BEHAVIOR THERAPY 27, 159-169, 1996

Group Parent Training: Is It Effective for Children of All Ages?

PENNEY R. RUMA

RAYMOND V. BURKE

RONALD W. THOMPSON

Father Flanagan's Boys' Home, Boys Town, Nebraska

Archival data from 304 mothers who attended group parent training were used to test for age effects on statistical and clinical significance of improvements in child behavior problems following participation in the program. The Total Problem T score from the Child Behavior Checklist served as the dependent measure for all analyses. Results indicated that, for the total sample, the severity of problem behaviors before treatment was the best predictor of treatment outcomes. When the sample was divided into age groups, older children had more severe behavior problems before treatment, but all groups improved. When outcomes were examined for clinically significant improvements, adolescents had the lowest rate of clinical recovery, but the only sig- nificant predictor of treatment effects was again the severity of behavior problems before treatment. In general, the data supported the null hypothesis that group parent training is effective for children from early childhood through adolescence. However, positive group parent training outcome for families with children of any age was best predicted by the seriousness of the child's behavior problems prior to treatment.

The question, "which treatments work best for which children?" remains largely unanswered by the treatment outcome research on children and ado- lescents. It has been suggested that age or developmental level is one factor that moderates treatment outcome (Forehand & Wierson, 1993; Kendall, Lerner, & Craighead, 1984). To investigate whether child age is a factor in treatment outcome, it is necessary to test the effects of specific treatments across a broad age range of children with varying degrees of pathology.

Reviews of the parent training research confirm its effectiveness as a treat- ment for changing problem behaviors in children (e.g., Dumas, 1989; Graz- iano & Diament, 1992; Kazdin, 1987, 1991). The success of parent training is characterized by the work of Patterson and his colleagues with antisocial children ranging in age from 3 to 12 years (Patterson, 1986). Limited effects,

Reprints may be obtained from Penney R. Ruma, M.S., Program Planning, Research, and Evaluation, Father Flanagan's Boys' Home, 13603 Flanagan Boulevard, Boys Town, NE 68010.

159 0005-7894/96/0159-016951.00/0 Copyright 1996 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

160 RUMA ET AL.

however, have been found in the few studies that have examined the effects of parent training for adolescents (Bank, Marlowe, Reid, Patterson, & Wein- rott, 1991; Dishion, Patterson, & Kavanagh, 1991).

Treatment research with children, in general, seldom differentiates between younger and older children, making it difficult to evaluate given techniques for different age groups (Kazdin, 1993). Typically, when age is examined as a factor in treatment outcome, meta-analysis is applied to numerous studies using similar interventions (Lipsey & Wilson, 1993). Only a few studies, how- ever, have actually identified age as a contributing factor in treatment outcome (Bath, Richey, & Haapala, 1992; Dishion & Patterson, 1992; Miller, Barrett, Hampe, & Noble, 1972).

A recent study by Dishion and Patterson (1992) is an exception. They ex- amined age effects for parent training for two age groups of children. Both the clinical and statistical significance of behavior change were examined for each group. The authors predicted parent training would be less effective with older children. Using the Total Aversive Behavior (TAB) score on the Family Interaction Coding System (FICS; Reid, 1978), they found, however, that parent training decreased behavior problems in both younger (2.5 to 6.5 years) and older (6.5 to 12.5 years) children even though older children were more likely to be in the clinical range before treatment.

The current study is an extension of the Dishion and Patterson (1992) study. We examined the effects of a group parent training program for three age groups of children: early childhood, middle childhood, and adolescence. Our two younger age groups are the same categories used by Dishion and Patterson, but we also had the opportunity to include adolescents. While parent training has most often been used as an intervention for families with younger chil- dren, all of these age groups are typically represented in classes offered by the Boys Town Common Sense Parenting ® (CSP) program. Therefore, it was important for us to examine the effectiveness of the program for the broad range of families and children being served.

The CSP program was adapted from the Teaching Family Model (TFM) of group home care (Phillips, Phillips, Fixsen, & Wolf, 1973; Wolf, Phillips, et al., 1976) and the Boys Town Family Home (BTFH) program (Coughlin & Shanahan, 1988; Peter, 1986). In both the TFM and BTFH approaches, married couples are trained to use behavioral methods with conduct problem children and adolescents in group home settings. Evaluation studies have indicated significant behavioral and academic effects (Jones, Weinrott, & Howard, 1981; Thompson et al., in press; Wolf, Braukmann, & Ramp, 1987). In the development of the CSP program, skills from these approaches were adapted for use by parents in their own homes.

During the evolution of CSP, both 6- and 8-week programs have been offered. Recently completed research suggests that there is no difference in treatment outcome between these two program variations (Thompson, Ruma, Schuch- mann, & Burke, 1994); therefore, data from both program variations were combined for this study. Furthermore, when compared to a wait-list control

AGE EFFECTS IN PARENT TRAINING 161

group of parents, statistically significant improvements in reported child be- havior problems, parents' attitudes, and overall family satisfaction levels were found for families who completed CSP (Thompson, Ruma, Schuchmann, & Burke, 1993). Positive outcomes for the program have also been reported for families who differed significantly on referral source, age of children, income level, and ethnicity (Burke, Martinez, Ruma, Schuchmann, & Thompson, 1993; Thompson, Grow, Ruma, Daly, & Burke, 1993), but a critical exam- ination of outcomes based on child age has not been completed. In the current study, treatment outcomes were tested for both statistical and clinical significance. We hypothesized that older children would be less successful in making both statistically and clinically significant changes in behavior problems.

Method Participants

CSP classes are offered to parents in Omaha, NE; Grand Island, N£; Orlando, EL; Delray Beach, EL; and San Antonio, TX. We examined archival data from 304 mothers who attended CSP classes during 1991 and 1992 at these sites for the current study. Ninety-eight mothers dropped out of treatment leaving 206 mothers in the pre-post analysis. Families typically attend CSP classes because of behavior problems they are experiencing with their children. Pro- fessional agencies and the courts also refer parents to the classes so they can learn better parenting skills. In San Antonio, for example, all of the parents who attended classes were referred by the Texas Department of Social Ser- vices because of suspected child abuse or neglect.

A diverse group of families is represented in this sample. Families had sig- nificant differences across sites on all demographic variables except child sex. At the two Nebraska sites, more of the families were comprised of two parents than at the other sites. Racially, the families were also diverse. At all sites except San Antonio the greatest percentage of parents were white. Most of the parents in San Antonio were Hispanic. Although complete socioeconomic status information was not available for this sample, limited employment data were provided. Seventy-five percent of the parents in Omaha were employed, in contrast to the parents at the San Antonio site, all of whom were unem- ployed. Demographic characteristics of the families at each site are indicated (see Table 1).

Mothers identified a "target child" in the family to be the focus of treatment. This was the child who exhibited the most behavior problems. If the mother identified more than one child in the family with behavior problems, the oldest child was chosen. Overall, 67 % of the target children were males, and 33 % were females. They ranged in age from 2 to 16 years. Target children at the Orlando site were older than at the other sites. They also had more reported behavior problems. San Antonio mothers reported the fewest behavior prob- lems for their children. At all of the sites, parents reported that on the average

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TABLE 1 DEMOGRAPHICS BY SITE (n = 206)

Grand San Delray Omaha Orlando Island Antonio Beach F X 2

n = 104 n = 14 n = 3 4 n = 3 8 n = 16 (4, 201) (4, n=206)

Parent Race White 97% 71% 97% 5 % 56% 136.95"* Black 1% 10% 0% 28% 44% Am. Indian 1% 5% 0% 0% 0% Hispanic 0% 5% 0% 64% 0% Other 1% 9% 3% 3% 0%

Age M 35.77 37.91 33.20 28.33 36.12 9.92** SD 7.07 5.79 5.06 5.87 7.86

Family constellation 1 Parent 33% 64% 49% 67% 62% 2 Parent 67% 36% 51% 33% 38% 18.06"*

Employment FTE/PTE 76% 64% 60% 0% 56% 62.37**

Referral source Self/friend 62 % 77 % 68 % 0 % 7 % Agency/court 38% 23% 32% 100% 93% 61.08"*

Child Age M 5.83 12.21 9.06 7.92 9.94 SD 4.59 2.01 3.90 3.89 3.89 11.27"*

Sex Male 66% 71% 70% 58% 81% 3.14

CBCL total problem score

Pretest M 63.80 74.07 64.82 60.53 66.00 4.77** SD 10.90 8.28 .9.02 8.65 11.76

Age Group Early childhood 62% 0% 24% 34% 13% Middle childhood 22 % 36 % 38 % 53 % 56 % Adolescence 16% 64% 38% 13% 31% 49.80**

** p < .001.

these target ch i l d r en had b e h a v i o r p r o b l e m s in the b o r d e r l i n e c l in ica l to c l in-

ical range.

Parent Training Procedure

C S P has a s tandard c u r r i c u l u m and fo rmat . E a c h sess ion is s chedu led for 2 hours . D u r i n g the first h o u r o f e a c h class , h o m e w o r k a s s ignmen t s and ski l ls

AGE EFFECTS IN PARENT T R A I N I N G 163

from the previous sessions are reviewed, and a new skill is taught using direct instruction and modeling by the parent trainer. Videotaped vignettes and read- ings from a parent manual (Burke & Herron, 1992) are also used to help par- ents understand the application of each skill. During the second hour, parents role play situations using the skill being taught. All parents are taught the same skills, which include the use of clear communication, positive reinforce- ment and consequences, preventive and corrective teaching, self-control, and problem solving. Examples and role-play situations are varied to demonstrate application of the skills with children at different ages. A detailed description of program procedures may be found elsewhere (Thompson, Grow, et al., 1993).

Parent trainers at all the sites included in this study had used a detailed trainers' manual and had been trained extensively in the CSP program. All of the trainers also had previous experience with the BTFH program. Their formal academic training ranged from some college to graduate degrees. How- ever, the staff training was designed so no prerequisite level of formal edu- cation in the behavioral sciences was required. Both male and female trainers taught classes at all of the sites.

Measures Mothers completed the Child Behavior Checklist (CBCL; Achenbach, 1991a)

on the identified target child at the first and last class. At the first class, mothers were asked to rate their child's behavior during the time period identified in the CBCL instructions (prior 2 months for 2 and 3 year-olds and prior 6 months for 4 to 16 year-olds). At the last class, mothers were asked to rate their child's behavior since they began parent training.

We used the CBCL Total Problem T score as the dependent variable for all analyses. The CBCL is widely used by researchers and practitioners as a general measure of a child's functioning. It was standardized on children and adolescents aged 2 through 18 and allows comparisons across both sex and age groups. Reliability studies have indicated test-retest reliability coefficients from .89 to .93 for the broadband scores on the CBCL (Achenbach, 1991b). Two broadband problem behavior factors, Internalizing (e.g., depression, anxiety) and Externalizing (e.g., delinquent behavior, aggression), are included in the overall Total Problem score. A Total Problem T score between 60 and 63 places a child in the borderline clinical range, and a T score of 64 or greater is considered to be in the clinical range. The Total Problem score is the most reliable indicator of a child's overall pathology (Achenbach, 1991b).

Results Pretraining Comparisons

In addition to the comparisons of participants across sites reported in Table 1, the sample was also divided according to child age group in order to compare group parent training outcomes with the findings of Dishion and Patterson (1992). We compared three age groups: early childhood, 2 to 5 years

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TABLE 2 TOTAL PROBLEM T SCORES ON THE CHILD BEHAVIOR CHECKLIST

Pre Post

M SD M SD

Early childhood 62.18 10.76 57.28 12.58 Middle childhood 64.44 9.72 59.20 11.81 Adolescence 68.49 9.97 64.60 10.61

(n = 88); middle childhood, 6 to 11 years (n = 71); and adolescence, 12 to 16 years (n = 47). One-way ANOVAs indicated no gender differences for target children at pretest for any of the age groups. Therefore, gender was collapsed for all further analyses. Means and standard deviations of the CBCL Total Problem T scores at both pre- and posttest are reported in Table 2. A one-way ANOVA indicated significant age group differences in the severity of child behavior problems at pretest, F(2, 203) = 5.82, p < .05. Post hoc analyses revealed that Total Problem scores for adolescents were significantly higher than those in the early chi ldhood group (Tukey a = 7.24, p < .05). Differences between the early and middle chi ldhood groups and between the middle childhood and adolescent groups were not statistically significant. Sig- nificant differences between age groups were also found for race ~2 (2, n = 206) = 16.41, p < .001 and family constellation ~2 (2, n = 206) = 8.43, p < .05.

Statistical Significance

We completed a hierarchical regression analysis to examine the effects of age and other possible confounding variables on treatment outcome. These included C B C L pretest scores, family constellation, race, and site. These were included because we found significant differences on these variables across age groups and significant differences on almost all variables across sites. Results are presented in Table 3. The Total Problem T score at pretest and family constellation were the only significant predictors of treatment outcome.

TABLE 3 HIERARCHICAL REGRESSION ANALYSIS FOR VARIABLES PREDICTING TREATMENT OUTCOME

(n = 206)

Variable B SE B

Step 1 Total Problem T score (pretest) .77 .04 .74**

Step 2 Total Problem T score (pretest) .77 .04 .74** Family constellation (1 vs. 2 parents) -1.78 .78 -.09*

Notes. R 2 = .55 for Step 1;AR 2 = .01 for Step2(ps<.05) . ** p < .001. * p < .05.

AGE EFFECTS IN PARENT TRAINING 165

The relative predictive value was greatest for the severity of child behavior problems at pretest.

Clinical Significance Comparisons of CBCL pretest scores based on child age group suggested

that adolescents had more severe behavior problems than the younger age groups in the sample. Chi-square analyses indicated a significant difference in the percentage of children in each age group with clinically significant behavior problems before parent training ~2 (2, n = 206) = 6.56, p < .05. Forty-nine percent of the early childhood group, 61% of the middle childhood group, and 70% of the adolescent group scored in the clinical range at pretest.

We examined a subsample of 119 children with Total Problem T scores of 64 or greater at pretest to determine if a clinically significant change in their behavior problems occurred following parent training. Using the approach of Jacobson and colleagues (Jacobson & Revensdorf, 1988; Jacobson & Truax, 1991) to ensure that any change found was not due to measurement error, we also included the Reliable Change Index (RC) in our analysis. The RC is used to derive the boundaries of the confidence interval around the cutoff point. It is calculated by dividing the difference score (posttest-pretest) by the stan- dard error of the difference score.

On the CBCL, a change of 8 T score points was necessary to ensure that reliable change had actually occurred. Table 4 summarizes the percentages of these children who exhibited no change, minimal change, reliable change, or reliable change with recovery following parent training. Minimal change was defined as less than an 8-point improvement. A reliable change indicates that the change score met the RC standard, but did not reach the normal range. Reliable change with recovery (clinically significant change) refers to children and adolescents who improved at least 8 points and also moved from the clini- cal to normal range on the CBCL.

There were significant differences among age groups in the percentage of

TABLE 4 PERCENT OF CHILDREN SHOWING CLINICALLY SIGNIFICANT IMPROVEMENT AFTER TREATMENT

Clinical Significance

Reliable No Change M i n i m a l Rel iable Change With

Age or Worse Change Change Recovery

Early childhood (2-5) (n = 43) 28% 47% 2% 23%

Middle childhood (6-1 i) (n = 43) 23% 30% 5% 42%

Adolescence (12-16) (n = 33) 27% 52% 15% 6%

166 RUMA ET AL.

children who made a reliable change with recovery. Fewer adolescents made clinically significant behavior changes following treatment compared to both the early childhood group 22 (1, n = 119) = 4.15, p < .05 and the middle childhood group ~2 (1, n = 119) = 12.82, p < .001. The middle childhood group had the greatest number of children who made clinically significant gains, but adolescents, who had the largest percentage of youth in the clinical range initially, had the lowest recovery rate. The difference in the percent of recovery for the two youngest age groups following parent training approached significance ~2 (1, n = 119) = 3.39, p = .07.

Target children were divided into two groups based on whether they met the criteria for clinical recovery or not. We then conducted a logistic regres- sion analysis using problem severity, child age, race, family constellation, and class location on recovery status. The 22 value for the overall model equalled 22.66 (p < .01). The severity of reported child behavior problems at pretest was the only significant predictor of clinically significant change following parent training (B = .1992, p < .001). Again, contrary to our hypothesis, age was not a significant predictor of clinical recovery.

Discussion Our hypothesis that group parent training would be less effective with older

children was only partially supported. In the hierarchical regression analysis, we tested for the effects of a number of variables on which the families differed across sites and age groups. The best predictor of outcome was the severity of problems at pretest. In terms of clinical significance, when we compared children in early childhood, middle childhood, and adolescence we found that the adolescents had the lowest rate of clinical recovery, suggesting an age effect on outcome. However, when we completed the logistic regression analysis, age again was not a significant predictor of clinical recovery. The most parsimonious interpretation of the data is that adolescents did have a lower rate of clinically significant improvement, but it was because they had more severe problems before their parents attended group parent training.

One may hypothesize for several reasons that parent training might be less effective with parents of older children. As children get older they develop a stronger sense of emerging identity and strive for more autonomy. Peers often become a greater source of influence, and children spend less and less time at home (Forehand & Wierson, 1993) Studies have also indicated that older children and adolescents referred for treatment often reflect long-standing behavior problems that parents have failed to deal with in the past (Rutter, Graham, Chadwick, & Yule, 1976). Our results point to the severity of prob- lems as the reason why parent training may be less effective with older chil- dren. Also consistent with this interpretation, Bank et al. (1991) found parent training to be only marginally effective with parents of adolescents who had serious antisocial behavior problems.

Our finding that the program was less effective for children with the most

AGE EFFECTS IN PARENT TRAINING 167

severe behavior problems is not surprising. CSP is a brief intervention deliv- ered in a group format. The program uses the same curriculum for all families. Used alone, this intervention may be insufficient for treating the most severely distressed families. There may, however, be other reasons for these findings. Parents practice the skills taught during CSP classes through role play; how- ever, their use of the skills at home with their children was not assessed for this study. Perhaps parents of children with severe behavior problems fail to master or generalize the skills as successfully as parents of children with less serious problems. Or, perhaps, it may take longer for these children to re- spond to the skills their parents implement. Alternatively, parents who view their children negatively and inflate their reports of child behavior problems may also be less likely to implement the skills they are taught. Without mea- sures of parental skill acquisition, in-home application of skills, and direct observation of behavior changes it is impossible to know what accounts for treatment outcomes.

These results are generally consistent with those of Dishion and Patterson (1992) even with the addition of the third age group, adolescence. The unique contribution of the current study is the suggestion that severity of behavior problems is the factor that is responsible for age effects in parent training, especially with parents of adolescents. There are several limitations, however, that must be considered. We had no control or comparison group to isolate behavior changes due to the treatment as opposed to other factors. Follow-up data were not available, making it impossible to examine long-term effects of the program. Finally, outcome measurement was limited to a single, global rating of psychopathology by one informant. Future studies should be designed to remediate these deficiencies.

On the positive side, even though in many field studies it is impossible to adhere to the demanding methodological standards set for clinical research (Peterson & Bell-Dolan, 1995), the results can still be used to advance prac- tical knowledge about treating families. There are several strengths of the cur- rent study. First, our own previous research has indicated that the program has statistically and clinically significant treatment effects when compared to a wait list control condition. Second, the fact that the sample is hetero- genous makes it more like samples faced by practitioners in the field. Our results indicate that group parent training is a treatment that is beneficial to a wide range of parents and children. For children with more serious behavior problems, however, other services and treatment may be necessary to achieve clinical recovery.

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RECEIVED: March 24, 1995 ACCEPTED: January 22, 1996