed hereprimarily aimed at training parents tomanage their children’s problem behav-ior and, in some cases, to increasechildren’s skills. It is important to notethat all of the BPT studies reportedimprovements in children’s behaviorassociated with the interventions,although we did not attempt to charac-terize the quality of this evidence forchild behavior change. We asked a dif-ferent question: Can BPT be used as away to help parents with stress-relatedemotional distress? There were consist-ent findings of collateral benefits of par-ent behavioral training in reducingdepressive symptoms in mothers,although the effect sizes were small.Children’s problem behaviors and pa-

rental depressive symptoms have beenshown to covary in a bidirectional fash-ion over a 1-year period [Hastingset al., 2006]. It is likely that reductionin problem behavior is both, in part, acause and an effect of improvement inparental affect. The average weightedeffect size for reductions in depressivesymptoms was d 5 0.25, whichapproaches the 0.26 effect size derivedfrom nine studies that measured depres-sive symptoms in a recent Barlow et al.[2003] meta-analysis of the collateralbenefits of several theoretical approachesto parent training for parents of childrenwithout disabilities. We believe thatthere is sufficient evidence to warrantthe claim that these treatments are evi-dence-based as ways to help parentswith stress-related distress, particularlydepressive symptoms, at least for theshort term for middle class WhiteAmerican mothers. The evidence sug-gests that BPT may not only changeparenting behavior, but also it has smallbut consistent collateral benefits.

Cognitive behavioral training wasalso consistently effective in six studiesreviewed in this synthesis. Unlike theBPT studies, reductions in parental dis-tress were the primary target of theseinterventions. CBT was used to provideparents with coping skills for reducingor preventing the effects of environ-mental stress associated with parentingchildren with developmental disabilities.Rather than attempting to effect paren-t–child behavior change, these interven-tions were designed for parents to learnand support the use of self-managementskills that would directly impact theirown well being. When CBT was thesole treatment approach, the averageunweighted effect size was d 5 0.34,evidence for relatively small but consist-ent benefits. These interventions for themost part were transferred from stressmanagement and psychotherapy treat-ments for people in the general popula-tion. There is sufficient evidence also tobelieve that these approaches can beconsidered to be evidence-based withthe same caveats as for the BPT results.Given the evidence for bidirectionaleffects of depressive symptoms and childproblem behaviors, a reasonable hy-pothesis in future research would bethat children’s problem behavior andwell being would improve as a result oftheir parents achieving greater wellbeing by using CBT coping skills.None of the counseling and stress-man-agement interventions in this reviewasked whether there were collateral pos-itive changes in children’s behavior asso-ciated with improvement in parentaldepressive symptoms, a potentially usefulquestion to address in future research.

Multiple component interventionswere clearly more effective than BPT orCBT alone. This finding is consistentwith Folkman and Lazarus [1980]theory of stress, understood to be theproduct of a complex interactionbetween cognitive appraisal, familyresources, and instrumental behavior.The multicomponent interventions alsomeet standards for evidence-based treat-ments at least in middle class mothersand in the short term. One interventionwas designed based on family systemstheory [Pelchat et al., 1999]. It was theonly study in this synthesis thatattempted to address some of the needsof siblings and other family memberswhile primarily focusing on the parentsof infants. When more complex inter-vention methods were presented toparents over a relatively longer periodof time than in the single componentstudies, there were substantial reductions

Cognitive behavioraltraining was also

consistently effective insix studies reviewed in

this synthesis.


in parental distress. The five studies withmultiple component interventions hadan average unweighted effect size ofd 5 0.90 is very close to the averageeffect sizes for studies in the generalpsychotherapy literature when treatmentgroups were compared to no-treatmentcomparison groups (d 5 0.82) andexceeds the average effect size whentreatments were compared with a pla-cebo (d 5 0.48) [Wampold et al.,1997]. This finding is very encouragingand suggests that the stresses manyparents of children with developmentaldisabilities experience and the resultingdistress are amenable. A second genera-tion of studies is warranted by extensivechanges in our understanding of adapta-tion in families of children with devel-opmental disabilities. We would hopethat future studies include all familymembers, measure family quality of lifeas well as empowerment, parenting self-efficacy, and perceptions of the positivecontributions that children with disabil-ities make to their families. These stud-ies were primarily concerned withdecreasing distress, but recent researchindicates that it is realistic to aim notonly for reduced family problems butalso for positive adaptation in which thebenefits of intervention include mean-ingful improvements in positive wellbeing and quality of life. Several meth-odological and measurement issuesshould be addressed in future studies.Efforts should be made to expand theuse of direct observation in assessing theimpact of treatments aimed at thewhole family as a unit. The recipientsof future supportive interventionsshould include as many coresident fam-ily members as possible. Fathers, withseparate complete posttest data andanalyses, were included in only three ofthe studies and comprised 11% of thetotal sample. None of the studies lookedat the emanative effects of supportingparents on siblings without disabilities.

An analysis of the quality of thesestudies suggests that there is consider-able room for improvement in thedesign, conduct, and reporting of inter-vention research. Studies with largersample sizes are needed, and threats tointernal and external validity need to bebetter controlled in future research. Itwas encouraging to find several studiesusing random assignment, standardizedmeasures with mature psychometricproperties, and treatment manuals withadequate reporting of the importantdetails of the study. It is hoped thatfuture studies will also provide effectsizes and sufficiently report on the char-

acteristics of the children and parents,so that evidence for external validitycan be evaluated better. An area thatdeserves much more research attentionis the question of the efficacy of thesetreatments for parents from the manyethnic and linguistic minority familiesin the contemporary US. Several of thestudies did include some parents withlow incomes and most included singlemothers, who on average are more vul-nerable to economic insecurity. How-ever, the number of parents from tradi-tionally underserved groups in the USwas vanishingly small in these studies. Itis hoped that researchers will turn theirattention to finding and evaluatingeffective methods of supporting thesefamilies. A logical place to begin wouldbe to evaluate the efficacy of the mosteffective treatments in this literaturewhen provided to different populations

of parents and when specific accommo-dations in the treatment methods aremade to reflect cultural and/or socialclass differences. Longer term follow-updata is needed. On the basis of our ex-perience with families, we believe that acomprehensive system of family supportwould make interventions available onan as-needed basis, as family circum-stances change over the life cycle.Common events such as divorce, mov-ing to a new home or neighborhood,young adult children leaving home, andchanges in the needs of children withdisabilities over time need to bereflected in the support services avail-able to these families. Research has notyet begun to look at the longitudinalneeds for and benefits of supportiveinterventions. It is hoped that futureresearch will build an evidence base forsupport through the life cycle.

Clinical utility in part is a matterof evidence for external validity. Three

of the studies reported here were evalu-ations of interventions that were imple-mented as part of public social serviceprograms, suggesting that parentingeducation can be delivered on a largerscale [Feldman and Werner, 2002; Saltet al, 2002; Hudson et al., 2003]. Simi-larly, Kirkham [1993] implemented aCBT intervention with a relatively largenumber of parents and Singer et al.[1993] included a replication of theircombined intervention by a group otherthan the originators of the intervention.These findings begin to build a case forclinical utility but they are only thebeginning. There is much work yet tobe done before it can be said that thesemethods are proven to be effectiveacross the full range of ethnic, linguistic,and socioeconomic groups in the USand over longer periods of time. Theresults of this meta-analysis suggest thatresearchers now have a solid foundationof evidence on which to build futureforms of family support. n

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