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Investigating Mechanisms of Change in the Collaborative Problem Solving Model Georgina Heath Submitted for the Degree of Doctor of Psychology (Clinical Psychology) School of Psychology Faculty of Health and Medical Sciences University of Surrey Guildford, Surrey United Kingdom September 2016 Abstract Collaborative Problem Solving (CPS; Greene & Ablon, 2006) is a treatment model designed to reduce behavioural difficulties among children and adolescents by developing their cognitive, emotional and social skills. The aim of this study was to evaluate the effectiveness of the CPS

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Investigating Mechanisms of Change in the Collaborative Problem

Solving Model

Georgina Heath

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyGuildford, SurreyUnited KingdomSeptember 2016

Abstract

Collaborative Problem Solving (CPS; Greene & Ablon, 2006) is a treatment model designed to reduce behavioural difficulties among children and adolescents by developing their cognitive, emotional and social skills. The aim of this study was to evaluate the effectiveness of the CPS approach in an outpatient setting and to explore whether child executive functioning (EF), increased parental empathy, and/or reduced parental stress are possible mechanisms of change within the CPS model. Forty-two families of children aged 3-12 years with behavioural difficulties completed a 12-week in-home CPS treatment programme. Caregiver report measures were completed pre and post-treatment. The results suggest that post CPS there were significant reduction in child behavioural difficulties, improved child executive functioning, increased parental empathy, reduced parental stress, and an improvement in caregiver-child relationships. Regression analyses indicated that improvements in child EF appeared to be the primary mechanism of change within the CPS model, predicting approximately 22% of variance in child behavioural outcomes. Reduced parental stress also accounted for a small amount of variance, however changes in parental empathy were not a predictor of child behavioural outcomes. Child behaviour pre-intervention was not associated with the amount of change produced in child

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executive functioning, parental empathy or parental stress, which indicates that positive changes can occur through CPS, regardless of the severity of behavioural difficulties at outset. These results suggest that child EF and low parental stress are critical for healthy child and adolescent development, and should be a focus for interventions aimed at reducing child behavioural difficulties. Keywords: Collaborative Problem Solving; Children; Behavioural Difficulties; Executive Functioning; Parental Empathy; Parental Stress

AcknowledgementsFirstly I would like to thank Cat, my housemate, my course mate, my shoulder to cry on, my cheerleader, and my best friend. I could not have got through this course without you!Secondly, I would like to thank my parents for their unwavering support and belief in me. You encouraged me to pursue a career that would challenge and excite me, for which I am very grateful.

Thirdly, I would like to express my deepest gratitude for the staff team in the service who kindly agreed to support my MRP and spent their valuable time collecting, anonymising, and sending data to make this study possible. In particular, I would like to thank Michael Hone and Alisha Pollastri, for their consistent support and availability, assisting me with my endless queries!

Finally I would like to thank my supervisor Professor Chris Fife-Schaw for his unwavering support and advice throughout my research project, and for assisting me with his extensive statistical knowledge.

Contents

MRP Empirical Paper 5MRP Appendices 65Major Research Project Proposal 85MRP Literature Review 105Summary of Clinical Experience 162Table of Assessments Completed in Training 165

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Major Research Project

Investigating Mechanisms of Change in the Collaborative Problem Solving Model

Year 3 (Cohort 42)PsychD Clinical Psychology

URN: 6290288

Word Count: 9,938(Excluding Title Page, Statement of Journal Choice, Abstract, Tables,

References and Appendices)

Abstract

Collaborative Problem Solving (CPS; Greene & Ablon, 2006) is a treatment model designed to reduce behavioural difficulties among children and adolescents by developing their cognitive, emotional and social skills. The aim of this study was to evaluate the effectiveness of the CPS approach in an outpatient setting and to explore whether child executive functioning (EF), increased parental empathy, and/or reduced parental stress are possible mechanisms of change within the CPS model. Forty-two families of children aged 3-12 years with behavioural difficulties completed a 12-week in-home CPS treatment programme. Caregiver report measures were completed pre and post-treatment. The results suggest that post CPS there were significant reduction in child behavioural difficulties, improved child executive functioning,

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increased parental empathy, reduced parental stress, and an improvement in caregiver-child relationships. Regression analyses indicated that improvements in child EF appeared to be the primary mechanism of change within the CPS model, predicting approximately 22% of variance in child behavioural outcomes. Reduced parental stress also accounted for a small amount of variance, however changes in parental empathy were not a predictor of child behavioural outcomes. Child behaviour pre-intervention was not associated with the amount of change produced in child executive functioning, parental empathy or parental stress, which indicates that positive changes can occur through CPS, regardless of the severity of behavioural difficulties at outset. These results suggest that child EF and low parental stress are critical for healthy child and adolescent development, and should be a focus for interventions aimed at reducing child behavioural difficulties.Keywords: Collaborative Problem Solving; Children; Behavioural Difficulties; Executive Functioning; Parental Empathy; Parental Stress

Introduction Externalizing behaviour in children and adolescents includes aggressive, hyperactive, delinquent, antisocial and disruptive behaviour. Such behaviours are key characteristics of the diagnoses of oppositional defiant disorder, conduct disorder and attention deficit hyperactivity disorder (American Psychological Association, DSM-V, 2013). Although a moderate level of externalizing behaviour is typical, and even expected, in child and adolescent development (Tremblay et al., 2004), a small proportion of youths display persistent and stable behavioural difficulties (Kjeldsen, Janson, Stoolmiller, Torgersen, & Mathiesen, 2014) and 5.7% of youths worldwide have a diagnosis of a disruptive behavioural disorder (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015).Traditional interventions and approaches to managing externalizing behaviour in children and adolescents have primarily been based upon Behavioural Theory. Behavioural Theory originated in the 1920s and stipulated that human behaviour is learnt from the environment (Skinner, 1938). Accordingly, this theory assumes that behavioural difficulties in children have been learnt as a result of parenting practices or other environmental influences. For example, the child has learnt that externalizing behaviour will either provide them with something, such as attention, or allow them to avoid something they do not wish to do (Patterson, 1982). Behavioural Theory is based on the underlying assumption that children are in control of their behaviour and lack the will to behave appropriately. Consequently, behavioural interventions aim to motivate compliant behaviour through operant methods such as reward and punishment systems.

Behavioural methods have been implemented worldwide, and there is considerable research detailing the benefits of such methods for increasing child prosocial behaviour (see Chorpita et al., 2011 for a review). Operant behavioural methods have proved to be effective at teaching and reinforcing basic lessons such as what behaviours are acceptable or unacceptable within a given situation. They can also provide an additional incentive to behave in a desired way, if the child has the skills required to do so. Difficulties arise, however, when such approaches are used with children who are aware of the basic lessons and are motivated to behave well, but have skills deficits that are preventing them from doing so. Various limitations of the research regarding behaviour management programmes have been documented, including lack of follow up, high attrition rates, and lack of clinically significant change despite results reaching statistical significance, with a considerable proportion of children remaining in the clinical range post treatment (see Cavell, 2000 for a

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review). Several studies have indicated that the effectiveness of behavioural approaches may not always be sustained in the long term (Mohr, & Pumariega, 2004; VanderVen, 1995, 2009) and researchers have argued that behavioural approaches have not been updated with the recent advances in research regarding the aetiology of disruptive behavioural disorders (Cavell, Harrist, & Del Vecchio, 2013).

Collaborative Problem Solving To address the shortcomings of behavioural methods, the Collaborative Problem Solving model (CPS) was developed. The CPS model conceptualises oppositional behaviour as the product of skill deficits in the domains of executive functioning, cognitive flexibility, language processing, emotion regulation, and social skills. It was originally outlined by Ross Greene in his book “The Explosive Child” (1998) and has since been developed further for clinical populations by Greene and Ablon (2006). Since its development, the CPS model has been used to understand and help children and adolescents with behavioural problems in outpatient facilities, schools, residential homes and inpatient units across America and Canada. Contrary to behavioural assumptions, the understanding behind the CPS model is that children are lacking the skills to behave adaptively, not the will. The philosophy behind CPS is that ‘children do well if they can’ (Greene & Ablon, 2006). The model proposes that the motivation behind a child’s externalizing behaviour is not to be purposefully oppositional, but to express (albeit in a maladaptive manner) that they are struggling with a particular demand or situation. Following this philosophy, the approach views and treats oppositional behaviour in a similar manner to a learning disability. In the initial stage, specific skill deficits are identified for each child, by recognising situations in which they are routinely struggling to meet adult expectations. Following this, CPS facilitates the child to develop the skills that they are lacking through engaging in a collaborative problem solving process with an adult who helps tailor this to their developmental level.

Stages of the CPS Model The first stage of the CPS model is for the adult caregiver to begin identifying situations that regularly trigger oppositional behaviour. By identifying these situations, known as ‘problems to be solved’ within the model, adults are able to anticipate difficulties before they occur and intervene beforehand. For every problem to be solved, there are three possible ways in which an adult can respond within the CPS framework. These are categorized as “Plan A”, “Plan B”, and “Plan C”. Plan A is simply the imposition of adult will. This is where an adult continues to pursue their expectation of a child despite the fact this may trigger challenging behaviour. Plan C is to withdraw the expectation, for the meantime at least, in order to reduce oppositional behaviour. Plan B is to solve the problem collaboratively and is the premise of the CPS model. This is when both adult and child work together to solve the problem in a mutually satisfactory and realistic manner. Implementing Plan B consists of three stages. The first stage is aimed at gathering information to achieve a clear understanding of the child’s perspective regarding a specific recurring problem, and requires a lot of empathising from the adult. The second stage aims to define the problem and voice both the adult and child’s concerns. Stage three involves the adult and child collaboratively brainstorming solutions together that will attend to both of their concerns. The child is encouraged to generate the first solution and no solutions are disregarded. Instead, the adult helps the child to think through the consequences of each solution, until a mutually agreed and feasible

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solution is reached. Progress is regularly reviewed to see whether the solution is working or if the process needs to be revisited.The CPS model proposes that, using Plan B, many skills are taught implicitly through the problem solving process. Stage one of adult empathy and understanding helps to teach the child to regulate their emotions in order to identify and express their concerns rationally. Defining the problem in stage two helps teach the child empathy by encouraging them to perspective-take and recognise the impact of their actions on others. Finally, brainstorming solutions collaboratively in stage three helps develop problem-solving skills by teaching the child to produce solutions and consider their outcomes in order to select one that addresses both child and adult concerns. CPS authors posit that the entire process helps the child to build skills in executive functioning, language processing, cognitive flexibility, emotion regulation and social processing.

CPS Evidence-Base The CPS approach is currently implemented in a number of outpatient, inpatient, and school settings across America and Canada (for a review see Pollastri, Epstein, Heath, & Ablon, 2013). The most documented effect of CPS is the reduction in child externalizing behaviour. This has been reported by parents of oppositional children in several outpatient settings, who noted active improvements in child behaviour following the CPS intervention as well as improved parent-child interactions (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Johnson et al., 2012). In one study these improvements were equivalent, and in some cases superior, to the improvements found in a parent-training control group (Greene et al., 2004). Another study found that the reduction of physical aggression post-CPS was not only sustained, but showed greater improvements six months post-discharge (Stewart, Rick, Currie, & Rielly, 2009).In addition, there is an accumulating evidence base to suggest that implementing CPS in inpatient, residential, and juvenile justice settings can significantly reduce the number of restraints and seclusions used (Greene, Ablon, & Martin, 2006; Martin, Krieg, Esposito, Stubbe, & Cardona, 2008; Pollastri, in review). In some cases, these reductions have been dramatic. For example, Yale-New Haven Children’s Hospital reported a 97% reduction in the use of restraints and a 69% reduction in the use of seclusions following CPS implementation (Martin et al., 2008). Qualitative reports from staff working in such facilities describe decreased youth opposition, increased compliance with adult expectations, and an improvement in relationships between staff and youths (Pollastri, in review). However, as these units invested time and effort into implementing the CPS approach, there is a possibility that the qualitative reports and less restrictive procedures observed were motivated by a desire to prove that the intervention worked. School settings have reported similar improvements, evidenced by a significant decrease in discipline referrals (Schaubman, Stetson, & Plog, 2011), reduced number of suspensions per year, decreased time spent in ‘time-out’, and an increase in school attendance post-CPS implementation, although the majority of this research has been unpublished (see Pollastri et al., 2013 for review). Other CPS outcomes have included decreased parental and teacher stress (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Schaubman et al., 2011) and improved child social skills following CPS implementation (Stewart et al., 2009; Epstein & Saltzman-Benaiah, 2010). In addition, CPS has recently been recommended for use in residential group homes for children with a history of trauma, due to its child-centred

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empathic focus (Greer, 2015).The primary limitation of the CPS evidence base is that, to date, there has been only one randomized controlled trial conducted in which the sample size was small, and a number of studies have remained unpublished. In addition, the majority of studies have utilized pre/post designs, which can establish whether change occurred over the course of the intervention, but cannot rule out whether confounding variables influenced these changes, such as maturation effects. Furthermore, very few studies have collected follow up data, so it is unclear whether positive changes are sustained over time. Although there is no known contrary evidence in the literature indicating that CPS is ineffective or less effective in comparison to other interventions, this might be due to the biased tendency to publish positive results (the ‘file drawer problem’; Rosenthal, 1979).

Mechanisms of Change in the CPS modelThere is an expanding evidence base for the efficacy of CPS in reducing disruptive behaviour among children and adolescents, however little is known about the mechanisms driving these effects. The current study aims to explore possible agents of change in the relationship between CPS and observed child outcomes, in order to provide a greater understanding of the CPS model and increase its validity as an effective treatment choice. Determining which specific factors are associated with improved functioning in children and adolescents has wider clinical implications by identifying key components required for healthy child and adolescent development.

Parental EmpathyThe first agent of change proposed is caregiver empathy. Empathy can be defined as the ability to understand and share the feelings and thoughts of another (Snow, 2000). The CPS philosophy that ‘children do well if they can’ tends to change the assumption that child misbehaviour is intentional and malicious, to viewing misbehaviour as the child’s way of communicating that they are struggling to meet the demands expected of them. This change in attribution is expected to foster a greater sense of empathy among parents, teachers and staff working with child behaviour disorders. In addition, Plan B of the CPS model encourages adults to spend time actively listening to the child’s concerns, to empathize with and validate these concerns, and ensure that their concerns are attended to during the problem solving process. It is anticipated that this change in attribution and collaborative approach encourages greater empathy among caregivers of children with behaviour disorders. The notion that parental empathy plays an important role in the development of child prosocial behaviour and adjustment has gained increasing recognition within child clinical and developmental psychology literature (Eisenberg, 1990). Feschbach (1990) argues that not only does parental empathy directly foster child prosocial behaviour; it is also associated with other parenting attributes known to foster such traits, such as parental warmth and sensitivity. This has been supported by research which has found associations between high parental empathy and child prosocial behaviour, including child empathy (Farrant, Devine, Maybery, & Fletcher 2012; Upshaw, Kaiser, & Sommerville, 2015), altruism (Richaud, Mesurado, & Lemos, 2013), attachment security (Stern, Borelli, & Smiley, 2015), and parenting practices that resulted in decreased child anger (Strayer & Roberts, 2004). In contrast, low parental empathy has been associated with increased child conduct problems (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008), child relational and overt bullying (Curtner-Smith et al., 2006), and an increased risk of physical child abuse (Rodriguez, 2013).

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Furthermore, research has shown that interventions targeted at increasing parental empathy may help to reduce child behavioural problems. Flory (2004) developed an intervention with the sole focus of increasing parental empathy. This study found that by changing parental negative attributions of child misbehaviour and increasing parental empathy there was a significant reduction in child psychopathology. However as this study was based on a sample of eleven, future research is required to add weight to this evidence. Other studies have reviewed interventions that focused on increasing parental empathy in addition to improving other parenting practices. The results from these studies found significant reductions in child behavioural problems following the interventions (Edwards, Sullivan, Meany-Walen, & Kantor, 2010; Havighurst, Wilson, Harley, Prior, & Kehoe, 2010; Havigurst et al., 2013; Osbuth, Moretti, Holland, Braber, & Cross, 2006; Van Zeijl et al., 2006). Moreover, Christopher, Saunders, Jacobvitz, Burton & Hazen (2013) found that low empathy mothers may benefit most from parenting interventions. However as these interventions also targeted other parenting practices and did not conduct mediation analyses it is difficult to ascertain whether the reduction in child behavioural difficulties was the result of increased parental empathy or other factors.To date, there has been no study that has measured whether empathy increases among adults utilising the CPS approach, however, as this is one of the primary aims of CPS, this is presumed to be the case. In addition, based upon a review of the literature and their own clinical experience, Ashworth, Tapsak, and Li (2012) proposed that increased parental empathy is the primary mechanism of change in CPS. Therefore if the CPS intervention increases parental empathy as predicted, and evidence suggests that high parental empathy is associated with improved child behavioural outcomes, it follows that increased parental empathy may account for positive child outcomes following the CPS intervention.

Executive FunctioningThe second mechanism of change proposed is executive functioning (EF) skills in children and adolescents. Executive functioning refers to a set of higher order cognitive functions including planning, shifting cognitive set, working memory, response inhibition and problem solving (Miyake et al., 2000). There is currently a strong evidence base to suggest that EF deficits are associated with child externalising behaviour (Poland, Monks, & Tsermentseli, 2015; Schoemaker, Mulder, Deković, & Matthys, 2013; Woltering, Lishak, Hodgson, Granic & Zelazo, 2015), antisocial behaviour (Brunton & Hartley, 2013; Enns, Reddon, Das, & Boukos, 2007; Enns, Reddon, Das, & Boudreau, 2008; Sorge, Skilling, & Toplak, 2015) and aggression (Ellis, Weiss, & Lochman, 2009; Granvald & Marciszko, 2015; Raaijmakers et al., 2008). One meta-analysis collating data from 126 studies, involving 14,786 participants, found a robust association between behavioural difficulties and EF deficits (Ogilvie, Stewart, Chan, & Shum, 2011).The correlation between EF and physical aggression has been found in children as young as 17-41 months old (Séguin, 2009), and EF deficits appear to play a causal role in predicting later behavioural difficulties (Martel et al., 2007; Hughes & Ensor, 2008). One study found that EF deficits mediated the relationship between socioeconomic status and aggression (Shameem & Hamid, 2014). Correspondingly, higher performance on EF tasks has been associated with prosocial behaviours (Williams, Moore, Crossman, & Talwar, 2016). In addition, interventions intended to enhance child EF skills have had beneficial effects in reducing child externalising and internalising behaviour (Kam,

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Greenberg, & Kusche, 2004; Domitrovich, Cortes, & Greenberg, 2007; Bierman et al., 2008; Piehler et al., 2013; Van der Oord, Ponsioen, Geurts, Ten Brink, & Prins, 2014). For example, several studies have evaluated the efficacy of the Promoting Alternative Thinking Strategies (PATHS; Kusche & Greenberg, 1994) school curriculum, which focuses on enhancing children’s social-emotional competence, problem solving skills and emotion regulation skills. Randomised controlled trials have found that, following implementation of PATHS, there was a significant reduction in teacher rated child externalizing and internalizing behaviour and these behaviour improvements were maintained at 1-2 year follow up (Kam et al., 2004; Riggs, Greenberg, Kusche & Pentz, 2006; Domitrovich, Cortes & Greenberg, 2007).Studies evaluating interventions targeted at developing EF skills also found improvements in working memory, inhibitory control, attention shifting, problem solving, verbal fluency and social-emotional competence, in addition to a reduction in behavioural difficulties (Bierman et al., 2008; Bierman, Nix, Greenberg, Blair, & Domitrovic, 2008; Daunic et al., 2012; Domitrovich et al., 2007; Healey & Halperin, 2014; Riggs et al., 2006). Furthermore, EF interventions appeared to be of most benefit for children with greater EF deficits at baseline (Bierman et al., 2008), and one study found that improvements in EF fully mediated the relationship between the EF intervention and reduction in child conduct problems (Piehler et al., 2013). These findings support the CPS theory that children who display externalising and internalising behaviour do so because of skills deficits that prevent them from responding adaptively to a given situation. The authors of CPS propose that the regular use of ‘Plan B’ conversations helps children develop these lagging skills. Therefore, as CPS aims to enhance child EF through the collaborative problem solving process, and evidence suggests that improvements in EF are associated with reduced child conduct problems, it follows that EF development may also be a mechanism of change in the CPS model.

Parental StressThe final variable that will be analysed as a possible agent of change in the CPS model is parental stress. There is a growing evidence base to suggest that not only do child behavioural difficulties heighten parental stress (Baker, 2003; Eyberg, Boggs, & Rodriguez, 1992; Ross, 1998; Solem, 2011) but parental stress can also lead to an increase in child internalizing and externalizing behaviours (Anthony, 2005; Baker, 2003; Krahé, 2015; Liu & Wang, 2015) therefore potentially contributing to the continuity of unwanted behaviours. This cycle was outlined in a transactional model by Baker (2003), and has been supported by a recent longitudinal study, which found that over a time span of four years, parenting stress mediated changes in child aggression (Krahé, 2015). Furthermore, Solem (2011) found that having a child with behavioural difficulties predicted 57% of the variance in parenting stress.Parental stress has been associated with parenting practices that are more punitive, irritable, and critical, which in turn increases negative child-parent interactions and the likelihood that a child will develop conduct problems (Pinderhughes, Dodge,

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Bates, Pettit, & Zelli, 2000). In addition, Anthony (2005) found that parenting stress was significantly related to children’s social competence, and a subsequent study found that parenting stress could predict later child social skills difficulties (Neece, 2008). These studies have highlighted the need to target parenting stress in interventions aimed at reducing child behavioural difficulties. One study by Kazdin and Whitley (2003) attempted this, by targeting parental stress in an intervention called parent problem solving (PPS). This intervention was delivered as an additional component to parent management training and ran over the course of the treatment. The results indicated that families who received the additional PPS displayed enhanced therapeutic change in comparison to those who received parent management training alone. With regards to the CPS model, several studies have indicated that, following CPS implementation, parents and teachers reported decreased stress and increased feelings of competency (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Schaubman et al., 2011). Therefore it is expected that parenting stress may be a mechanism of change in the CPS model, accounting for some of the variance in child behavioural outcomes following the CPS intervention.

Study Hypotheses• Are there changes on measures of child behaviour, parental

empathy, child EF, parenting stress, and successful use of the CPS model, following participation in a CPS in-home treatment program?

• Do changes in parental empathy, child EF, and/or parenting stress explain the effect of the intervention on child behaviour?

Method

Participants and ProcedureParticipants were recruited from an accredited children’s mental health centre in an inner city area in Ontario, Canada. The centre provides services for children up to the age of 12 who have complex mental health needs, including severe emotional, behavioural and social difficulties, and their families. Caregivers of children with behavioural difficulties typically refer for treatment, although occasionally family doctors or emergency departments direct a family to the centre.

CPS in-home therapy is a treatment offered at the centre for families who are struggling to cope with their child’s behavioural difficulties. Using the CPS model, a child and youth caseworker delivers treatment to the child and their family in their home (see introduction for an outline of the CPS model). The case worker will visit the family home 2-3 times per week for up to 12 weeks to observe the family dynamics, teach the caregivers the CPS approach and help them to put it into practice by modelling the approach and providing guidance on how to apply the CPS principles within the home environment. Caseworkers at the centre invited all families who had been referred for in-home CPS treatment between January 2015-January 2016 to participate in the study by giving them verbal and written information about the study rationale and procedure (see Appendix A for information sheet). The study inclusion criteria followed the centre’s referral criteria for in-home treatment. Caregivers had to have a child aged between 0-12 years (usually 3+) referred to the centre for behavioural difficulties. Children were

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required to function at low average or above on a verbal performance scale. Verbal IQ was typically measured by a formal IQ assessment prior to being referred. If this was not the case, a low average or above verbal performance was assumed unless deficits in this area were evident, in which case an IQ assessment was conducted. Children diagnosed with autism (not including children with Asperger’s Syndrome or Pervasive Development Disorder Not Otherwise Specified) and children with a learning disability (scores in the mild intellectual disability range or below) were excluded from the study. Caregivers had to have completed CPS in-home treatment and post intervention outcome measures at the time of data collection in January 2016 to be included in the study.As part of routine data collection, the service asked caregivers to complete measures of child behaviour, child EF, and parental stress pre- and post-treatment. To take part in the research, participants were asked to fill out a further two questionnaires at the same time points to assess parental empathy and a CPS specific questionnaire designed to capture change over time in parenting variables central to the CPS model. They were also asked to consent to their data being used for study purposes (see Appendix B for consent form). Participants were assured that participation was completely voluntary, that they could withdraw at any time, and deciding not to participate would not impact their clinical care. Informed consent was obtained from all caregivers included in the study. The study protocol received ethical approval from the University of Surrey Faculty Ethics (Appendix C) and was conducted in accordance with the ethical standards stipulated by the 1964 Declaration of Helsinki and its later amendments. During the data collection period between January 2015 and January 2016, 126 children and their caregivers were offered in-home CPS treatment. Of these, 75 caregivers consented to participate in the study and completed the pre-intervention measures, and 42 completed both pre- and post-intervention measures. Of the 33 participants to not complete post intervention measures, 26 were still receiving treatment (and would be given post-measures on completion), four caregivers had not completed the post intervention measures and three caregivers had dropped out of treatment.The majority of children referred were male (73.8%) and children ranged in age from 3-12 years (M=7.19, SD=2.58). Almost all families’ first language was English, aside from one, who spoke English fluently enough to participate in the treatment programme (see Table 1 for sample characteristics). Forty-five percent of caregivers were single parents. Education levels of primary caregivers ranged from completing elementary school to completing university, with the mode education level being completing community college. For the majority of families the household income was greater than $60,000 per year, and the main source of income was employment. Of the 42 primary caregivers who participated in the research, 31 were of European/Caucasian origin, seven were North American origin and one caregiver was Black African origin. In three cases the recipients’ origin was unknown or they declined to provide the information.

Table 1: Sample Characteristics (N=42)

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Frequency

Percentage (%)

Gender of child (male)

31

73.8

Primary caregiver who completed questionnaires

Mother

36

85.7

Father

5

11.9

Grandmother

1

2.4

Caregiver living arrangements

Single caregiver

19

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45.2

Caregiver living with spouse/partner

22

52.4

Language

English

38

90.5

French

1

2.4

Caregiver Education

Some secondary school

5

11.9

Completed secondary school

4

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9.5

Some community college

6

14.3

Completed community college

12

28.6

Some university

1

2.4

Completed university

10

23.8

Missing

4

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9.5

Spouse Education

Some secondary school

2

4.8

Completed secondary school

3

7.1

Some community college

3

7.1

Completed community college

5

11.9

Completed university

8

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19

Missing

21

50

Family Income

$0 - 9,999

0

0

$10,000 - $19,999

12

28.6

$20,000 - $29,999

4

9.5

$30,000 - $39,999

2

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4.8

$40,000 - $49,999

2

4.8

$50,000 - $59,999

1

2.4

Greater than $60,000

17

40.5

Missing

4

9.5

Income Source

Disability

5

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11.9

Social Assistance

9

21.4

Employment

22

52.4

Other

2

4.8

Missing

4

9.5

Measures

Child Behaviour

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The ‘Strengths and Difficulties Questionnaire’ (SDQ; Goodman, 1997) was used to assess child internalizing, externalizing and prosocial behaviour. The SDQ is designed for parents or teachers of children aged 2-17 years and it consists of 25 questions divided into five subscales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behaviour. Answers are provided using a three point Likert scale (‘not true’, ‘somewhat true’, or ‘very true’) in response to statement such as “generally liked by other children” and “often loses temper”. For each subscale, scores range from 0-10. Scores classified as ‘very high/abnormal’ are as follows: emotional symptoms (7-10), conduct problems (6-10), hyperactivity/inattention (9-10), peer relationship problems (5-10), and prosocial behaviour (0-5 – very low). Scores are summed from all scales minus the prosocial scale to generate a ‘total difficulties’ score, which ranges from 0-40. Scores of 0-13 are considered to be average, 14-16; slightly raised, 17-19; high, and scores of 20-40 are deemed as ‘very high’. An additional subscale measuring the impact the child’s difficulties are having on family life was also used, which looks at whether difficulties, upset the child, and interfere with home life, friendships, classroom learning and leisure activities using a four point likert scale from “not at all” to a “great deal”. Scores on the impact scale range from 0-10, with a very high score falling between 3-10. The versions used in this study were the English (USA) versions for 2-4 year olds (Appendix D), 4-10 year olds (Appendix E), and 11-17 year olds (Appendix F). If the child was 4 years old they were given the 4-10 year old version of the SDQ. The SDQ has demonstrated sound psychometric properties with a mean internal reliability coefficient of 0.73 (Goodman, 2001).

Child Executive FunctioningCaregivers completed the ‘Behaviour Rating Inventory of Executive Function’ (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) in order to assess child EF. Answers are provided using a three point Likert scale (‘never a problem’, ‘sometimes a problem’, or ‘often a problem’). The BRIEF is an 86-item questionnaire developed for parents and teachers to measure EF skills of children and adolescents aged between 5-18 years. It aims to measure the following eight EF skills: inhibit, shift, emotional control (which are summed to provide a behavioural regulation index score), initiate, working memory, plan/organize, organization of materials, and monitor (which are summed to provide a metacognition index score). These eight subscales are added together to provide a global executive composite (GEC) score as a measure of overall child EF. The raw scores from these subscales are converted to T scores, which were used for interpretation in this study. T-scores range from 0-100, with an average score of 50 (SD=10). A T-score of 65 or above is classified as clinically significant (with greater deficits in that area). The BRIEF has demonstrated satisfactory psychometric properties, with high internal consistency ranging between .80-.98 (Gioia et al., 2000). Please note that the BRIEF is subject to copyright and therefore cannot be included in the appendix, however the service involved in this study purchased access to use this measure.

Parenting StressIn order to measure caregiver stress, caregivers filled out the “Parenting Stress Index – Short Version” (PSI; Abidin, 1995), which is a 36-item questionnaire designed to measure parenting stress using three subscales: parental distress, parent-child

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dysfunctional interaction, and difficult child. Each subscale contains 12 statements rated on a five point Likert scale from 1 “strongly agree” to 5 “strongly disagree”. Subscale scores range from 12 to 60. A Total Stress score is also calculated by summing the subscale scores, and ranges from 36 to 180. Higher scores on the subscales and total score indicate a higher level of stress. Internal consistency has been found to range from .55-.80 for parents and .62-.70 for children (Abidin, 1995). Please note that the PSI is subject to copyright and therefore cannot be included in the appendix, however the service involved in this study purchased access to use this measure.

Successful adoption of the CPS modelIn order to assess whether caregivers had adopted the CPS philosophy, how successful they were at using the CPS plans and any changes within parent-child relationships, caregivers completed the “Think Kids - Change Over Time” (TK-COT; Pollastri, Katzenstein, Epstein, & Ablon – in preparation) questionnaire. This measure is a 15-item parent-report questionnaire that was designed by the creators of CPS as a means to measure change over treatment using parenting variables central to the CPS model. It includes three subscales: parent/child relationship quality, adherence to the CPS philosophy, and ability to understand/ predict challenging behaviour. The questionnaire includes items such as “I cannot predict my child’s meltdowns or tantrums” and “my child behaves in negative ways in order to get attention” and answers are scored on a 7-point Likert scale ranging from “strongly agree” to “strongly disagree”. Raw scores for each subscale are summed and then divided by the number of questions forming that subscale, to produce a subscale score ranging between 1-7 (no Total score is produced for this measure). Clinical ranges have not been calculated for this measure, however a higher score equals fewer difficulties in that area. The internal reliability of the TK-COT subscales range from .76-.83 (see Appendix G).

Parental EmpathyParental empathy was measured using the “Interpersonal Reactivity Index” (IRI; Davis, 1983). This questionnaire measures empathy using the four subscales of perspective taking, emotional concern, psychological egoistic distress, and fantasy. The IRI has demonstrated satisfactory internal consistency with reliability coefficients ranging from .71–.77 (Davis, 1983). An adapted version of the IRI was used in this study that was modified by Psychogiou, Daley, Thompson, and Sonuga-Barke (2008), who reworded the original items in order to measure child-directed parental empathy, as opposed to general empathy, and omitted the fantasy scale (see Appendix H). The questionnaire includes items such as “I sometimes find it difficult to see things from my child's point of view”, and “I am often quite touched by things that I see happen to my child” and answers are provided using a 5-point Likert scale ranging from “does not describe me very well” to “describes me very well”. There is no total score for this measure. All subscale scores range from 0-28. There are no formal clinical cut offs for the IRI, however a higher score on the perspective taking and emotional concern subscales is associated with increased empathy, whereas a high score on the personal distress subscale is associated with greater personal distress.

Empathy was also measured using the “adherence to CPS philosophy” subscale from the TK-COT (Pollastri, Katzenstein, Epstein, & Ablon – in preparation). This subscale includes four questions that are designed to measure how well parents are adhering to the CPS philosophy that ‘children do well if they can’.

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For example, “my child intentionally pushes my buttons or manipulates me”. The CPS intervention aims to shift parents’ beliefs from viewing their child’s misbehaviour as intentional, to the child’s expression that they are struggling to meet parental expectations due to EF deficits. This philosophy shift is expected to foster greater empathy and ability to perspective-take among parents. This subscale has demonstrated internal reliability with a reliability coefficient of .76.In addition to analysing the IRI and TK-COT subscales separately, a total empathy score was also created by summing the perspective taking subscale score from the IRI (range 0-28) and the adherence to CPS philosophy score from the TK-COT (range 1-7). These subscales were chosen as they were considered to be most representative of the form of parental empathy that the CPS model is attempting to change. Specifically, the parent’s ability to take the child’s perspective and view behavioural difficulties as an expression of distress as opposed to a willful act. This provided an “overall empathy” score ranging from 0-35, with a higher score indicating increased empathy.

Child and Family Demographics Demographics including age and sex of child, first language of family (English, French or other), whether the child was from a single parent family, education level of caregiver/s, approximate family income, and source of income were collected pre-treatment using a demographic questionnaire (see Appendix I).

Analytic Approach Paired-sample t-tests employing the bootstrap method (using 2,000 bootstrap samples) were used to assess whether child behaviour, child EF, parental empathy, parenting stress, and successful use of the CPS model (using the Overall and Subscale scores), changed following in-home CPS treatment (see Table 2). Cohen’s d was calculated for each t-test by dividing the difference between pre-and post means with the pooled standard deviation. Unless otherwise stated, all data appeared normally distributed with skew and kurtosis values below + or -2 (see Table 3 for skew and kurtosis values).

Following this, correlations were conducted to test the association between changes in parental empathy, child EF, and/or parental stress with child behavioural outcomes (using the SDQ overall score) following the CPS intervention. Change scores were computed by calculating the mean difference in child EF (using the GEC score), parental empathy (using the Overall Empathy score) and parental stress (using the Total Stress score) between pre and post intervention. Three ‘mediation’ analyses were then conducted to assess whether changes in parental empathy, child EF, and/or parental stress accounted for variance in child behavioural outcomes following the CPS intervention, when prior child behavioural difficulties were controlled for. Prior child behaviour was controlled for in order to explore whether the level of pre-intervention behaviour difficulties affected the amount of change within parental empathy, child EF and parental stress. The PROCESS mediation macro (Hayes, 2013) for SPSS was used to conduct the analyses, with prior behaviour as the independent variable, post behaviour as the outcome variable and changes in parental empathy, child EF and parental stress as the ‘mediating’ variables (see Figure 1).

Figure 1: ‘Mediation’ Model

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The PROCESS mediation analyses were not used to directly test a formal mediation model as it was not assumed a priori that prior behaviour ‘caused’ the changes resulting from the CPS programme – the assumption was that the CPS programme would lead to the changes. Rather the technique was used to test the possibility that children’s levels of problematic behaviour might limit the amount of change observed. It was also used as a means to conduct three regression analyses concurrently and to use the bootstrapping feature of this software, which develops estimates of indirect effects using bias-corrected bootstrap confidence intervals. Bootstrapping has become an increasingly recommended approach for inference about indirect effects. In contrast to other methods that assume a standard normal distribution when calculating the p-value and confidence intervals for indirect effects, bootstrapping does not assume normality and repeatedly samples from the data set (2,000 bootstrap samples were used in the study) estimating the indirect effect and producing confidence intervals from each resampled data set. As the bootstrapping method does not rely on assumptions of normality it has been particularly recommended for small sample sizes (Preacher & Hayes, 2004).

Due to the small sample size in this study, the major effects were analysed without covariates, however ideally initial EF, parental empathy and parental stress would be included as covariates in the mediation analyses (see limitations in discussion). As sex and age were not found to be significant predictors of behaviour change over time, these were also not included as covariates. There were no observable differences between the 42 participants who completed pre and post-intervention measures compared to the three caregivers who dropped out of treatment, or the four caregivers who did not complete post-questionnaires.

Results Child BehaviourThere was a significant reduction in overall behavioural difficulties from pre- to post-intervention (see Table 2). Analysing data from the subscale scores indicated that following the CPS intervention there was a significant reduction in child emotional distress, child behavioural difficulties, child hyperactivity and concentration difficulties, and child difficulties getting along with peers. There was also a slight increase in child prosocial behaviour from pre-intervention to post intervention, however this just failed to reach statistical significance. Furthermore, the SDQ results showed a significant reduction in the impact of difficulties on the child’s life following the CPS intervention. Using the SDQ four-band categorization scoring (Goodman, 1997), showed that the mean child overall score and behavioural difficulties score went from being categorized as ‘very high’ pre-intervention to ‘high’ post-intervention. Scores from the subscales ‘emotional distress’, ‘hyperactivity difficulties’, and ‘difficulties with peers’ reduced from a categorization of ‘high’ to ‘slightly raised’. Prosocial behaviour also increased from ‘low’ to ‘slightly lowered’ in comparison to the norm.

Parental EmpathyEmpathy was measured using the IRI and the ‘adherence to CPS philosophy’ subscale of the TK-COT (see Table 2). A total empathy score was created by adding the ‘perspective taking’ subscale score of the IRI with the ‘adherence to CPS philosophy’ subscale score of the TK-COT. The majority of the data appeared normally distributed, with the exception of the post kurtosis score for the IRI emotional concern subscale (see Table 3). Skew and kurtosis scores between -2 and +2 are considered to

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be acceptable indicators of a normal distribution (George & Mallery, 2010). As the post IRI emotional concern kurtosis value was 3.807, performing statistical tests that assume normal distribution may be inaccurate. In order to account for this, the bootstrap method using 2,000 bootstrap samples was used, which does not assume normality (Preacher & Hayes, 2004). The results showed a significant increase in overall parental empathy from pre-intervention to post-intervention. Analysing data from the subscale scores indicated that following the CPS intervention there was a significant increase in parental perspective taking and a significant increase in adherence to the CPS philosophy that ‘children do well if they can’. No significant differences were found between pre and post-intervention on the IRI subscales of parental emotional concern and parental personal distress.Table 2: Means, Standard Deviations, Ranges and Results from Paired Sample T-Tests

MeasureSubscale

Mean Pre (SD)Mean Post (SD)

Possible score rangesMean

Difference95% CI

t(df)pd

SDQOverall

21.81 (5.72)18.48 (5.91)

0-403.33

1.98, 4.714.76 (41)

.000**.57

Emotional distress4.57 (2.99)3.74 (2.84)

0-10.83

.22, 1.452.64 (41)

.015*.29

Behavioural difficulties5.71 (1.74)4.60 (1.80)

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0-101.11

.60, 1.693.92 (41)

.002**.63

Hyperactivity difficulties7.90 (2.21)7.29 (2.31)

0-10.61

.10, 1.192.24 (41)

.039*.27

Difficulties with peers3.62 (2.31)2.86 (2.17)

0-10.76

.31, 1.293.02 (41)

.004**.34

Prosocial behaviour5.88 (1.84)6.62 (1.95)

0-10.74

-1.50, -.07-2.03 (41)

.051.39

Impact of difficulties on life5.16 (2.42)3.61 (2.96)

0-101.55

.42, 2.632.83 (37)

.010*.57

IRI & TK-COTOverall Empathy

19.20 (5.64)

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22.20 (6.01)1-353.0

-4.84, -1.32-3.26 (39)

.003**.52

IRIPerspective Taking

16.15 (5.51)18.28 (5.53)

0-282.13

-3.62, -.63-2.68 (39)

.013*.39

Emotional Concern22.45 (4.23)22.75 (3.54)

0-280.3

-1.52, .93-.47 (39)

.627.08

Personal Distress12.73 (5.03)11.73 (4.66)

0-281.0

-.35, 2.551.37 (39)

.183.21

Table 2: Means, Standard Deviations, Ranges and Results from Paired Sample T-TestsTK-COTAdherence to CPS Philosophy

3.02 (1.48)3.90 (1.24)

1-7.88

-1.37, -.32-3.35 (40)

.001**.64

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Parent/Child Relationship Quality4.21 (.86)4.91 (1.02)

1-7.70

-1.00, -.45-4.84 (40)

.000**.75

Ability to Predict Challenging Behaviour3.82 (1.67)4.57 (1.37)

1-7.75

-1.28, -.20-2.71 (40)

.013*.49

BRIEFGlobal Executive Composite

73.35 (9.07)68.71 (12.31)

0-1004.64

1.32, 8.032.63 (30)

.018*.43

Behavioural Regulation Index76.91 (9.23)

70.56 (11.63)0-1006.35

3.03, 10.063.58 (31)

.005**.61

Metacognition Index68.32 (10.83)65.16 (12.93)

0-1003.16

-.29, 6.551.82 (30)

.081

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.27PSITotal Stress

106.39 (16.18)94.80 (17.60)

36-18011.59

6.90, 16.954.38 (40)

.001**.69

Parental Distress33.66 (8.78)29.00 (7.34)

12-604.66

2.20, 7.173.55 (40)

.002**.58

Parent-Child Dysfunctional Interaction29.90 (7.42)27.51 (6.92)

12-602.39

.78, 4.052.92 (40)

.009**.33

Difficult Child42.83 (5.67)38.29 (7.95)

12-604.54

2.15, 6.983.65 (40)

.004**.66

*p<0.05; **p<0.01SDQ = Strengths and Difficulties Questionnaire IRI = Interpersonal Reactivity IndexTK-COT = Think Kids – Change Over TimeBRIEF = Behaviour Rating Inventory of Executive Function

MeasureSDQ subscale

Skew

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Kurtosis

PrePostPrePostSDQ

Overall-.164.142-.542-.655

Emotional distress-.144.515-.940-.413

Behavioural difficulties-.104.408-.616.295

Hyperactivity difficulties-.992-.504.399-.853

Difficulties with peers.722.809.052.502

Prosocial behaviour-.281-.074-.584-.927

Impact on child’s life.354.518-.302-.599

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IRIIRI Emotional Concern

-.769-1.633.6673.807

IRI Perspective Taking-.469-.194.225-.115

IRI Personal Distress-.100.161.288-.050

IRI & TK-COTEmpathy Total Score

-.452-.135.453-.286PSI

Total Stress.047.222-.092-.016

Parental Distress.225.432-.334.740

Parent-Child Dysfunctional Interaction-.119.729-.364-.044BRIEF

Difficult Child-.335.423.342-.283

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Behavioural Regulation Index-.317.285.418-.946

Metacognition Index-.477-.323-.407-.456

Global Executive Composite (GEC)-.363-.194-.640-.600

TK-COTParent/ Child Relationship Quality

.413-.388-.407.201

Ability to Predict Challenging Behaviour.136-.116-.780-.861

Adherence to CPS Philosophy.596.105-.465-.044

Change ScoresChange in Behaviour (SDQ Overall score)

-.355-.017

Empathy Change (Empathy Total score).825.284

Change in Stress (Total Stress score)-1.0842.092

Change in EF (GEC score)

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-.8551.961

Table 3: Skew and Kurtosis ValuesChild EFThirty-one participants completed the BRIEF at pre and post intervention. The BRIEF is only administered to children aged 5 years and above, which explains why there was less pre and post data for this measure. The results showed a significant decrease in overall child EF deficits as measured by the BRIEF Global Executive Composite (see Table 2). This result appeared to be primarily driven by a decrease in child behavioural regulation difficulties, which is a sum of the BRIEF subscales ‘inhibit’, ‘shift’, and ‘emotional control’. There was no significant difference between pre- and post-intervention scores on the Metacognition Index, which is made up of the subscales ‘initiate’, ‘working memory’, ‘plan/organize’, ‘organization of materials’ and ‘monitor’, although a small effect size was found.

Parental StressThe findings showed a significant decrease in overall parental stress following the CPS intervention. Results from the subscale scores indicated that post CPS intervention there was a significant decrease in parental personal distress, parent-child dysfunctional interaction and difficult child characteristics (see Table 2). The majority of data from the PSI appeared normally distributed, however the kurtosis value for ‘change in stress’ was 2.092, which suggests a slightly non-normal distribution for this variable.

Successful Adoption of the CPS ModelAnalysing data from the TK-COT indicated that there was a significant increase in overall parent/child relationship quality. In addition, there was a significant increase in parent’s ability to predict their child’s challenging behaviour and a significant increase in adherence to the CPS philosophy that ‘children do well if they can’, all of which are targeted by the CPS model.

Correlation AnalysesData was initially analyzed using Pearson’s product moment correlation coefficient (one-tailed) to explore the relationships between variables (see Table 4).

Table 4: Pearson’s Correlation ResultsVariables

12345

1. Pre Behaviour-

2. Post Behaviour.689**

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-

3. Change in EF-.135.378*

-

4. Change in Parental Empathy.325*.000-.304

-

5. Change in Parental Stress-.170.284

.636**-.388*

-* Correlation is significant at p<.05 (one-tailed)* Correlation is significant at p<.01 (one-tailed)

The correlation analyses showed that of the three hypothesized mechanisms of change, only change in EF was significantly correlated with child post-intervention behaviour. Change in parental stress showed some correlation with post behaviour, which just failed to reach significance (p=.067). As expected, child pre-behaviour was significantly associated with child post-behaviour. A significant positive correlation was also found between change in parental stress and change in child EF. It appeared that greater child behavioural difficulties reported at pre-intervention were associated with greater change in parental empathy over the course of the intervention. However change in parental empathy was negatively associated with change in child EF and change in parental stress.

Regression AnalysesIt was hypothesized that changes in child EF, parental empathy and parental stress following the CPS intervention would predict child behavioural outcomes post-intervention, when controlling for pre-intervention child behaviour. To test these hypotheses, three sets of regression analyses were conducted utilizing the Hayes (2013) mediation macro (2,000 bootstrap samples were used).

Change in EFThe results showed that child pre-CPS behaviour was not associated with changes in EF, however changes in EF were significantly correlated with positive child behaviour outcomes post CPS (see Table 5). As expected, pre child behaviour was positively correlated with post child behaviour. Together, pre-intervention child behaviour and changes in EF accounted for 70.26% of the variance in post-intervention child behaviour. Changes in EF accounted for 22.08% of variance in post child behaviour

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when controlling for pre-intervention child behaviour. Importantly, pre-existing behaviour levels did not predict the amount of change in EF observed suggesting that change in EF can occur even where children are presenting with considerable behavioural problems. When child EF is improved, this accounts for positive child behavioural outcomes.

Table 5: Child EF Regression AnalysesRegression

Dependent VariableIndependent Variable(s)

Coeffsetp

LLCIULCI

1Change in EF

Constant.868

7.369.118.907

-14.20315.939

Pre-behaviour-.246.319-.771.447-.900.407

2Post Behaviour

Constant2.8302.4471.157.257

-2.1827.843

Change in EF.281.062

4.560.000

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.155

.407

Pre Behaviour.784.107

7.313.000.564

1.0033

Post BehaviourConstant

3.0743.173.969.341

-3.4169.564

Pre Behaviour.714.138

5.192.000.433.996

Change in Parental Empathy

The second set of analyses showed that child pre-CPS behaviour did not predict changes in parental empathy. Changes in parental empathy showed a slight correlation with positive child behaviour outcomes, although this just failed to reach significance. Together, pre-intervention child behaviour and changes in parental empathy accounted for 53.13% of the variance in post-intervention child behaviour (see Table 6). Changes in parental empathy accounted for only 5.05% of variance in post child behaviour when controlling for pre child behaviour. These results suggest that parental empathy is not a significant predictor of positive behavioural outcomes, following the CPS intervention.

Table 6: Parental Empathy Regression AnalysesRegression

Dependant VariableIndependent Variable(s)

Coeff

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setp

LLCIULCI

1Change in Empathy

Constant-2.471

3.600-.686.497

-9.7594.818

Pre-behaviour.249.1591.570

.125-.072.571

2Post Behaviour

Constant1.9992.692.743.462

-3.4557.454

Change in Empathy-.241.121

-1.998.0531-.485.003

Pre Behaviour.787.122

6.463.000.540

1.0343

Post BehaviourConstant

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2.5942.779.934.356

-3.0318.219

Pre Behaviour.727.123

5.932.000.479.975

Changes in Parental StressThe third analysis showed that child pre-CPS behaviour was not associated with changes in parental stress, however changes in parental stress significantly predicted post-intervention child behaviour (see Table 7). Together, pre-intervention child behaviour and changes in parental stress accounted for 58.08% of the variance in post-intervention child behaviour. Changes in parental stress accounted for 9.99% of variance in post child behaviour when controlling for pre child behaviour. These results indicate that the level of child behavioural difficulties pre-intervention is not associated with the amount of change in parenting stress. When parental stress is improved, this accounts for a small amount of variance in child behavioural outcomes post intervention.

Table 7: Parental Stress Regression AnalysesRegression

Dependent VariableIndependent Variable(s)

Coeffsetp

LLCIULCI

1Change in Stress

Constant1.362

10.343.132.896

-19.55822.282

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Pre-behaviour-.596.460-1.294

.203-1.527.335

2Post Behaviour

Constant2.7652.4121.146.259

-2.1187.647

Change in Stress.112.037

3.009.005.037.188

Pre Behaviour.776.110

7.075.000.554.998

3

Post BehaviourConstant

2.9182.6491.102.277

-2.4408.275

Pre Behaviour.709.118

6.010.000.470.947

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Discussion The present study had two primary aims. Firstly, to contribute to the evidence base regarding the efficacy of CPS and, secondly, to explore possible mechanisms of change within the CPS model. It was hypothesized that improvements in child EF, parental empathy, and/or parental stress might be the driving forces resulting in reduced child behavioural difficulties post-intervention. As expected, the results from this study found a significant reduction in child behavioural difficulties following the CPS intervention. In particular, reductions were most profound for child externalizing behaviour and the impact of difficulties on the child’s life. Reductions were also found in child emotional distress, child hyperactivity and concentration difficulties and child difficulties getting along with peers. In addition, child prosocial behaviour increased following the intervention. These findings support the growing evidence base that suggests that child behavioural difficulties reduce following the CPS intervention (see Pollastri et al., 2013 for a review). However, despite these positive reductions, behavioural improvements did not occur for all children, which indicates that a small minority of families did not respond to CPS in the way expected. In addition, the majority of children were still being classified as ‘high’ or ‘slightly raised’ on subscales of the SDQ, suggesting that whilst difficulties lessened they did not disappear. Previous research by Stewart et al. (2009) found that reductions in child externalizing behaviour were not only sustained but showed further improvements six months post-discharge. In the current study post intervention measures were completed three months after pre-intervention measures, which did not leave much time for changes to occur. It is possible that as children’s EF skills develop through the use of ‘Plan B’ conversations, and parents continue to respond to the child in an empathic fashion, behavioural difficulties might continue to reduce in line with community norms. The results from this study also found a significant increase in parental empathy following the CPS intervention. In particular, the CPS approach appeared to improve parental perspective taking and produce a shift in parent’s understanding of child behavioural difficulties, from the belief that misbehaviour is intentional to the belief that it is a form of communication, as is the premise of the CPS model. There has been no prior study to measure whether parental empathy increases post CPS intervention; however Ashworth, Tapsak and Li (2012) hypothesized that this would be the case. To be able to take the child’s perspective and understand/empathise with their concerns is one of the primary goals of the CPS model. By improving parental perspective taking and shifting beliefs regarding behavioural difficulties, these findings indicate that the CPS intervention is achieving what it sets out to. Contrary to expectations, however, there was no increase in parental emotional concern or reduction in personal distress, following the intervention. As the majority of caregivers scored highly on emotional concern prior to the intervention, this could explain why little change was observed on this subscale.

In line with one of the primary goals of CPS, the findings from the present study showed a significant decrease in child EF deficits. Furthermore, these findings appeared to be primarily driven by a reduction in child behavioural regulation difficulties, as measured by the BRIEF subscales ‘inhibit’, ‘shift’, and ‘emotional control’. However, minimal change was found on the ‘metacognition’ subscales,

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which includes the EF skills ‘initiate’, ‘working memory’, ‘plan/organize’, ‘organization of materials’ and ‘monitor’. These findings suggest that the CPS model helps children to develop skills specifically in the areas of emotion regulation, flexible thinking (the ability to shift cognitive set in order to tolerate change), and the ability to inhibit and control impulses in order to stop engaging in a behaviour. This supports previous research, which has found an improvement in emotion regulation skills (Pollastri, in review) and social skills (Stewart et al., 2009; Epstein & Saltzman-Benaiah, 2010) following the CPS intervention. In accordance with previous research the findings from the present study showed a significant decrease in caregiver stress post CPS intervention (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Schaubman, et al., 2011). Specifically, there was a substantial reduction in the level of distress caregivers experienced within the parenting role, a decrease in dysfunctional interactions occurring between parent and child, and a significant decrease in child behavioural problems that can make parenting more difficult. Furthermore, there was significant improvement in relationship quality between the parent and the child, and this showed a large effect (d =.75), an improvement in parent’s ability to predict their children’s behavioural difficulties and increased adherence towards the CPS philosophy that ‘children do well if they can’, in line with the goals of the CPS model.

The second aim of this study was to explore mechanisms of change in the CPS model to investigate what might be driving the reduction in child behavioural difficulties. The results showed that changes in child EF was the most significant mechanism of change in this study, accounting for approximately 22% of positive behavioural outcomes following the CPS intervention. This indicates that when child EF is improved, this can predict positive child behavioural outcomes. Reduced parental stress also appeared to have some influence on child behavioural outcomes, accounting for approximately 10% of the variance in post child behaviour. In addition, these two improvements in parental stress and child EF were highly correlated, indicating that parents who reported greater reduction in parenting stress following the intervention also reported fewer child EF deficitsHowever, improved parental empathy was not a significant predictor of positive behavioural outcomes following the CPS intervention, only accounting for approximately 5% of the variance in child behavioural outcomes. In addition, improvements in parental empathy were negatively correlated with improvements in child EF and parental stress, which was contrary to expectations. It is unclear why this might be, however it was possibly due to less change being observed on the empathy measure (as participants scored relatively high at outset), or due to limitations with the small sample size and questionnaire used to measure empathy (see limitations). As expected, child pre-intervention behaviour scores was the most significant predictor of post-intervention behaviour, accounting for approximately 48% of the variance in child behavioural outcomes. Importantly, pre-existing behaviour levels did not predict the amount of change observed in child EF, parental empathy, or parental stress. This indicates that the CPS intervention can produce positive changes in these domains even when children are presenting with considerable behavioural problems.

LimitationsThe findings from this study need to be considered within the light of its limitations. The primary limitation of this study was that there was no control group. This was due to difficulties obtaining an appropriate control group of children with behavioural

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difficulties that were either receiving an alternative treatment or no treatment. As a result a controlled trial could not be conducted and therefore it is difficult to compare CPS to other treatment options or to ascertain whether maturation effects influenced the results. In addition the lack of control group meant that formal mediation analyses could not be conducted, as the relationship between CPS (vs. control) and behavioural outcomes could not be assessed. Instead, mechanisms of change were explored by means of regression, controlling for prior child behaviour.A further limitation of this study was the small sample size used, with only 42 participants completing both pre and post measures. Due to this sample size, there may have been insufficient power to detect change and the major effects were analysed without covariates. As a result, it is unclear whether covariates such as initial levels of child EF, parental empathy and parental stress confounded the results. For example, there may have been little change on measures of parental empathy for parents with a high level of empathy at the outset, but high empathy levels might still be associated with variance in child behavioural outcomes post intervention, which this study was unable to explore. Furthermore, this study did not collect any follow up data, and therefore it is unclear whether positive changes were sustained over time. Another limitation that needs to be considered is the possibility of sampling bias. During the data collection period, 126 children and their caregivers were offered in-home CPS treatment, however only 75 caregivers consented to participate in the study (42 of which, completed the intervention within the data collection period). Therefore it is possible that the sample was biased, with caregivers who agreed to participate differing in some ways to those who declined. In addition, three caregivers dropped out of treatment and four did not completed post-intervention measures. There were no noticeable differences on pre-intervention or demographic measures between those who completed the treatment compared to those who dropped out. Nonetheless it is possible that the results might have differed had all post-intervention measures been collected.Furthermore, all of the outcome measures used in this study relied on caregiver-report measures, which are open to bias as participants may respond in a social desirably manner or report what they think is expected of them. For example, reporting high parental empathy because they know that this is an expected and socially desired trait. This was emphasized in a study by Rodriguez (2013), who found a discrepancy between behavioural measured empathy and self-reported empathy, with lower empathy found behaviourally than was disclosed using a self-report measure. Therefore the findings in this study may have been confounded by participants responding in a socially desirable way. It should be noted, however, that the failure to find significant improvements in some of the parent reported measures is evidence against a generalised social desirability response bias. This could be improved in future studies by using more objective behavioural measures, for example independent tests of child EF as opposed to parent report.Finally, it is possible that the adapted version of the IRI used in this study to measure parental empathy might not have had sufficient validity. The original IRI is a reliable and validated measure to assess general empathy and includes the scales of perspective taking, empathic concern, personal distress and fantasy (Davis, 1983). However, in this study an adapted version was used (Psychogiou et al., 2008) which omitted the fantasy scale (concerned with how well somebody can empathise with fictitious characters) and altered the questions to be directed at parental empathy as opposed to general empathy. This appeared to fit well for the perspective taking subscale, in which statements were changed from the generic “I sometimes find it

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difficult to see things from the ‘other guys’ point of view” to parent specific “I sometimes find it difficult to see things from my child’s point of view”. However for the subscales ‘emotional concern’ and ‘personal distress’ these alterations appear to have resulted in more leading and emotive statements. For example, a statement in the emotional concern subscale was changed from “when I see someone being taken advantage of, I feel kind of protective towards them” to “when I see my child being taken advantage of, I feel kind of protective towards them”. The latter clearly invites people to answer in a more socially desirable way, as it is far more expected within society for people to feel protective towards their child than the anonymous ‘someone’. This could explain why less change was observed on these subscales.

Clinical ImplicationsThis study has helped support CPS as an effective treatment choice in order to reduce child behavioural difficulties in outpatient settings. Implementing the CPS approach in family homes also resulted in additional positive effects including building children’s EF skills and improving stress and empathy among parents. Due to the relatively low rate of attrition in this study (7%), the CPS treatment option appears to be favourable in comparison to behavioural interventions. Current figures have shown that while behavioural parent training programs may be effective for those who complete them, there are serious issues with lack of engagement and rates of attrition between 39-48% (see Staudt 2007 for a review). The discrepancy in attrition rates suggests that the CPS model engages caregivers in a way that behavioural parent training may not. In addition, the findings from this study have wider clinical implications. The present findings add to the current wealth of research to suggest that EF deficits are associated with child behavioural difficulties (see Ogilvie, Stewart, Chan, & Shum, 2011 for a review) and can predict child behavioural outcomes (Martel et al., 2007; Hughes & Ensor, 2008). The correlation between EF and physical aggression has been found in children as young as 17 - 41 months old (Séguin, 2009) and EF deficits have been found to be independently associated with behavioural problems by the age of four (Hughes & Ensor, 2008). Thus, identifying EF deficits in preschool children as a precursor to future aggressive or antisocial behaviour, and developing more early interventions for these at risk children, may help to prevent future behavioural problems developing (Piquero, 2001). Despite the wealth of research to suggest that child EF plays an important role in child functioning, there is a scarcity of interventions focused on enhancing EF skills. Many of the interventions that do focus upon building child EF skills have been implemented as curriculums in schools, which have had positive results in improving child cognitive skills and reducing behavioural difficulties (Kam, Greenberg, & Kusche, 2004; Domitrovich, Cortes, & Greenberg, 2007; Bierman et al., 2008; Van der Oord et al., 2014). There have been limited interventions at building child EF skills within the family home. The results from this study show that CPS is a promising intervention to help children improve EF skills with support from their caregivers alone. This is likely to be beneficial for families of children who attend a mainstream school and do not have access to adapted school curriculums.

Furthermore the findings from this study indicate that whilst behavioural difficulties may heighten parental stress, parental stress may also play a causal role in predicting future child behaviour, with reduced parental stress predicting improved

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child behaviour. This adds to the growing evidence base (Krahe, 2015; Solem, 2011) and supports Baker’s (2003) transactional model that high parenting stress contributes to a worsening in child behavioural difficulties over time, which in turn contributes to a worsening in parenting stress, forming a vicious cycle. This could be explained by research which has found correlations between parental stress and more punitive, critical parenting resulting in negative child-parent relationships and child externalizing behaviour (Pinderhughes et al., 2000). It is speculated that the CPS model reduces parental stress by encouraging parents to predict child behavioural difficulties and respond proactively as opposed to reactively. It also places emphasis on improving parent-child relationships through collaboration, which is likely to both reduce parental stress and challenging child behaviour. Parental stress has often been overlooked in interventions aimed at improving child behaviour, and might have been viewed as a positive side effect caused by reduced child externalizing behaviour, rather than as a mechanism of change within the intervention. Kazdin and Whitley (2003) found that by adding an additional component to traditional parent management training focused on parental stress reduction resulted in enhanced therapeutic change. The findings from the present study and the evidence base highlight the need to consider and preferably target parenting stress in interventions aimed at reducing child behavioural difficulties. Contrary to expectations, this study did not find that parental empathy was a mechanism of change in the CPS model. Previous research has found that high parental empathy has been associated with child prosocial behaviour (Farrant et al., 2012; Richaud et al., 2013; Stern et al., 2015) and low parental empathy with increased child behavioural problems (Curtner-Smith et al., 2006; Moor & Silvern, 2006; Psychogiou et al., 2008). However there is no known research that has explored whether parental empathy is predictive of future child behavioural outcomes. It remains unclear whether the findings in the present study were because empathy is not a predictor of child behavioural outcomes, or due to the methodological limitations of the study (see limitations section). As the sample scored high on empathy prior to the intervention, this might also explain why less change was observed on this measure.

Future Research Future research utilizing randomized controlled trials are critical in order to validate CPS as an effective treatment choice. To date, there has only been one study utilizing a randomized controlled design (Greene et al., 2004). As a result, it is difficult to ascertain how CPS compares to other treatment options or to differentiate the outcomes from confounding variables such as maturation effects or nonspecific effects from receiving any therapeutic treatment. Furthermore, it would be useful to conduct longitudinal studies to determine whether the reduction in child behavioural difficulties and other beneficial outcomes observed post CPS intervention are maintained in the longer term.Although this study explored three potential mechanisms of change within the CPS model, a number of other possible mediators may also be influential in the outcomes of CPS. For example, child language processing and social skills, or parenting factors such as parenting style and warmth. Furthermore, this study explored mechanisms of change in the CPS model within an outpatient setting only. There has been no research into whether there are similar mechanisms of change or different factors that drive child behaviour changes within school or inpatient/residential settings.

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Another recommended avenue for future research is to identify variables that might moderate the efficacy of the CPS intervention. For example, to explore whether there are certain demographic factors such as age of child, socioeconomic status of family, single parent families, or cultural background that influence the effectiveness of CPS in reducing child behavioural difficulties. Results from these investigations will promote a better understanding of the CPS model, and the intervention can be targeted towards children who will gain the most benefit.

The findings from the present study suggest that parental empathy is not a predictor of child behavioural outcomes, however it is unclear whether this was due to the methodological limitations of the study. Future investigations would be beneficial in order to explore this further, perhaps using a different measure of parental empathy that is less susceptible to social desirability bias. This study also highlighted a lack of research exploring whether parental empathy is predictive of future child behavioural outcomes outside of the CPS model. This would be a valuable avenue to investigate, in order to confirm or disregard the well-held perception that parental empathy is critical for healthy child and adolescent development (Feshbach, 1990).

ConclusionThis study aimed to contribute to the current evidence base regarding the efficacy of the CPS approach in outpatient settings and to explore what mechanisms of change may be driving the efficacy of the CPS model. In line with previous research, this study found that following the CPS intervention there was an improvement in child behaviour, child EF skills, and a reduction in parental stress. In addition, this was the first study to demonstrate that parental empathy improved post CPS intervention. Child EF appeared to be the primary mechanism of change within the CPS model, as when child EF improved this predicted positive child behavioural outcomes. Reduction in parental stress also accounted for some variance in child behavioural outcomes. Critically, prior levels of child behaviour were not associated with the amount of change in child EF, parental empathy, or parental stress, which implies that the CPS intervention can produce positive change regardless of the level of behavioural difficulties at the outset. These findings indicate that child EF and low parental stress are critical for healthy child and adolescent development, and should be identified as a focus for interventions aimed at reducing child behavioural difficulties.

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Piquero, A. (2001). Testing Moffitt’s Neuropsychological Variation Hypothesis for the Prediction of Life-Course Persistent Offending. Psychology, Crime, & Law, 7, 193-215.

Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A. & Rohde, L. A. (2015). Annual Research Review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56, 345–365. Poland, S. E., Monks, C. P., & Tsermentseli, S. (2015). Cool and hot executive function as predictors of aggression in early childhood: Differentiating between the function and form of aggression. The British Journal of Developmental Psychology, doi:10.1111/bjdp.12122Pollastri, A. R., Epstein, L. D., Heath, G. H., & Ablon, J. S. (2013). The Collaborative Problem Solving Approach: Outcomes Across Settings. Harvard Review of Psychiatry, 21, 188-199.

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arousal to others’ emotions. Frontiers In Psychology, 6, 1-11.Van der Oord, S., Ponsioen, A. B., Geurts, H. M., Ten Brink, E. L., & Prins, P. M. (2014). A pilot study of the efficacy of a computerized executive functioning remediation training with game elements for children with ADHD in an outpatient setting: outcome on parent- and teacher-rated executive functioning and ADHD behaviour. Journal Of Attention Disorders, 18(8), 699-712. VanderVen K. (1995). "Point and levels systems”: Another way to fail children and youth. Child and Youth Care Forum, 24, 345-67.VanderVen, K. (2009). Why focusing on control backfires: A systems perspective. Reclaiming Children and Youth, 17(4), 8.Van Zeijl, J., Mesman, J., Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer, F., Stolk, M. N., . . . Alink, L. R. (2006). Attachment-Based Intervention for Enhancing Sensitive Discipline in Mothers of 1- to 3-Year-Old Children for Externalizing Behaviour Problems: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, 74, 994-1005. Williams, S., Moore, K., Crossman, A. M., & Talwar, V. (2016). The role of executive functions and theory of mind in children's prosocial lie-telling. Journal Of Experimental Child Psychology, 141, 256-266. Woltering, S., Lishak, V., Hodgson, N., Granic, I., & Zelazo, P. D. (2015). Executive function in children with externalizing and comorbid internalizing behaviour problems. Journal of Child Psychology and Psychiatry. doi: 10.1111/jcpp.12428.

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List of Appendices

Appendix A: Information Sheet for ParticipantsAppendix B: Consent FormAppendix C: University of Surrey Ethical ApprovalAppendix D: Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), USA Version for 2-4 year oldsAppendix E: Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), USA Version for 4-10 year oldsAppendix F: Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), USA Version for 11-17 year oldsAppendix G: Think Kids: Change Over Time (TK-COT; Pollastri, Katzenstein, Epstein, & Ablon – in prep)Appendix H: Interpersonal Reactivity Index (IRI; Davis, 1983); Adapted Version (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008)Appendix I: Demographics QuestionnaireAppendix J: Journal of Abnormal Child Psychology – Instructions for Authors

Appendix A

Information Sheet for Participants

Participant Information Sheet

PROJECT TITLE:

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Investigating Mechanisms of Change in the Collaborative Problem Solving Model

Introduction

I am a student from the University of Surrey, UK currently completing a doctorate in clinical psychology. I would like to invite you to take part in a research project. Before you decide you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. Talk to others about the study if you wish.

What is the purpose of the study?

This study seeks to investigate what factors may be influencing Collaborative Problem Solving treatment outcomes. It also aims to build upon previous research to explore whether using Collaborative Problem Solving in an in-home treatment programme reduces child and/or adolescent behavioural difficulties, and if so, whether this is maintained two months following treatment.

Why have I been invited to take part in the study?

Because you have been referred for the in-home treatment programme at xxxxx

Do I have to take part?

No, you do not have to participate. There will be no adverse consequences in terms of your care or treatment if you decide not to participate. You can withdraw from the study at any time without giving a reason.

What will my involvement require?

Your consent for the researcher to access your data from the questionnaire measures collected by xxxxx. You will also be asked to complete two additional questionnaires. The questionnaires will be given to you before and after treatment by your caseworker. These additional questionnaires will take approximately 10 minutes to complete.

What will I have to do?

If you would like to take part please sign the consent form attached and return this to your case worker.

What are the possible disadvantages or risks of taking part?

Some of the questions in the questionnaire may cover sensitive topics concerning your child or your own functioning, which could be upsetting. If you have any concerns about completing the questionnaires you are advised to discuss these with your caseworker.

What are the possible benefits of taking part?

It is unlikely that you will benefit directly, but it is hoped that your involvement in the research will help to gain a greater understanding of what aspects of the Collaborative Problem Solving model contribute to better treatment outcomes. This improved understanding may help other families in the future who use the

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Collaborative Problem Solving approach.

What happens when the research study stops?

At the end of the research study, a summary of the findings will be posted on the xxxxx centre’s website. The findings will also hopefully be published and will be accessible on http://thinkkids.org/learn/research/.

What if there is a problem?

Any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact Georgina Heath, Principal Investigator at [email protected]. You may also contact xxxxx, Director of xxxxxx Centre, at xxxxxx.

Will my taking part in the study be kept confidential?

Yes. All of the information you give will be anonymised so that those reading reports from the research will not know who has contributed to it.

Data will be stored securely in accordance with the Data Protection Act 1998.

Contact details of researcher

Georgina Heath,University of Surrey,Department of Clinical Psychology,Guildford,Surrey,GU2 7XH,United Kingdom447709996278

Who is organising and funding the research?

The University of Surrey, UK, in collaboration with xxxx Centre, xxxx, Canada.

Who has reviewed the project?

The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the University of Surrey Ethics Committee.

Thank you for taking the time to read this Information Sheet.

Appendix B Consent Form

Consent Form

• I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, and likely duration of the study, and of what I will be expected to do.

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• I have been advised about any possible ill-effects on my well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result. I shall inform researchers immediately if I suffer any deterioration of any kind in my well-being.

• I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I agree that I will not seek to restrict the use of the results of the study on the understanding that my anonymity is preserved.

• I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice. I understand that withdrawing from the study will have no impact on my clinical care.

• I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.

Tick to consent

• I voluntarily agree to take part in the study on the mechanisms of change in the Collaborative Problem Solving model, which involves completing questionnaire measures before and after treatment and consenting for my data to be accessed for research purposes

Name of volunteer (BLOCK CAPITALS) ........................................................

Signed ........................................................

Date ……………......................................

Name of researcher/person taking consent (BLOCK CAPITALS) .........................................

Signed ...........................................

Date …………………

Appendix CUniversity of Surrey Ethical Approval

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Appendix D

Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997)

USA version for 2-4 year olds

Appendix E

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Strengths and Difficulties Questionnaire(SDQ; Goodman, 1997)

USA version for 4-10 year olds

Appendix F

Strengths and Difficulties Questionnaire(SDQ; Goodman, 1997)

USA version for 11-17 year olds

Appendix G

Think Kids: Change Over Time (TK-COT)(TK-COT; Pollastri, Katzenstein, Epstein, & Ablon – in prep)

TK-COT (Think:Kids Change Over Time) Administration and Scoring Instructions

TK-COT Administration:

• This measure was designed as a parent-report measure (see separate TK-COT-E for educators)

• This measure was designed to detect longitudinal changes over time, but could be used to measure individual differences in subscale scores

Subscale 1:  Parent/Child Relationship Quality

Items 1, 4, 5, 8, 10 (reversed), 12 (reversed), 14 (reversed)Higher score means better relationship- you want these scores to increase over timeCronbach's alpha = .83

Subscale 2: Adherence to CPS Philosophy

Items 2 , 7 , 11 , 15  Higher score means higher adherence – you want these to increase over timeCronbach's alpha = .76

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Subscale 3: Ability to Understand/Predict Challenging Behaviour

Items 3 , 6 , 9  Higher score means better ability to predict- you want these to increase over timeCronbach's alpha = .81

Note: Item 13 does not fit into any of these subscales.

Appendix H

Interpersonal Reactivity Index (IRI; Davis, 1983)

Adapted Version (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008)

INTERPERSONAL REACTIVITY INDEX

The following statements inquire about your thoughts and feelings in a variety of situations. For each item, indicate how well it describes you by choosing the appropriate letter on the scale at the top of the page: A, B, C, D, or E. When you have decided on your answer, fill in the letter on the answer sheet next to the item number. READ EACH ITEM CAREFULLY BEFORE RESPONDING. Answer as honestly as you can. Thank you.

ANSWER SCALE:

A B C D EDOES NOT DESCRIBES MEDESCRIBE ME VERYWELL WELL

• I often have tender, concerned feelings for my child. (EC)

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• I sometimes find it difficult to see things from my child's point of view. (PT)(−)

• Sometimes I don't feel very sorry for my child when he/she is having problems. (EC)(−)

• When my child is caught in emergency situations, I feel apprehensive and ill-at-ease. (PD)

• I try to look at my child's side of disagreement before I make a decision. (PT)

• When I see my child being taken advantage of, I feel kind of protective towards him/her. (EC)

• I sometimes feel helpless when my child is in a middle of a very emotional situation. (PD)

• I sometimes try to understand my child better by imagining how things look from his/her perspective. (PT)

• When I see my child get hurt, I tend to remain calm. (PD)(−)

• My child's misfortunes do not usually disturb me a great deal. (EC)(−)

• If I am sure I am right about something, I don't waste much time listening to my child's arguments. (PT)(−)

• If my child is in a tense emotional situation, it scares me. (PD)

• When I see my child being treated unfairly, I sometimes don't feel very much pity for him/her. (EC)(−)

• I am usually pretty effective in dealing with my child's emergencies. (PD)(−)

• I am often quite touched by things that I see happen to my child. (EC)

• I always try to take an objective approach to dealing with my child. (PT)

• In dealings with my child I would describe myself as a pretty soft-hearted person. (EC)

• I tend to lose control during my child's emergencies. (PD)

• When I am upset at my child, I usually try to ‘put myself in his/her shoes’ for a while. (PT)

• When I see my child who badly needs help in an emergency, I go to pieces. (PD)

• Before criticising my child, I try to imagine how I would feel if I were in his/her place. (PT)

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NOTE: (-) denotes item to be scored in reverse fashionPT = perspective-taking scaleEC = empathic concern scalePD = personal distress scale

A = 0B = 1C = 2D = 3E = 4

Except for reversed-scored items, which are scored:

A = 4B = 3C = 2D = 1E = 0

Appendix IDemographics Questionnaire

Appendix JJournal of Abnormal Child Psychology – Instructions for Authors

Instructions for Authors Manuscript Submission Submission of a manuscript implies: that the work described has not been published before; that it is not under consideration for publication anywhere else; that its publication has been approved by all co-authors, if any, as well as by the responsible authorities – tacitly or explicitly – at the institute where the work has been carried out. The publisher will not be held legally responsible should there be any claims for compensation.

Permissions Authors wishing to include figures, tables, or text passages that have already been published elsewhere are required to obtain permission from the copyright owner(s) for both the print and online format and to include evidence that such permission has been granted when submitting their papers. Any material received without such evidence will be assumed to originate from the authors.

Online Submission Please follow the hyperlink “Submit online” on the right and upload all of your manuscript files following the instructions given on the screen.

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Authors – NEW SUBMISSION REQUIREMENT AS OF NOVEMBER 1, 2011: A Disclosure of Conflict of Interest form signed by each author must be included with the manuscript submission. Submissions received without the signed Disclosure of Conflict of Interest form(s) cannot be sent out for peer review. The Disclosure of Interest form may be found on and downloaded from the Journal of Abnormal Child Psychology Homepage

Title Page The title page should include: The name(s) of the author(s)A concise and informative titleThe affiliation(s) and address(es) of the author(s)The e-mail address, telephone and fax numbers of the corresponding author

Abstract Please provide an abstract of 150 to 250 words. The abstract should not contain any undefined abbreviations or unspecified references.

Keywords Please provide 4 to 6 keywords which can be used for indexing purposes.

Text Formatting Manuscripts should be submitted in Word. Use a normal, plain font (e.g., 10-point Times Roman) for text. Use italics for emphasis.Use the automatic page numbering function to number the pages. Do not use field functions. Use tab stops or other commands for indents, not the space bar. Use the table function, not spreadsheets, to make tables. Use the equation editor or MathType for equations. Save your file in docx format (Word 2007 or higher) or doc format (older Word versions). Manuscripts with mathematical content can also be submitted in LaTeX.

Headings Please use no more than three levels of displayed headings.

Abbreviations Abbreviations should be defined at first mention and used consistently thereafter.

Footnotes Footnotes can be used to give additional information, which may include the citation of a reference included in the reference list. They should not consist solely of a reference citation, and they should never include the bibliographic details of a reference. They should also not contain any figures or tables. Footnotes to the text are numbered consecutively; those to tables should be indicated by superscript lower-case letters (or asterisks for significance values and other statistical data). Footnotes to the title or the authors of the article are not given reference symbols. Always use footnotes instead of endnotes.

Acknowledgments Acknowledgments of people, grants, funds, etc. should be placed in a separate section on the title page. The names of funding organizations should be written in full.

All JACP manuscripts should be submitted to Editorial Manager in 12-point Times New Roman with standard 1-inch borders around the margins.

Page length: 35 pages; Text must be double-spaced; APA Publication Manual standards must be followed.Please use the standard mathematical notation for formulae, symbols etc.:

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Italic for single letters that denote mathematical constants, variables, and unknown quantities Roman/upright for numerals, operators, and punctuation, and commonly defined functions or abbreviations, e.g., cos, det, e or exp, lim, log, max, min, sin, tan, d (for derivative) Bold for vectors, tensors, and matrices. Please always use internationally accepted signs and symbols for units (SI units). Generic names of drugs and pesticides are preferred; if trade names are used, the generic name should be given at first mention.

Citation Cite references in the text by name and year in parentheses. Some examples: Negotiation research spans many disciplines (Thompson 1990).This result was later contradicted by Becker and Seligman (1996).This effect has been widely studied (Abbott 1991; Barakat et al. 1995; Kelso and Smith 1998; Medvec et al. 1999).

Reference list The list of references should only include works that are cited in the text and that have been published or accepted for publication. Personal communications and unpublished works should only be mentioned in the text. Do not use footnotes or endnotes as a substitute for a reference list.

Reference list entries should be alphabetized by the last names of the first author of each work. Journal article Harris, M., Karper, E., Stacks, G., Hoffman, D., DeNiro, R., Cruz, P., et al. (2001). Writing labs and the Hollywood connection. Journal of Film Writing, 44(3), 213–245.

Article by DOI Slifka, M. K., & Whitton, J. L. (2000) Clinical implications of dysregulated cytokine production. Journal of Molecular Medicine, doi:10.1007/s001090000086

Book Calfee, R. C., & Valencia, R. R. (1991). APA guide to preparing manuscripts for journal publication. Washington, DC: American Psychological Association.

Book chapter O’Neil, J. M., & Egan, J. (1992). Men’s and women’s gender role journeys: Metaphor for healing, transition, and transformation. In B. R. Wainrib (Ed.), Gender issues across the life cycle (pp. 107–123). New York: Springer.

Online document Abou-Allaban, Y., Dell, M. L., Greenberg, W., Lomax, J., Peteet, J., Torres, M., & Cowell, V. (2006). Religious/spiritual commitments and psychiatric practice. Resource document. American Psychiatric Association. http://www.psych.org/edu/other_res/lib_archives/archives/200604.pdf. Accessed 25 June 2007.

Journal names and book titles should be italicized. For authors using EndNote, Springer provides an output style that supports the formatting of in- text citations and reference list. EndNote style (zip, 3 kB)

TABLES All tables are to be numbered using Arabic numerals.Tables should always be cited in text in consecutive numerical order. For each table, please supply a table caption (title) explaining the components of the table. Identify any previously published material by giving the original source in the form of a reference at the end of the table caption. Footnotes to tables should be indicated by superscript lower-case letters (or asterisks for significance

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values and other statistical data) and included beneath the table body.

ETHICAL RESPONSIBILITIES OF AUTHORS

This journal is committed to upholding the integrity of the scientific record. As a member of the Committee on Publication Ethics (COPE) the journal will follow the COPE guidelines on how to deal with potential acts of misconduct.

Authors should refrain from misrepresenting research results which could damage the trust in the journal, the professionalism of scientific authorship, and ultimately the entire scientific endeavour. Maintaining integrity of the research and its presentation can be achieved by following the rules of good scientific practice, which include:

The manuscript has not been submitted to more than one journal for simultaneous consideration.

The manuscript has not been published previously (partly or in full), unless the new work concerns an expansion of previous work (please provide transparency on the re-use of material to avoid the hint of text-recycling (“self-plagiarism”)).

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be included: “Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.”

Major Research Project Proposal

Investigating Mechanisms of Change in the Collaborative Problem Solving Model

Year 1 (Cohort 42)PsychD Clinical Psychology

URN: 6290288

Word Count: 2,999(Excluding Title Page, References and Appendices)

Submitted: 12.09.14

Introduction

Background and Theoretical Rationale

Collaborative Problem Solving (CPS) is a model that conceptualizes conduct problems as the result of impairments in the domains of executive functioning, cognitive flexibility, language processing, emotion regulation, and social skills (Greene, 1998; Greene & Ablon, 2006). The CPS philosophy is that ‘children do well if they can’. Based on this philosophy, oppositional behaviour is viewed as a means for the child to express that they are struggling with a situation or demand because they do not have the skills to communicate this in an adaptive manner. Following this theory, the CPS model conceptualizes and treats oppositional behavior similarly to a learning disability. Initially, specific skill deficits are identified by recognizing situations in which the child regularly struggles to meet adult expectations. The child is then helped to develop these skills by engaging in a collaborative problem solving process with an adult who adapts this to the child’s ability.

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Mediating and Moderating Factors in the CPS modelThere is growing research in favour of the effects of CPS in reducing challenging behaviour among children and youths in outpatient, inpatient facilities and schools across America and Canada (see Pollastri, Epstein, Heath, & Ablon, 2013 for a review). However, there is currently no known research into what factors may be influencing CPS treatment outcomes. Investigating potential mediating and moderating factors that influence or drive the relationship between CPS and observed child outcomes is important in order to gain a deeper understanding of the CPS model and strengthen its validity as an effective treatment choice. In addition, exploring what factors are related to improved child outcomes has wider clinical implications by identifying the necessary components required for healthy child and adolescent development. In an attempt to examine this, the aim of the current study is to investigate what mediating and moderating factors play a role within the CPS model. The first mediating factor proposed is caregiver empathy. Empathy is typically defined as the ability to understand and share the emotions and thoughts of another (Snow, 2000). The CPS philosophy that ‘children do well if they can’ intends to change the notion that a child’s externalizing behaviour is intentional or malicious, to perceiving oppositional behaviour as the child’s way of communicating that they are finding it difficult to meet adult expectations. The CPS model promotes adults to spend time actively listening to the child’s concerns, to empathize with and validate these concerns, and ensure that their concerns are attended to during the problem solving process. It is anticipated that this change in attribution and collaborative approach encourages greater empathy among caregivers of children with behaviour disorders. Several studies have found an association between low parental empathy and increased child conduct behaviour (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008), and increased child bullying (Curtner-Smith et al., 2006), whereas high parental empathy has been associated with child prosocial behaviour (Farrant, Devine, Maybery, & Fletcher 2012; Strayer & Roberts, 2004). Furthermore, interventions aimed at increasing parental empathy have lead to improved outcomes among children and adolescents (Flory, 2004; Havighurst, et al., 2009, 2010, 2013; Moretti, Holland, Moore, & McKay, 2004). Empathy has also been proposed as the primary mechanism of change in CPS in a recent review paper (Ashworth, Tapsak, & Li, 2012). Based on this research, it is expected that if the CPS approach increases parental empathy, this may mediate the relationship between CPS and behavioural outcomes among children and adolescents. The second mediating factor proposed is child and adolescent executive functioning (EF) skills. EF skills have been defined as a set of higher order cognitions which include planning, shifting cognitive set, working memory, response inhibition and problem solving (Miyake et al., 2000). There is currently a wealth of research to suggest that deficits in EF are linked with child externalising behaviour (Schoemaker, Mulder, Deković, & Matthys, 2013), aggressive behaviour (Ellis, Weiss, & Lochman, 2009; Raaijmakers et al., 2008), and antisocial behavior (Brunton & Hartley, 2013; Enns, Reddon, Das, & Boukos, 2007; Enns, Reddon, Das, & Boudreau, 2008). In addition, interventions aimed to enhance EF skills in children have had beneficial effects in reducing oppositional behaviour (Kam, Greenberg, & Kusche, 2004; Domitrovich, Cortes, & Greenberg, 2007; Bierman et al., 2008; Piehler et al., 2013). As CPS aims to develop EF skills through the collaborative problem solving process, it follows this may mediate the relationship between CPS and behavioural outcomes among children and

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adolescents. In addition to exploring what mechanisms may drive the efficacy of CPS, this study will also assess whether parental stress moderates the relationship between CPS and child conduct problems. Parental stress has been associated with parenting practices that are more punitive, irritable and critical, which in turn increases negative child-parent interactions and the likelihood that a child will develop conduct problems (Webster-Stratton, 1990; Pinderhughes, Dodge, Bates, Pettit, & Zelli, 2000). Previous research has indicated that, following CPS implementation, parents and teachers reported decreased stress and increased feelings of competency (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Schaubman et al., 2011). Therefore it is expected that parental stress may moderate the relationship between CPS and child behavioural outcomes, with lower levels of parental stress associated with greater improvements in child behaviour.

Research questions• Are there changes on measures of child behaviour, parental

empathy, child EF, and parental stress following participation in a CPS in-home treatment program?

• Does parental empathy mediate the relationship between CPS and child behavioural outcomes?

• Does EF mediate the relationship between CPS and child behavioural outcomes?

• Does parental stress moderate the relationship between CPS and child behavioural outcomes?

• Are any changes in child behaviour maintained at three-month follow up?

Method

ParticipantsChildren with behavioural difficulties and their caregivers will be recruited from xxxxxx Centre in xxxxx, Canada. Contact was made with the xxxxx centre via previous work colleagues in Boston, United States, and an agreement has been made with the director of the xxxxx Centre for data to be collected there. The xxxxx Centre is an accredited children’s mental health centre, which provides services using the CPS model for children up to the age of 12 who have complex mental health needs, including severe emotional, behavioural and social difficulties, and their families. Caregivers with children with behavioural difficulties usually self refer for treatment, although occasionally family doctors or emergency departments will direct a family to the Centre.

Inclusion criteriaThis study will use the service’s referral criteria as its inclusion criteria, which is…

• Children aged between 0-12 years (usually 3+) referred to the children’s mental health centre in xxxx for behavioural difficulties, and their caregivers.

• Children will be required to have clinical scores on the Brief Child and Family Phone Interview.

• In line with referral criteria for the centre, children will be

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required to function at low average or above on a verbal performance scale. Verbal performance is typically measured by a formal IQ assessment prior to being referred. If this is not the case, a low average or above verbal performance is assumed unless deficits in this area are evident, in which case an IQ assessment may be conducted.

Exclusion criteria• Children diagnosed with autism (not including children with

Asperger’s Syndrome or Pervasive Development Disorder Not Otherwise Specified (PDD-NOS).

• Children with a learning disability (scores in the mild intellectual disability range or below).

Sample SizeA target of 100 participants will be recruited for the study. Similar studies examining factors mediating the relationship between parenting interventions and child behavioural outcomes have detected mediation effects between r = .27-.40 (Gardner, Burton, & Klimes, 2006; Gardner, Hutchings, Bywater, & Whitaker, 2010; Hanisch, Hautmann, Pluck, Eichelberger, & Dopfner, 2014). According to Kenny (2014), if similar effect sizes of .3 are obtained in this study, in order to obtain power of .8 a sample size of 84 - 92 is required.

Expected Response RateBased upon current referral rates of children and their caregivers at the xxxxx Centre, it is estimated that 300 families will be referred from in-home treatment during the period of data collection between January and September 2015. It is anticipated that a third of eligible participants will consent to participate in the study in order to achieve the target sample size of 100 participants.

Design This study will employ a within participants treatment evaluation design. Child behaviour, child EF, parental empathy, parental stress, and parental success in applying the CPS model will be measured pre- and post-treatment and at three month follow up to assess whether outcomes improve post-treatment and, if so, whether improvements in child behaviour are mediated by improvements in child EF and parental empathy, or moderated by parental stress.

Measures

• Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) is a brief behavioural screening questionnaire for children between 2-17 years old. The SDQ consists of 25 questions about positive and negative child attributes, which are divided into five subscales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behaviour. The version used in this study will be the English (USA) versions for 2-4 year olds (Appendix B), 4-10 year olds (Appendix C), and 11-17 year olds (Appendix D). For the purposes of this study, if the child is 4 years old

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they shall be given the 4-11 year old version of the SDQ. The SDQ has demonstrated sound psychometric properties with a mean internal reliability coefficient of 0.73 (Goodman, 2001).

• Behaviour Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) is an 86-item questionnaire developed for parents and teachers to assess the EF skills of children and adolescents aged between 5-18 years. There is also a version for preschool children aged 2-5 years (BRIEF-P). The measure has demonstrated satisfactory psychometric properties, with high internal consistency ranging between .80-.98 (Gioia et al., 2000). Please note that the BRIEF is subject to copyright and therefore cannot be appended to this proposal, however xxxxx Centre have purchased access to use this measure.

• Parental Stress Index – Short Version (PSI; Loyd & Abidin, 1985) is a 36-item questionnaire designed to measure parental stress using three subscales: child characteristics, parent characteristics, and situational/demographic life stress. Internal consistency has been found to range from .55-.80 for parents and .62-.70 for children (Loyd & Abidin, 1985). Please note that the PSI is subject to copyright and therefore cannot be appended to this proposal, however xxxxx Centre have purchased access to use this measure.

• Interpersonal Reactivity Index (IRI; Davis, 1983) is a questionnaire that measures empathy using the four subscales of perspective taking, emotional concern, psychological egoistic distress, and fantasy scale. The IRI has demonstrated satisfactory internal consistency with reliability coefficients ranging from .71–.77 (Davis, 1983). An adapted version of the IRI will be used in this study that was modified by Psychogiou, Daley, Thompson, and Sonuga-Barke (2008), who reworded the original items in order to measure child-directed parental empathy, as opposed to general empathy, and omitted the fantasy scale (see Appendix E).

• Think Kids - Change Over Time (TK-COT; Pollastri, Katzenstein, Epstein, & Ablon – in preparation) is a 22 item parent-report questionnaire designed to assess whether caregivers have adopted the CPS philosophy, how successfully they are using the CPS plans and any changes in parent-child relationships. It includes four subscales: interactive stress and struggle, philosophy shift, positive relationship factors, and successful use of plans. Internal reliability of the TK-COT subscales range from .76-.83 (see Appendix F).

• The Brief Child and Family Phone Interview (BCFPI; Boyle et al., 1993) is a standardized intake screening and treatment outcome measure used for children aged between 3-18 years in mental health services in Canada and Sweden. It aims to screen for child mental health disorders and the interview covers topics such as basic concerns, child behavioural and emotional problems, and child and family functioning. The interview has demonstrated high internal consistency for all subscales (Cronbach’s alpha = .75-.85) with the exception of

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the conduct problems subscale (.68) (Cunningham et al., 2001).

• Demographics – Demographics including age and sex of child, child diagnosis, and race/ ethnic group will be collected pre-treatment over the phone when completing the BCFPI (see Appendix G).

Procedure

Participants will be recruited from xxxxx Children’s Centre in Ottawa. Child and youth caseworkers working at the Centre will be asked to invite families who have been referred for in-home CPS treatment to participate in the study by giving them verbal and written information about the study rationale and procedure. CPS in-home therapy is a treatment offered to families who are struggling to cope with their child’s social, emotional and/or behavioural difficulties. Using the CPS model, a child and youth caseworker works alongside the child and their family in their home (see Pollastri et al., 2013 for an overview of the CPS approach). The case worker will visit the family home 2-3 times per week for up to 12 weeks to observe the family dynamics, teach the caregivers the CPS approach and help them to put it into practice by modeling the approach and providing guidance on how to apply the CPS principles within the home environment. The xxxxx Centre asks caregivers to complete the BCFPI, BRIEF and PSI pre- and post-treatment. To take part in the research, potential participants will be asked to consent to fill out a further three questionnaires at the same time points (the SDQ, TK-COT and IRI) and agree for all of their data to be used for study purposes. At the end of the treatment, participants will be asked whether they agree to be contacted over the phone three months following treatment to be asked about their child’s behaviour and functioning (using questions from the SDQ) and they will be given the incentive of being entered into a prize draw to win a $100 gift voucher. A separate information and consent form will be given at this point, and participants will be asked to provide contact details if they agree to be contacted. Potential participants will be assured that participation is completely voluntary, that they can withdraw at any time, and deciding to not participate will not impact their clinical care (see Figure 1 for flow diagram of procedure).

Caregivers asked to sign a consent form and provide telephone contact details if they agree to be contacted for a brief phone call three months post-treatmentCaregivers who provide consent will receive a telephone call three months post-treatment to be asked questions about their child’s behaviour using questions from the

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SDQ Caregivers referred to in-home CPS treatment are provided with verbal and written information about the study and asked for consent to participate. Caregivers complete the SDQ, BCPFPI, BRIEF, PSI, Adapted IRI and the TK-COT pre-treatmentFamilies participate in up to 12 weeks of CPS in-home treatmentCaregivers complete the SDQ, BCPFPI, BRIEF, PSI, Adapted IRI and the TK-COT post-treatment

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Figure 1: Flow diagram of study procedure

Contingency Plan If it proves difficult to obtain three month follow up data from participants over the telephone call, the contingency plan would be to omit the three month follow up, and solely collect data pre- and post- CPS treatment. No major difficulties are anticipated in collecting pre-and post-data as the majority of measures are collected as routine procedure (except from the IRI, TKCOT, and SDQ). If there were difficulties in obtaining consent from participants to complete these three extra measures for research purposes, the contingency plan would be to use the routine data collected and focus on whether EF is a mediating factor and whether parental stress is a moderating factor using the BCFPI as the sole measure of child behaviour (parental empathy as a mediating factor would be omitted from the study).

Project Costing The overall cost estimated for the project is estimated at £200, calculated as follows:

• £60 gift vouchers (in the form of a $100 dollar giftcard to offer participants in a prize draw as incentive to provide 3-month follow up data)

• £100 phone bill to Canada phoning participants to obtain follow up data.

• £10 printing to print off SDQ, IRI and TKCOT.• £30 postage to send questionnaires to and from Ottawa.

Ethical Considerations

An ethical application will be made to the University of Surrey Faculty Ethics. Significant social/ emotional/ behavioural difficulties may be uncovered among the children. If these difficulties cannot be addressed by in-home CPS treatment, families will be referred to alternative services. Families will be advised to discuss any concerns they have about completing the questionnaires or the CPS treatment model with their caseworker. If questionnaire scores indicate that the child’s behaviour deteriorates over treatment Crossroad’s staff would explore more intensive services within the organization. All data will be anonymised and sent from Canada via secure password protected emails.

R&D Considerations As the research will take place in Ottawa Canada, an NHS ethics application need not be made. The xxxxx Centre has stated that their research ethics board will defer to the University of Surrey Faculty Ethics approval.

Proposed Data Analysis T-tests or their non-parametric equivalents will be used to assess whether child behaviour, child EF, parental empathy, parental stress, and successful use of the CPS model, change following in-home CPS treatment. If significant differences are observed between pre-, post-, and follow-up data in these outcome measures, two

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mediation analyses using the Process software (Hayes, 2013) on SPSS will be conducted to assess whether parental empathy and/or child EF mediate the relationship between CPS and child behavioural outcomes. Initial EF, parental empathy and child behavioural outcomes will be included as covariates in the mediation analyses. Sex and age may also be included as covariates if it is found that they are significant predictors of change over time. A moderation analysis using the Process software will also be conducted to assess whether parental stress moderates the relationship between CPS and child behavioural outcomes, including the covariates outlined above.

Involving/Consulting Interested Parties The most useful form of service user consultation would be to consult caregivers who have undergone the in-home CPS treatment at xxxxxx Centre. However, as it would be breaking patient confidentiality to acquire details of people who have passed through the programme, and as the CPS model is not currently used in the UK to ask participants here, it was felt that this was not a feasible option. However, the director of the Centre and the Research Coordinator at Think:Kids (which is where CPS originated from) have both been consulted and their input has been utilised regarding the study design and procedure.

Dissemination strategy

• Feedback of the study findings will be provided to the xxxx Centre and the Think:Kids staff team in Boston (where CPS originated from) by executive summary.

• The research article will be submitted to a peer-reviewed journal, with consent from xxxxx Centre.

References

Ashworth, K., Tapsak, S., & Li, S. T. (2012). Collaborative Problem Solving: Is Empathy the Active Ingredient? Graduate Student Journal of Psychology, 14, 83-92. Bierman, K. L., Domitrovich, C. E., Nix, R. L., Gest, S. D., Welsh, J. A., Greenberg, M. T., . . . Gill, S. (2008). Promoting Academic and Social-Emotional School Readiness: The Head Start REDI Program. Child Development, 79, 1802-1817. Boyle, M.H., Offord, D.R., Racine, Y., Fleming, J.E., Szatmari, P., & Sanford, M. (1993). Evaluation of the Revised Ontario Child Health Study Scales. Journal of Child Psychology and Psychiatry, 34, 189–213.Brunton, I., & Hartley, T. (2013). Enhanced Thinking Skills and the

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Association between Executive Function and Antisocial Behavior in Children and Adult Offenders: Scope for Intervention? Journal of Forensic Practice, 15, 68-77.Cunningham, C.E., Pettingill, P., & Boyle, M.H. (2001). The Brief Child and Family Phone Interview (BCFPI) Interviewer’s Manual. Hamilton, ON: Canadian Centre for the Study of Children at Risk, Hamilton Health Sciences Corporation, McMaster University. Curtner-Smith, M. E., Culp, A. M., Culp, R., Scheib, C., Owen, K., Tilley, A., . . . Coleman, P. W. (2006). Mothers' Parenting and Young Economically Disadvantaged Children's Relational and Overt Bullying. Journal of Child & Family Studies, 15, 177-189.

Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T. (2007). Improving Young Children’s Social and Emotional Competence: A Randomized Trial of the Preschool “PATHS” Curriculum. The Journal of Primary Prevention, 28, 67-91.

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Havighurst, S., Wilson, K., Harley, A., Kehoe, C., Efron, D., & Prior, M. (2013). 'Tuning into Kids': Reducing Young Children's Behavior Problems Using an Emotion Coaching Parenting Program. Child Psychiatry & Human Development, 44, 247-264. Havighurst, S. S., Wilson, K. R., Harley, A. E., & Prior, M. R. (2009). Tuning in to Kids: An Emotion-Focused Parenting Program – Initial Findings from a Community Trial. Journal of Community Psychology, 37, 1008-1023. Havighurst, S. S., Wilson, K. R., Harley, A. E., Prior, M. R., & Kehoe, C. (2010). Tuning in to Kids: Improving Emotion Socialization Practices in Parents of Preschool Children-Findings from a Community Trial. Journal of Child Psychology and Psychiatry, 51, 1342-1350. Hayes, A.F. (2013). An Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York: Guilford Press. Kam, C., Greenberg, M. T., & Kusche, C. A. (2004). Sustained Effects of the PATHS Curriculum on the Social and Psychological Adjustment of Children in Special Education. Journal of Emotional and Behavioral Disorders, 12, 66-78. Kenny, D. (2014). Mediation: Power and Effect Size. http://davidakenny.net/webinars/Mediation/Power/Power.html.Loyd, B. H., & R. R. Abidin. R. R. (1985). Revision of the Parent Stress Index. Journal of Pediatric Psychiatry, 10, 169-177.Miyake A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A., & Wager, T. D. (2000). The Unity and Diversity of Executive Functions and their Contributions to Complex "Frontal Lobe" Tasks: A Latent Variable Analysis. Cognitive Psychology, 41, 49-100.Moretti, M. M., Holland, R., Moore, K., & McKay, S. (2004). An Attachment-Based Parenting Program for Caregivers of Severely Conduct-disordered Adolescents: Preliminary Findings. Journal of Child and Youth Care Work, 19, 170-179.Piehler, T. F., Bloomquist, M. L., August, G. J., Gewirtz, A. H., Lee, S. S., & Lee, W. S. C. (2013). Executive Functioning as a Mediator of Conduct Problems Prevention in Children of Homeless Families Residing in Temporary Supportive Housing: A Parallel Process Latent Growth Modeling Approach. Journal of Abnormal Child Psychology. http://dx.doi.org/10.1007/s10802-013-9816-y.

Pinderhughes, E.E., Dodge, K.A., Bates, J.A., Pettit, G.S., & Zelli, A. (2000). Discipline Responses: Influence of Parents’ Socioeconomic Status, Ethnicity, Beliefs about Parenting, Stress, and Cognitive-Emotional Processes. Journal of Family Psychology, 14, 380–400.

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Pollastri, A.R., Katzenstein, T., Epstein, L.D., & Ablon, J.S. (in prep).  Reliability, Validity, and Stability of the Think:Kids Measure of Change Over Time (TK-COT) for use with the Collaborative Problem Solving Approach. 

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Psychogiou, L., Daley, D., Thompson, M. J., & Sonuga-Barke, E. J. S. (2008). Parenting Empathy: Associations with Dimensions of Parent and Child Psychopathology. British Journal of Developmental Psychology, 26, 221-232.

Raaijmakers, M. A. J., Smidts, D. P., Sergeant, J. A., Maassen, G. H., Posthumus, J. A., van Engeland, H., & Matthys, W. (2008). Executive Functions in Preschool Children with Aggressive Behavior: Impairments in Inhibitory Control. Journal of Abnormal Child Psychology, 36, 1097-1107.

Rodriguez, C. M. (2013). Analog of Parental Empathy: Association with Physical Child Abuse Risk and Punishment Intentions. Child Abuse & Neglect, 37, 493-499.

Schaubman, A., Stetson, E., & Plog, A. (2011). Reducing Teacher Stress by Implementing Collaborative Problem Solving in a School Setting. School Social Work Journal, 35, 72-93.Schoemaker, K., Mulder, H., Deković, M., & Matthys, W. (2013). Executive Functions in Preschool Children with Externalizing Behavior Problems: A Meta-Analysis. Journal of Abnormal Child Psychology, 41, 457-471. Snow, N. E. (2000). Empathy. American Philosophical Quarterly, 37, 65-78. Strayer, J., & Roberts, W. (2004). Children's Anger, Emotional Expressiveness, and Empathy: Relations with Parents’ Empathy, Emotional Expressiveness, and Parenting Practices. Social Development, 13, 229-254. Sullivan, J. R. (2007). Diagnostic Group Differences in Parent and Teacher Ratings on the BRIEF and Conners' Scales. Journal of Attention Disorders, 11, 398–406.Webster-Stratton, C. (1990). Stress: A Potential Disruptor of Parent Perceptions and Family Interactions. Journal of Clinical Child Psychology, 19, 302-312.

Literature Review

Are Parental Empathy and Executive Functioning Mechanisms of Change in the Collaborative Problem Solving Model?

Year 1 (Cohort 42)PsychD Clinical Psychology

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URN: 6290288

Word Count: 7,995(Excluding Title Page, Abstract, Acknowledgements, Statement of Journal Choice,

Tables, References and Appendix)

Submitted: 06.06.2014

AbstractCollaborative Problem Solving (CPS) is an intervention used with children and adolescents displaying problematic internalizing and externalizing behaviour. Although there is a growing evidence base for the efficacy of CPS in reducing child behavioural problems, there is currently no research into what is driving these changes. This literature review proposes parental empathy and child executive functioning (EF) as two factors that may mediate the relationship between CPS intervention and child behavioural outcomes. The review explores the literature in the last ten years on interventions targeted at increasing parental empathy and improving EF skills with the aim of reducing child behavioural problems. Following a computerized literature search using the databases PsychINFO, Medline, Psychology and Behavioral Sciences Collection, and PsychARTICLES, a total of eleven papers were identified concerning parental empathy and eight papers were identified regarding EF. Review of the evidence indicates that interventions focused on increasing parental empathy and developing EF skills can lead to improved child behavioural outcomes. As increasing parental empathy and developing EF skills are both targeted in the CPS model, it follows that these two factors may mediate the observed relationship between CPS intervention and improved outcomes. Future research exploring potential mediating factors will help increase understanding of the mechanisms of change underlying the CPS model and may identify critical aspects required for healthy child and adolescent development.

Keywords: Executive Functioning, Parental Empathy, Collaborative Problem Solving, Child, Adolescent

IntroductionCollaborative Problem SolvingCollaborative Problem Solving (CPS) is a model that conceptualises oppositional behaviour as the product of skill deficits in the domains of executive functioning, cognitive flexibility, language processing, emotion regulation, and social skills. It was originally outlined by Ross Greene in his book “The Explosive Child” (1998) and has since been developed further for clinical populations by Greene and Ablon (2006). Since its development, the CPS model has been used to understand and help children and adolescents with behavioural problems in outpatient facilities, schools, residential homes and inpatient units across America and Canada. The philosophy behind CPS is that ‘children do well if they can’ (Greene & Ablon, 2006). CPS proposes that the aim behind a child’s externalizing behaviour is not to be purposefully oppositional, but to express (albeit in a maladaptive manner) that they are struggling with a particular demand or situation. Following this philosophy, the

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CPS approach views and treats oppositional behaviour in a similar manner to a learning disability. In the initial stage, specific skill deficits are identified for each child, by recognising situations in which they are routinely struggling to meet adult expectations. Following this, CPS facilitates the child to develop the skills that they are lacking through engaging in a collaborative problem solving process with an adult who helps tailor this to their developmental level. By identifying situations that trigger oppositional behaviour, known as ‘problems to be solved’ in the CPS model, adults are able to anticipate difficulties before they occur and intervene beforehand. For every problem to be solved, three possible ways in which an adult can respond have been classified within the CPS framework. These are categorized as Plan A, Plan B, and Plan C. Plan A is simply the imposition of adult will. This is where an adult continues to pursue their expectation of a child despite the fact this may trigger challenging behaviour. Plan C is to withdraw the expectation, for the meantime at least, in order to reduce oppositional behaviour. Plan B is to solve the problem collaboratively and is the premise of the CPS model. This is when both adult and child work together to solve the problem in a mutually satisfactory and realistic manner. Implementing Plan B consists of three stages. The first stage is aimed at gathering information to achieve a clear understanding of the child’s perspective regarding a specific recurring problem, and requires a lot of empathising on the adult’s behalf. The second stage aims to define the problem and voice both the adult and child’s concerns. Stage three involves the adult and child collaboratively brainstorming solutions together that will attend to both of their concerns. The child is encouraged to generate the first solution and no solutions are disregarded. Instead, the adult helps the child to think through the consequences of each solution, until a mutually agreed and feasible solution is reached. The CPS model proposes that, using Plan B, many skills are taught implicitly through the problem solving process. Stage one of adult empathy and understanding helps to teach the child to separate their emotions in order to identify and express their concerns rationally. Defining the problem in stage two helps to teach the child empathy by encouraging them to perspective-take and recognise the impact of their actions on others. Finally, brainstorming solutions collaboratively in stage three helps develop problem-solving skills by teaching the child to produce solutions and consider their outcomes in order to select one that addresses both child and adult concerns. CPS authors posit that the entire process helps the child to build skills in executive functioning, language processing, cognitive flexibility, emotion regulation and social processing.

CPS Evidence-Base The CPS approach is currently implemented in a number of outpatient, inpatient, and school settings across America and Canada (for a review see Pollastri, Epstein, Heath, & Ablon, 2013). One of the most documented effects of CPS is the reduction in child externalizing behaviour. This has been reported by parents of children showing oppositional behaviour in outpatient settings, who noted active improvements in child behaviour following CPS intervention as well as improved parent-child interactions (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Johnson et al., 2012). In one study these improvements were equivalent, and in some cases superior, to the improvements found in a control group who underwent a ten-week parent-training program (Greene et al., 2004). A similar reduction of outbursts

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and physical aggression was reported in a residential setting, and these reductions were not only sustained, but showed greater improvements six months post-discharge (Stewart, Rick, Currie, & Rielly, 2009).In addition, there is an accumulating evidence base to suggest that implementing CPS in inpatient, residential, and juvenile justice settings can significantly reduce the number of restraints and seclusions used (Greene, Ablon, & Martin, 2006; Martin, Krieg, Esposito, Stubbe, & Cardona, 2008). In some cases, these reductions have been dramatic. For example, Yale-New Haven Children’s Hospital reported a 97% reduction in the use of restraints and a 69% reduction in the use of seclusions following CPS implementation (Martin et al., 2008). School settings have reported similar improvements, evidenced by a significant decrease in discipline referrals (Schaubman, Stetson, & Plog, 2011), reduced number of suspensions per year, decreased time spent in ‘time-out’, and an increase in school attendance post CPS implementation, although the majority of this research has been unpublished (for a review see Pollastri et al., 2013). Other CPS outcomes have included decreased parental and teacher stress and improved feelings of competence following CPS implementation (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Schaubman et al., 2011). Improved social skills in children exposed to the CPS approach have also been reported in two studies (Stewart et al., 2009; Epstein & Saltzman-Benaiah, 2010). One limitation of the CPS evidence base is that, to date, there has been only one randomized controlled trial (RCT) conducted in which the sample size was small, and a number of studies have remained unpublished. Despite this, there is no known contrary evidence in the literature indicating that CPS is ineffective or less effective in comparison to other interventions.

Mechanisms of Change in the CPS modelThere is an expanding evidence base for the efficacy of CPS in reducing disruptive behaviour among children and adolescents, however little is known about the mechanisms driving these effects. Exploring what factors may mediate the relationship between CPS and observed child outcomes will provide a greater understanding of the CPS model and increase its validity as an effective treatment choice. In addition, examining what specific factors are associated with improved functioning in children and adolescents has wider clinical implications by identifying key components required for healthy child and adolescent development. In an attempt to explore this, this literature review examines two proposed mediating factors that may be driving the efficacy of CPS. The first mediating factor proposed is empathy. Empathy can be defined as the ability to understand and share the feelings of another (Snow, 2000). The philosophy behind CPS aims to change the assumption that child misbehaviour is intentional and willful, to viewing misbehaviour as the child’s way of communicating that they are struggling to meet the demands expected of them. This change in attribution is supposed to foster a greater sense of empathy among parents, teachers and staff working with child behaviour disorders. In addition, Plan B encourages the adult to take the time to listen to the child’s concerns, empathise with and validate them, and ensure that the child’s concerns are addressed during problem solving. All of these components of Plan B are likely to increase adult empathy and help the child feel listened to and understood. Previous research has found that low parental empathy is associated with increased child conduct problems (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008),

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child relational and overt bullying (Curtner-Smith et al., 2006), and an increased risk of physical child abuse (Rodriguez, 2013). Whereas high parental empathy has been associated with child prosocial behaviour, including child empathy (Farrant, Devine, Maybery, & Fletcher 2012), and parenting practices that resulted in decreased child anger (Strayer & Roberts, 2004). These findings indicate that interventions aimed at increasing parental empathy may help to reduce child behavioural problems. In addition, in a recent review paper, Ashworth, Tapsak, and Li (2012) proposed that increased parental empathy is the primary mechanism of change in CPS. The second mediating factor proposed is executive functioning (EF) skills in child and adolescents. EF refers to a set of higher order cognitive functions including planning, shifting cognitive set, working memory, response inhibition and problem solving (Miyake et al., 2000). There is currently a strong evidence base to suggest that EF deficits are associated with child externalising behaviour problems (Schoemaker, Mulder, Deković, & Matthys, 2013), antisocial behaviour (Brunton & Hartley, 2013; Enns, Reddon, Das, & Boukos, 2007; Enns, Reddon, Das, & Boudreau, 2008) and aggression (Ellis, Weiss, & Lochman, 2009; Raaijmakers et al., 2008). Furthermore evidence suggests that EF may play a causal role in predicting later internalizing and externalizing problem behaviour (Martel et al., 2007; Hughes & Ensor, 2008). Therefore, it follows that interventions targeted at improving EF skills should help improve behavioural outcomes among children and adolescents. The CPS approach posits that children with behavioural problems have deficits in EF skills and that these deficits are improved by regularly engaging in the ‘Plan B’ process with adults. Therefore improved behavioural outcomes among children engaging in the CPS approach may be explained by enhanced adaptive functioning.

Aims The aim of this literature review is to focus on parental empathy and EF as two potential mediators of the relationship between CPS and reduced behavioural problems in children. The specific question this review intends to address is whether literature in the last ten years supports the notion that interventions aimed at increasing parental empathy and enhancing child EF skills are associated with improved behavioural outcomes among children and adolescents. If this is the case, it follows that these factors may be mechanisms of change in the CPS model, as the CPS approach aims to increase parental empathy and improve child EF.

MethodThe databases searched in this literature review were PsychINFO, Medline, Psychology and Behavioral Sciences Collection, and PsychARTICLES. The search included academic journals and reviews (books were excluded). Unfortunately, the majority of dissertations were not accessible through university or NHS databases and therefore dissertations were also excluded from this review. The search was time-limited to include papers published in the last 10 years (January 2004-March 2014) in order to focus on recent intervention developments. References of included papers were also searched to identify any relevant papers not found within the database search. The quality of included papers was assessed using the Critical Appraisal Skills Programme (CASP). For both the literature on parental empathy and EF the search terms “child*”, “youth*”, “adolescent*”, “juvenile*”, “young people”, “teenager”, “young person”, “infant” and “toddler” were used in combination with the key terms “behaviour* problem”, “conduct disorder”, “oppositional defiant disorder”, “aggression”,

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“aggressive”, “disruptive”, “delinquent”, “antisocial” and “prosocial”, in addition to the terms “intervention”, “treatment”, “training”, “therapy”, “program*” and “teaching”.Based on the aims of this review, explicit inclusion and exclusion criteria were applied. Exclusion criteria that applied to both parental empathy and EF papers were studies not written in English and studies from non-Western countries, due to possible cultural differences in interventions and parenting practices and subsequent difficulties generalizing findings to Western countries.

Parental EmpathyThe following key terms for parental empathy were searched in combination with the search terms above: “parent* empath*”, “caregiver* empath*”, “parent* understanding”, “caregiver understanding”, “parent* sympath*”, “caregiver sympath*”, “parent* compassion”, “caregiver compassion”. This search generated 278 papers, which was reduced to 210 when exact duplicates were removed. Ten additional articles were also identified searching the references of relevant papers. For this section of the review, studies that focused on interventions aimed at increasing parental empathy in order to improve child and adolescent behaviour were included. Based on this criteria, 210 papers were screened by their titles and abstracts for relevance and reduced to 35 full text articles that were assessed for eligibility. Following this, 11 papers that met the full criteria were selected for the parental empathy section of the review (see Figure 1). Reasons for exclusion included studies that were not interventions, interventions that did not focus on increasing parental empathy, or interventions that did not aim to reduce child problem behaviour. Executive FunctioningTo review the literature on EF, the search terms used were “executive function*”, “cognitive deficit*”, “cognitive impairment*” and “neurocognitive”. This search generated 434 papers, which was reduced to 337 when exact duplicates were removed. Inclusion criteria were applied to include intervention studies aimed at improving EF in order to reduce child and adolescent behaviour difficulties. Studies that were not interventions, interventions that did not focus on improving EF, or interventions not aimed at reducing child behavioural difficulties were excluded. Based on these criteria the original sample of 337 papers were screened for relevance and reduced to 37 full text articles to assess for eligibility. Five additional articles were also identified searching the references of relevant papers. Following this, 8 papers that met the full criteria were selected for the EF section of the review (see Figure 2).

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Articles included in the review (N= 11)Full text articles assessed for eligibility (N= 35)

Exclusion of articles after screening (N= 24)• Reason 1: Not an intervention study (n = 12)• Reason 2: Intervention not focused on increasing parental empathy (n=11)• Reason 3: Study did not measure change in child problem behaviour (n=1)

Additional potentially relevant articles identified from the references of relevant papers found in the database search (N= 10)Excluded – did not meet criteria (N=185)Exclusion of duplicate records (N= 68)

Potentially eligible records (N= 210)

Potentially eligible records identified through database searches of Medline, PsychInfo, PsychArticles, and Psychology and Behavioural Sciences Collection (N= 278)

Figure 1: Search procedure for parental empathy papers

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Articles included in the review (N= 8)Full text articles assessed for eligibility (N= 37)

Exclusion of articles after screening (N= 29)• Reason 1: Not an intervention study (n=10)• Reason 2: Intervention not focused on improving EF (n=11)• Reason 3: Intervention not aimed at reducing behavioral difficulties (n=4)• Reason 4: Written in a different language (n=2)

Excluded – did not meet criteria (N=305)Additional potentially relevant articles identified from the references of relevant papers found in the database search (N= 5)Exclusion of duplicate records (N= 97)

Potentially eligible records (N= 337)

Potentially eligible records identified through database searches of Medline, PsychInfo, PsychArticles, and Psychology and Behavioural Sciences Collection (N= 434)

Figure 2: Search procedure for EF papers

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ResultsThe literature search provided a final sample consisting of 19 papers. The first section of the results will focus on papers regarding parental empathy and the second section will focus on child EF.

Parental Empathy Table 1 provides a description of the studies included in the parental empathy section of the review, including the measures used in each study. Eleven studies in the literature were identified that evaluated six parenting interventions aimed at increasing parental empathy. Only one study in this review utilised an intervention that was focused solely on increasing parental empathy in order to reduce child psychopathology. Flory (2004) created a new clinical intervention called Emotionally Attuned Parenting, which aims to increase parental empathy by changing parent’s negative attributions of child misbehaviour. Flory (2004) evaluated this intervention in a pilot study in Australia with eleven parents of children with severe and chronic psychiatric disorders that had thus far been treatment resistant. Questionnaire and interview measures were administered pre and post intervention, all of which possessed sound psychometric properties.Paired samples t-tests found a significant decline in child-rated anxiety and depressive symptoms and a slight decline in child behavioural difficulties as rated by parents on the Child Behaviour Checklist (CBCL; Achenbach, 1991), although this failed to reach significance (t(10)=1.89, p=.08). In addition, the number of child psychiatric disorders significantly reduced post-intervention and diagnoses of conduct disorder/oppositional disorder dropped from 82% to 55%, however it is unclear how diagnosis was measured. These findings provide support for interventions aimed at increasing parental empathy to reduce child psychopathology, particularly given the severe and enduring psychiatric disorders present in this sample. However, as parental empathy was not measured explicitly it cannot be determined whether increased parental empathy was responsible for the reduction in child psychopathology. In addition, using the Reliable Change Index (RCI) may have been a more appropriate statistical test than paired samples t-tests. Finally, findings should be interpreted with caution given the very small sample size, lack of control group and limited follow up data. Future studies with more robust methodology and adequate power are needed to provide weight to these promising initial findings.The remaining studies in this section of the review focused on parenting programs that target increasing parenting empathy in addition to improving other aspects of parenting, with the aim of reducing child behavioural problems. Three of these studies were RCTs conducted by Havighurst and colleagues to evaluate the ‘Tuning into Kids’ (TIK) parenting program targeted at enhancing parental emotion socialisation practices and parental empathy in Australia. Child behaviour in all three studies was measured using parent report on the Eyberg Child Behavior Inventory 6 (ECBI-6; Eyberg & Pincus, 1999), which is a widely used measure that has demonstrated high reliability and validity.In the first study, 218 parents of children aged 4-5 years were randomly allocated to an intervention or waitlist control group (Havighurst, Wilson, Harley, & Prior, 2009). Analysis of covariance (ANCOVA) showed that post-intervention there was a significant increase in emotion coaching and a significant decrease in emotion dismissing measured using the Maternal Emotional Style Questionnaire (Lagace-Seguin & Coplan, 2005) among parents who participated in the programme. In

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addition significant improvements in child behaviour was observed among intervention group parents. However, the findings of this study are limited by reliance on parent-report measures and lack of follow up data.Table 1: Studies included within the parental empathy section of the review

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Publication and CountryInterventionDesignSample (n, child age, child characteristics)Measures UsedMain FindingsFlory (2004), AustrailiaEmotionally Attuned Parenting -aims to increase parental empathy by changing parent’s negative attributions of child misbehaviour Encourages parents to behave more empathically towards their child’s emotions. Total intervention sessions ranged from 5 to 13, dependant on how many sessions were required to understand the model.Pilot study, pre/post intervention, within subjectsN = 11 parents Children aged 6-13 (M=9.36). 64% girls.Clinical sample. All children had a range of severe and chronic psychiatric disorders. 82% had a diagnosis of either conduct disorder or oppositional defiant disorderMother completed:

• Child Behaviour Checklist (Achenbach, 1991), • Parenting Stress Index (Abidin, 1995) • Beck Depression Inventory (Beck, 1996).

Child completed:• Anxiety Disorders Interview Schedule for Children (Silverman & Albano, 1996) • Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond, 1978)• Children’s Depression Scale (Lang & Tisher, 1978).

The number of child psychiatric disorders significantly reduced post intervention (t(10) = 3.56, p=.005) Diagnoses of conduct disorder/oppositional disorder dropped from 82% to 55%. Child-rated anxiety and depressive symptoms significantly declined. Child behavioural difficulties declined (t(10)=1.89, p=.08). Havighurst, Wilson, Harley, & Prior (2009), AustraliaTuning into Kids (TIK)– aims to enhance parental emotion socialisation practices and teaches parents to develop awareness of their own and their child's emotions and to empathise with their child's emotions. Parents in the intervention group attended six weekly 2-hour sessions of the TIK program.Randomized controlled trial, between subjectsN= 218 parents Children aged between 4.0-5.11 years. 53% boys. Community sampleRandomly allocated to intervention (n=107) or waitlist control group

Parents completed:• Maternal Emotional Style Questionnaire (Lagace-Seguin & Coplan, 2005) – adapted

version.

• Difficulties in Emotional Regulation Scale (Gratz & Roemer, 2004)

• General Health Questionnaire-28 (Goldberg, 1981)

• Eyberg Child Behavior Inventory 6 (Eyberg & Pincus, 1999)

Emotion coaching significantly increased post intervention (p<.001, partial η2 = .15)Emotion dismissing significantly decreased post intervention (p<.001, partial η2 = .25)Child behaviour significantly improved post intervention ((p<.001, partial η2 = .09) No sig. differences were found on these measures for control group ppts.Havighurst, Wilson, Harley, Prior, and Kehoe (2010), Australia Tuning into Kids (TIK; see above for a description)Intervention group parents attended six weekly 2-hour sessions of the TIK program plus two booster sessions.Randomized controlled trial, between subjectsThe same sample as Havighurst, Wilson, Harley & Prior (2009) (n=216) was used.Parents completed:

• Difficulties in Emotional Regulation Scale (Gratz & Roemer, 2004)

• Maternal Emotional Style Questionnaire (Lagace-Seguin & Coplan, 2005) – adapted version including an Empathy/Connection scale.

• Observed emotion coaching – a subset of ppts (n=161) were videotaped at home

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during a structured parent-child story-telling task (Cervantes & Callanan,1998)

• Eyberg Child Behavior Inventory 6 (Eyberg & Pincus, 1999)

Child completed:• Peabody Picture Vocabulary Test III (Dunn & Dunn, 1997)

• Emotion Skills Task (Denham, 1986).

At six month follow up: Parent emotion coaching and parental empathy significantly increased (p<.001, d=1.08). Parents were significantly less dismissive of their child's emotions Waitlist control parents reported no significant changes on any of the measures. Intervention group children displayed enhanced emotional knowledge and fewer behavioural problems (p<.001, d=.57) compared to control group children. Havighurst et al. (2013), AustraliaTuning into Kids (TIK; see above for a description)Intervention group parents attended six weekly 2-hour sessions of the TIK program.Randomized controlled trial, between subjectsN = 54 mothersChildren aged between 4.0-5.11 years. 78% boys.Clinical sample – all children had externalising behaviour problemsRandomly allocated to intervention (n=31) or waitlist control group

Parents completed:• Difficulties in Emotional Regulation Scale (Gratz & Roemer, 2004)

• Maternal Emotional Style Questionnaire (Lagace-Seguin & Coplan, 2005) – adapted version including an Empathy/Connection scale.

• Observed emotion coaching – a subset of parent and children (n=161) were videotaped at home during a structured parent-child story-telling task (Cervantes & Callanan,1998)

• Eyberg Child Behavior Inventory 6 (Eyberg & Pincus, 1999)

Child completed:• Peabody Picture Vocabulary Test III (Dunn & Dunn, 1997)

• Emotion Skills Task (Denham, 1986).

Significant increases in parent empathy (p<.001, partial η2 =.28), emotion discourse and use of emotion labels were found compared to the waitlist control group. Parents were significantly less dismissive of their child's emotions Child behaviour significantly improved in both intervention and control group, however teacher-rated improvements were only observed for the children in the TIK program (p=.036, partial η2 =.16). Moretti, Holland, Moore, & McKay (2004), Canada Connect Parent Group Program aims to encourage a secure attachment between parents and adolescents with conduct disorder. Dedicates an entire session to developing parental empathy10-week psycho-educational program Pilot study, pre/post intervention, within subjectsN= 24 caregivers 16 adolescents aged between 13-16 (M=14.8). 50% male.Clinical sample – all adolescents diagnosed with conduct disorderParents completed:

• Child Behavior Checklist (Achenbach & Edelbrock, 1981)

Significant decreases were found in child externalising (p=.02, es=.25) and total behaviour difficulties (p=.02, es=.27) post-intervention.

Osbuth, Moretti, Holland, Braber, and Cross (2006), CanadaConnect Parent Group Program (see above for a description).10 week psycho-educational program

N = 48 caregivers Adolescents aged between 13-16 (M=14.51). 58% male.

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Clinical sample – adolescents with severe behavioural difficulties

Parents completed:• Childhood Report of Parenting Behavior (Schludermann & Schludermann, 1988)

• Parenting Sense of Competence Scale (Johnson & Mash, 1989)

• Comprehensive Adult-Parent Attachment Inventory (Moretti, McKay & Holland 2000)

• Family Adaptation and Cohesion Scales III (Olson et al., 1985)

• Child Behavior Checklist (Achenbach & Edelbrock, 1981)

Adolescents completed:• Youth Self-Report (Achenbach, 1991)

• Forms and Functions of Aggression (Little, Jones, Henrich, & Hawley, 2003)

Post intervention parental control practices significantly decreased and parenting satisfaction and competence significantly increased. Youth avoidance of caregivers significantly reduced.Parent reported adolescent behaviour problems (p<.001), including both internalising (p=.001) and externalising behaviours (p<.001) significantly reduced.Youth reported reduction in internalising behaviours (p<.05). *Note – effect sizes not provided.

Moretti & Osbuth (2009), CanadaStudy 1Connect Parent Group Program (see above for a description).10 week psycho-educational programWaitlist controlled study, within subjectsN= 20 caregivers Adolescents aged 12-16 (M=14.5). 65% maleClinical sample- adolescents with emotional and behavioural difficulties

Parents completed:• Parenting Sense of Competence Scale (Johnston & Mash, 1989)

• Child Behavior Checklist (Achenbach & Edelbrock, 1981)

• Treatment Engagement and Client Satisfaction (Moretti & Osbuth, 2009)

Parenting satisfaction and efficacy significantly increasedSignificant decreases in adolescent behaviour problems (p<.005, d=.64), including both internalising (p<.005, d=.63) and externalising difficulties (p<.011, d=.68). No significant changes were found on any measures during the four-month waitlist period. Findings were maintained at one year follow up and a further small decline was observed in adolescent’s behaviour problems (p<.019, d=.24).Moretti & Osbuth (2009), CanadaStudy 2Connect Parent Group Program (see above for a description).10 week psycho-educational program. Pre/post intervention, within subjectsN= 309 caregivers Adolescents aged 12-16 (M = 13.63). 56% maleCommunity sample Parents completed:

• Parenting Sense of Competence Scale (Johnston & Mash, 1989)

• Child Behavior Checklist (Achenbach & Edelbrock, 1981)

• Caregiver Strain Questionnaire (Brennan, Heflinger, & Bickman, 1997)

• Brief Child and Family Phone Interview (Cunningham, Pettingill, & Boyle, 2000)

• Conflict Tactics Scale- modified (Straus, 1979)

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• Affect Regulation Checklist (Moretti, 2003)

• Treatment Engagement and Client Satisfaction (Moretti & Osbuth, 2009)

Parenting satisfaction and perceived efficacy significantly increased post-intervention Significant reductions were observed in caregiver strain, caregiver aggression, youth behavioural problems (p<.001, d=.59), and youth aggression (p<.001, d=.74). Parents reported significant increases in their child’s ability to regulate affect, and improved quality of relationships.

Giannotta, Ortega & Stattin (2013), ItalyConnect Parent Group Program (see above for a description).10 week psycho-educational program. Pilot study, pre/post intervention, within subjectsN = 110 mothers 147 children aged 11-14 (M=12.46). 50% maleCommunity samplePpts who declined the intervention formed the control group (n=66).Parents completed:

• Parenting Sense of Competence Scale (Johnston & Mash, 1989)

• Eyberg Child Behavior Inventory (Eyberg & Ross, 1978)

• Parental Behavioral Control Scale (Kerr & Stattin, 2000)

• Parental Reactions Scale (Tilton, Weaver et al., 2010)

• Treatment Engagement and Client Satisfaction (Moretti & Osbuth, 2009)

Adolescents completed:• Alcohol and cigarette use questionnaire (Giannotta, Ortega, & Stattin, 2013)

Post intervention mothers reported a slight reduction in coldness and rejection compared to the control group (p=.11, d=.32) A moderate significant reduction in alcohol consumption among youths in the treatment group. No other significant results were found among any of the other measuresA high attrition rate was observed for both the intervention group (32%) and the control group (27%). Van Zeijl et al. (2006), Holland Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) -attachment based intervention that aims to increase maternal sensitivity, empathy, responsiveness and sensitive discipline towards the child. 6 week interventionRandomized controlled trial, between subjects N = 237 mothers 237 children aged 1-3. 56% boysClinical sample - children with externalising behaviour difficultiesRandomly allocated to intervention (n=120) or control group

Mothers completed:• Daily Hassles (Kanner, Coyne, Schaffer & Lazarus, 1981)

• Dutch Family Problems Questionnaire (Koot, 1997) – marital discord subscale used

• Cantrill Ladder (Cantrill, 1965)

• Infant Characteristics Questionnaire (Bates, Freeland, & Lounsbury, 1979)

• Child Behavior Checklist (Achenbach & Edelbrock, 1981).

• Maternal attitudes towards sensitivity and sensitive discipline (Bakermans-Kranenburg & Van IJzendoorn, 2003)

• Maternal sensitivity and maternal discipline - observed in laboratory sessions

Post intervention maternal sensitive discipline and attitudes towards maternal sensitivity and sensitive discipline improved. Modest significant reduction in child overactive behaviour (p<.01, partial η2 =.03), particularly for families with

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higher levels of daily hassles and marital discord. Changes in oppositional and aggressive behaviour were not observed.Edwards, Sullivan, Meany-Walen, and Kantor (2010) Child Parent Relationship Training (CPRT) aims to increase parental empathy, improve parent child relationships and develop parental ability and confidence 8 week interventionQualitative studyN= 5 parents5 children (ages and sex unknown)Community sample

• Researchers videotaped, transcribed and analysed all 8 training sessions

• Parents completed a post-intervention interview

Majority of parents reported an increased understanding and awareness of their children's needsParents noticed observed improvements in their child's behaviour, both at home and in school. Parents noted improvements in their parent-child interactions. Christopher, Saunders, Jacobvitz, Burton, and Hazen (2013), USA Positive Guidance – aims to build positive parent-child relationships, by reducing permissive parenting, explaining consequences and being responsive and emoathic to the child’s needs12-week intervention Pre/post intervention, within subjectsN = 49 parents49 children aged 2-3 (M=3)Community sample

• Observational coding of mother-child interaction – mothers rated on positive guidance, empathy, and permissiveness

• Observational coding of peer interactions – children rated on antisocial behaviours, physical aggression, verbal aggression, prosocial behaviours, positive social bids, and empathy

No significant main effect of intervention on child behaviour outcomesReduction in antisocial behaviours for children of low-empathy mothers post intervention (=-.59, t=-2.18, p=.037).

In order to address these limitations, Havighurst, Wilson, Harley, Prior, and Kehoe (2010) conducted a follow up study using the same sample to assess whether treatment effects were maintained six months later. A subset of participants (n=161) also participated in a videotaped observation of parents-child interactions during a structured story-telling task (Cervantes & Callanan, 1998) to assess parental emotion socialisation and child emotional knowledge. General Linear Modelling showed that, at six month follow up, parents reported utilising more emotion coaching strategies and emotion labels, being less dismissive of their child's emotions, and significantly increased empathy (d=1.08). Parents in the waitlist control group reported no significant changes on any of the measures. In addition, children with parents in the intervention group displayed enhanced emotional knowledge and fewer parent rated behavioural problems (d=.57) in comparison to control group children.

To assess whether these findings applied to a clinical sample, a third study was conducted with 54 caregivers in a clinical sample of children with externalising behaviour problems (Havighurst et al., 2013). As above, caregivers in the intervention group benefited from significant increases in empathy compared to the waitlist control group (partial η2 =.28). They were also less dismissive, used more emotion labels and engaged in more emotion discourse. Parents in both conditions reported improvements in child behaviour, however teacher-rated improvements were only observed for children whose parents participated in the TIK programme (partial η2

=.16). An advantage of these studies is the use of a control group to enable comparisons of treatment effects. Although, as there was no treatment comparison group, benefits

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gained may have been due to increased professional support as opposed to the TIK program itself. Another strength is the use of observation methods to assess child emotion knowledge and parent emotion coaching, which are likely to be more objective than self-report. In addition, all questionnaire measures used were psychometrically sound with satisfactory reliability. However, empathy was measured in study 2 and 3 by a five-item subscale of the Parental Emotional Style Questionnaire (an adapted version of the Maternal Emotional Style Questionnaire; Lagace-Seguin & Coplan, 2005). Although reliability for this subscale was satisfactory, with reliability coefficients of .67 (time 1), .82 (time 2), and .80 (time 3) it is unclear how valid the measure is as five items may be insufficient to detect true parental empathy. Furthermore, the third study had a small sample size, some missing data, and incomplete parental attendance. Moreover, all parents continued with their usual paediatric care during the study, which was not regulated, so the extent to which this supported or contradicted TIK strategies is unclear.Several parenting interventions identified that aimed to increase parental empathy were based on theories of attachment. One such intervention is the Connect Parent Group Program. This is a 10-week psycho-educational program that aims to increase parental empathy and encourage a secure attachment between parents and adolescents with conduct disorder. In a pilot study (n=16) conducted to evaluate the efficacy of the Connect Parent Group Program, Moretti, Holland, Moore, and McKay (2004) assessed child behaviour pre/post intervention using parent-report on the CBCL (Achenbach, 1991), which is a widely used measure with strong psychometric properties. The results showed a significant decrease in externalising (es=.25) and total behaviour difficulties (es=.27) following the intervention, although the study did not report what statistical tests were used to analyse the data which limits the findings.

In order to address the small sample size in the above study, Osbuth, Moretti, Holland, Braber, and Cross (2006) recruited an additional 32 caregivers and adolescents to the original sample. Following the intervention, caregivers reported utilising fewer parental control practices, and reported increases in parenting satisfaction and competence. Results also showed a reduction in adolescent behaviour problems (p<.001), including both internalising (p=.001) and externalising behaviours (p<.001) on the CBCL and youth reported reduction in internalising behaviours (p<.05) on the Youth Self-Report (Achenbach, 1991). All questionnaire measures used had satisfactory psychometric properties. However, effect sizes and the statistical tests used were not cited in this study to assess the magnitude of these effects. In addition, findings from these two studies should be interpreted cautiously due to the small sample size, self-report measures, and lack of control group or follow up data to see whether effects were maintained. To expand on these findings, Moretti and Osbuth (2009) conducted two additional studies. In the first study, caregivers of adolescents with clinically referred emotional and behavioural difficulties (n=20) were placed on a four-month waiting list before participating in the programme. Results from repeated measures general linear modelling showed that, post-intervention, parents reported significantly increased parenting satisfaction and efficacy and significant decreases in adolescent behaviour problems (d=.64), including both internalising (d=.63) and externalising difficulties (d=.68) on the CBCL. Importantly, no significant changes occurred on any of these measures during the waitlist period. In addition, these findings were maintained at one year follow up and a further small decline was observed in adolescent’s behaviour

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problems (d=.24).In the second study, 32 Connect programs were administered across 17 communities (n=309). Regression analyses indicated that parenting satisfaction and perceived efficacy significantly increased post-intervention and significant reductions were observed in caregiver strain, caregiver aggression, youth aggression (d=.74) and youth behavioural problems (d=.59) as measured on the Brief Child and Family Phone Interview (BCFPI; Cunningham, Pettingill, & Boyle, 2000), which has high convergence with the CBCL and has excellent psychometric properties. In addition, parents reported significant increases in their child’s ability to regulate affect, and improved quality of relationships. Maintenance of treatment effects in study 1 indicate that the Connect Program may result in long term changes, however the sample size was small in this study and, although the sample size was much larger in study 2, no follow up data was obtained to validate the long term effects of the programme. In addition, no control group was used in either study and both studies relied on parent self-report measures to assess change, which, despite all possessing sound psychometric properties, may be biased by demand characteristics. To explore whether the Connect Program would produce similar effects in a Mediterranean country, Giannotta, Ortega, and Stattin (2013) implemented the programme in a controlled trial in Italy. Following the intervention, ANCOVAs showed that mothers reported a slight reduction in coldness and rejection compared to those in the control group, however this failed to reach significance (p=.11, d=.32). In addition, there was a moderate significant reduction in alcohol consumption among youths in the treatment group. However, contrary to previous findings, no other significant results were found among any of the other measures and a high attrition rate was observed for both the intervention group (32%) and the control group (27%), which may have confounded the results. This modest effect size and high rate of attrition is likely due to cultural differences of implementing a programme in a country unfamiliar with receiving parenting interventions. All measures used had previously been found to be reliable and valid among an Italian sample apart from the ECBI (Eyberg & Ross, 1978) and the Parental Reactions Scale (Tilton, Weaver et al., 2010) both of which demonstrated satisfactory internal consistency in the current sample, however the validity of these measures in an Italian sample is unclear.

These findings indicate that the Connect Parent Group Program is a promising intervention for treatment of children with conduct disorder. Although parental empathy is not measured explicitly, the program does focus on empathy as one of its crucial components, and parental reports of increased child acceptance suggests that empathy increased in line with the aims of the intervention.

Another attachment-based intervention is the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD). This intervention aims to increase maternal sensitivity, empathy, responsiveness and sensitive discipline towards the child. Van Zeijl et al. (2006) conducted an RCT in order to assess the effectiveness of the parenting intervention with children with externalising behaviour difficulties. Repeated measures multiple analyses of variance from questionnaire and researcher observation data showed that, post-intervention, maternal sensitive discipline and attitudes towards maternal sensitivity and sensitive discipline improved. In addition, there was a modest significant reduction in child overactive behaviour (partial η2 =.03) on the CBCL, particularly for families whose parents reported higher levels of daily hassles and marital discord. However, changes in

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oppositional and aggressive behaviour were not observed, possibly due to the limited number of treatment sessions to tackle these more severe behaviours. A strength of this study is the randomized controlled design and use of observation measures to assess maternal sensitivity and discipline. However there was no follow up to see if treatment effects were maintained and the sample used was Caucasian and primarily from higher socio-economic backgrounds, therefore findings may not generalise to families from culturally or economically different backgrounds. In addition, it should be noted that attitudes towards sensitivity and sensitive discipline were measured on a questionnaire (Bakermans-Kranenburg & Van IJzendoorn, 2003) with low reliability (Cronbach’s = .54 and .58), which may have affected the results. Child Parent Relationship Training (CPRT) is an additional programme that aims to increase parental empathy as part of the treatment protocol for parents of children with behavioural difficulties. A qualitative study conducted by Edwards, Sullivan, Meany-Walen, and Kantor (2010) found that, following the 8-week CPRT intervention, the majority of parents reported an increased understanding and awareness of their children's needs, and noticed observed improvements in their child's behaviour, both at home and in school. Parents described changes in parenting practices from a more punitive to a more compassionate approach to their child's misbehaviour and noted improvements in their parent-child interactions. These reports suggest that parental empathy increased, which is in line with the goals of CPRT. However as empathy was not measured explicitly in this study this relationship cannot be confirmed.Furthermore, Christopher, Saunders, Jacobvitz, Burton, and Hazen (2013) found that low empathy mothers might benefit most from parenting interventions. Following a parenting intervention in positive guidance, findings from researcher observations showed that mothers rated as low in empathy who received hands on training (as opposed to seminar only training) benefited most from the intervention. Mixed model analyses showed that children of low-empathy mothers displayed fewer antisocial behaviours post intervention (=-.59). Mothers lacking in empathy may have benefited from learning practical skills that required them to take the perspective of their child. A strength of this study is the use of observation methods, rather than self-report, and that empathy was measured explicitly. However this study had a small sample size and no control group or third point follow up to see whether effects were maintained, which limits the findings.

Executive Functioning Table 2 provides a description of the studies included in the EF section of the review, including the measures used in each study. Eight studies were identified in the literature search that evaluated five different interventions aimed at improving EF skills among children and adolescents, in order to prevent or reduce child behavioural problems. Three of the studies identified evaluated the effects of the Promoting Alternative Thinking Strategies (PATHS; Kusche & Greenberg, 1994) programme with school children in the USA. PATHS is a curriculum implemented in schools that focuses on enhancing children’s social-emotional competence, problem solving skills and emotion regulation skills in order to reduce child behavioural problems.In the first study, Kam, Greenberg, and Kusche (2004) conducted a longitudinal RCT to evaluate the efficacy of the PATHS curriculum in

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133 children identified with special needs. Social and behavioural adjustment was assessed pre- and post-intervention and for two years follow up using interview and questionnaire measures, all of which possessed adequate reliability and validity. Following the PATHS intervention, a growth curve analysis indicated that there was a significant reduction in teacher-rated child externalising (d=.18) and internalising behaviour (d=.22) as rated by teachers on the CBCL and child-rated depressive symptoms (d=.49) compared to the control group. No significant group differences were found for social competence or social problem solving. In addition, effects were maintained at two-year follow up with increasing reductions in problem behaviour among PATHS children, whereas an increase in problem behaviour was observed in the control group. A second study utilizing a similar design aimed to explore possible mediating factors driving the efficacy of the PATHS curriculum. Riggs, Greenberg, Kusche, and Pentz (2006) proposed that inhibitory control and verbal fluency would mediate the relationship between the PATHS intervention and child behavioural improvements. Questionnaires and neuropsychological tests were administered among 318 students aged 7-9 pre-and post-intervention and at one-year follow up. All tests used were appropriate and possessed sound psychometric properties. Results from regression analyses showed that, following participation in the PATHS curriculum, children exhibited significantly fewer behavioural problems, both externalising (t= -3.26) and internalising (t= -2.23) as rated by teachers on the CBCL. Children also displayed improved inhibitory control measured using the Stroop Test (Golden, 1978) and improved verbal fluency on the McCarthy Scales of Children’s Abilities (McCarthy, 1971) in comparison to children in the control group. In addition inhibitory control was found to mediate the relationship between the intervention and child behavioural problems at one year follow up. However contrary to expectations, verbal fluency did not appear to be a mediating factor. To test whether similar behaviour changes would be found among preschool children, Domitrovich, Cortes, and Greenberg (2007) conducted a RCT implementing PATHS with 264 preschool children aged 3-4 enrolled in a Head Start programme for disadvantaged children. The PATHS curriculum was adapted slightly to fit the development abilities of preschool children. Similar to the studies above, findings from ANCOVAs indicated that, post-intervention, children demonstrated significantly improved emotion knowledge compared to those in the control group as measured on the Kusche Emotional Inventory (Kusche, 1984) and the Assessment of Children’s Emotions Scales (ACES; Schultz et al., 2001). They were also rated as being less withdrawn and more cooperative by teachers and having increased emotional and social competence as rated by both parents and teachers. However contrary to previous findings, no significant differences were found between groups on child behavioural assessment measures of inhibitory control,

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attention or problem solving, and neither teachers nor parents rated significant group differences on child externalising or internalising behaviour on the Preschool and Kindergarten Behavior Scales (Merrell, 1996). Table 2: Studies included within the EF section of the review

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Publication and CountryInterventionDesignSample (n, child age, child characteristics)Measures UsedMain FindingsKam, Greenberg, and Kusche (2004), USA Promoting Alternative Thinking Strategies (PATHS; Kusche & Greenberg, 1994) – school curriculum focused on enhancing children’s social-emotional competence, problem solving skills and emotion regulation skills PATHS taught in 20-30 minute lessons approximately 3 times per week for a school yearLongitudinal randomized controlled trial133 primary school children with special needsAge 6-8 years. 72% boys40% learning disabilities; 17% mild LD; 23% emotional & behavioural disorders; 16% physical disabilities; 4% multiple handicapsRandomly assigned to PATHS school curriculum or regular education

• Kusche Affective Interview (Kusche, Greenberg, & Beilke, 1988)• Social Problem Solving Interview (Greenberg & Kusche, 1988)• Children’s Depression Inventory (Kovacs, 1983)• Child Behavior Checklist – Teacher Report Form (Achenbach, 1991)• Teacher-Child Rating Scale – Social competence subscale (Hightower et al., 1986)

Significant reduction in teacher-rated child externalising (p<.05, d=.18) and internalising behaviour (p<.05, d=.22) and child-rated depressive symptoms (p<.05, d=.49) compared to control group. No significant group differences found for social competence or social problem solving.Two year follow up:Effects maintained plus further reductions in problem behaviour among PATHS children Problem behaviour increased in control groupRiggs, Greenberg, Kusche, and Pentz (2006), USA PATHS (Kusche & Greenberg, 1994) – see above for intervention descriptionPATHS taught in 20-30 minute lessons approximately 3 times per week for a school yearRandomized controlled trial318 primary school students Age 7-9 years (M=8.0). 50% boysRandomly assigned to PATHS school curriculum (n=153) or regular education (n=165)

• Weschler Intelligence Scale for Children- Revised (Weschler, 1974) - Vocabulary & Block Design subscales

• Stroop Test (Golden, 1978)• McCarthy Scales of Children’s Abilities (McCarthy, 1972) – Verbal Fluency Subtest• Child Behavior Checklist – Teacher Report Form (Achenbach, 1991)

Post intervention, significant reduction in behavioural problems, both externalising (t= -3.26, p<.01) and internalising (t= -2.23, p<.05) Improved inhibitory control and verbal fluency compared to control group Inhibitory control mediated relationship between intervention and child behavioural problems at one year follow up Domitrovich, Cortes, and Greenberg (2007), USA PATHS (Kusche & Greenberg, 1994) – adapted for preschool children. See above for intervention descriptionPATHS taught in lessons once per week plus extension activities for 9 monthsRandomized controlled trial 264 preschool children Children aged 3-4 years. 51% girlsAll children enrolled in Head Start program for disadvantaged childrenRandomly allocated PATHS school curriculum or waitlist control group

• Kusche Emotional Inventory (Kusche, 1984) – Recognition of Emotion Concepts subtest

• Assessment of Children’s Emotions Scales (Schultz et al., 2001)• Denham Puppet Interview (Denham, 1986)• Day/Night Inhibitory Control task (Diamond & Taylor, 1996)• Leiter-Revised Assessment Battery (Roid & Miller, 1997) – Attention

Sustained subtest• Challenging Situations Task (Denham, Bouril, & Belouad, 1994) –

Problem-solving subtest

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• Preschool and Kindergarten Behavior Scales (Merrell, 1996)• Head Start Competence Scale (Domitrovich, Cortes, & Greenberg,

2001)• Peabody Picture Vocabulary Test III (Dunn & Dunn, 1997)

Post-intervention, improved emotion knowledge compared to control group as measured on the Kusche Emotional Inventory (p<.01, es=.36) and the Assessment of Children’s Emotions Scales (p<.05, es=.37). Rated as less withdrawn and more cooperative by teachers Increased emotional and social competence as rated by both parents and teachers. No significant group differences for inhibitory control, attention, problem solving or behavioural problems. Bierman et al. (2008), USA Head Start REDI programme - designed for economically deprived children. Targets social-emotional competencies and cognitive skills including language and emergent literacy skillsIntervention taught in lessons, extension activities, teaching strategies & parent take-home materials across one year.Randomized controlled trial356 primary school childrenChildren aged 4 years. 54% girlsEconomically disadvantaged populationRandomly allocated into intervention or regular education control group

• Expressive One-Word Picture Vocabulary Test (Brownell, 2000)• Test of Language Development (Newcomer & Hammill, 1997) • Test of Preschool Early Literacy (Lonigan, Wagner, Torgesen, &

Rashotte, 2007)• Assessment of Children’s Emotion Skills (Schultz, Izard, & Bear,

2004)• Emotion Recognition Questionnaire (Ribordy, Camras, Stafani, &

Spacarelli, 1988)• Challenging Situations Task (Denham, Bouril, & Belouad, 1994)• Social Competence Scale (Conduct Problems Prevention Research

Group, 1995)• Teacher Observation of Child Adaptation – Revised (Werthamer-

Larsson, Kellam, & Wheeler, 1991)• Preschool Social Behavior Scale – Teacher Form (Crick, Casas &

Mosher, 1997)• ADHD Rating Scale (DuPaul, 1991)• Adapted Leiter-R Assessor Report (Roid & Miller, 1997)• Teacher ratings of learning engagement (Bierman et al., 2008)• Parent ratings of child language, communication and reading

engagement at home (Bierman et al., 2008)Child emotional competence and social problem solving improved post intervention compared to controls (es range = .21-.35)Teacher rated aggression, observer rated task orientation, and parent rated communication improved (es range = .25-.29)Child literacy and vocabulary scores significantly improved (es range = .15-.39)No significant group differences were found for any other measuresBierman, Nix, Greenberg, Blair, & Domitrovic, 2008, USAHead Start REDI programme – see above for intervention descriptionRandomized controlled trial356 primary school childrenChildren aged 4 years. 54% girlsEconomically disadvantaged populationRandomly allocated into intervention or regular education control group

• Backward word span task (Davis & Pratt, 1996)• Peg tapping task (Diamond & Taylor, 1996)• Dimensional Change Card Sorting (Frye et al., 1995)• Walk-a-line slowly task (Kochanska, Murray, Jaques, Koenig, &

Vandegeest, 1996)• Preschool Self-Regulation Assessment (Smith-Donald, Raver, Hayes,

& Richardson, 2007)• Expressive One-Word Picture Vocabulary Test (Brownell, 2000)• Test of Preschool Early Literacy (Lonigan, Wagner, Torgesen, &

Rashotte, 2007)• Social Competence Scale (Conduct Problems Prevention Research

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Group, 1995)• Teacher Observation of Child Adaptation – Revised (Werthamer-

Larsson, Kellam, & Wheeler, 1991)• Preschool Social Behavior Scale – Teacher Form (Crick, Casas &

Mosher, 1997)

Children’s baseline EF skills predicted language/emerging literacy ability and behavioural outcomes post intervention Children improved on working memory, inhibitory control, attention shifting, and task orientation (range between .20-.28)Self-regulation significantly mediated intervention effect on observer-rated social competence (29%) and aggression (43%)Greater improvements were found for children with poorer EF at baseline

Piehler et al. (2013), USAEarly Risers conduct prevention programme. Designed for children at risk of developing conduct problems. Aims to improve child skills, parent skills, child school support & family support.2 year programme Longitudinal randomized controlled trial137 formerly homeless families living in family supportive housingAll single parent families (98.5% single mothers)223 children aged between 6-12 years (M=8.12). 51% boys.Randomly allocated to intervention or treatment as usual controls

• Behavior Assessment System for Children (2nd Ed.) – Parent Rating Scale (Reynolds & Kamphaus, 2004)

Participation in intervention predicted EF growth (M= -.94; p=.001) EF growth predicted reduction in conduct problems (M= -.90, p<.001). EF fully mediated relationship between intervention and reduction in conduct problems.Daunic et al. (2012), USA Tools for Getting Along (TFGA) school curriculum. Targeted at developing social problem solving skills in children. 27 lessons administered 1-2 times per weekRandomized controlled trial1296 primary school children Children aged 9-10 years. 50.6% girls.Children matched and randomly allocated to intervention or regular education control group

• Problem-Solving Knowledge Questionnaire (Daunic et al., 2006)• Behavior Rating of Executive Function – Teacher Form (Gioia,

Isquith, Guy, & Kenworthy, 2000)• Clinical Assessment of Behavior – Teacher Rating Form (Bracken &

Keith, 2004)• Reactive-Proactive Aggression Scale (Dodge & Cole, 1987)• Anger Expression Scale for Children (Phipps & Steele, 2002)• Social Problem Solving Inventory – Revised (D’Zurilla, Nezu,

Maydeu-Olivares, 2002) Post intervention, students reported approaching problems more positively and utilising more rational problem solving style Children with poorer EF at baseline significantly improved on measures of problem-solving knowledge & teacher-reported EF skills Children with poorer EF at baseline showed significant reductions on measures of proactive aggression (p<.05, g=.09), trait anger (p<.01, g=.11) & anger expression (p<.01, g=.04) No significant changes found for teacher-rated internalising or externalising behaviourHealey & Halperin, 2014, New ZealandEnhancing Neurobehavioral Gains with the Aid of Games and Exercise (ENGAGE) programme. Aims to develop preschoolers’ self-regulation through use of games and exercises.5-week intervention. Games and exercised played 30 minutes daily (minimum) with parents Pilot study, pre/post intervention, within subjects25 families with ‘difficult to manage’ preschool children25 children aged 3-4 years (M=3.9). 76% boysChild’s hyperactivity < 92nd percentile on Behavior Assessment System for Children (Reynolds & Kamphaus, 2004)

• Behavior Assessment System for Children (Reynolds & Kamphaus, 2004)• Stanford Binet (Roid, 2003)• Developmental Neuropsychological Assessment (Korkman & Kirk, 2007)

Post intervention, parents reported significant reductions in child hyperactivity (p<.001, partial η2 =.397), attention

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problems (p<.001, partial η2 =.248) and aggression (p<.001, partial η2 =.240) Significant improvements observed in working memory and visuomotor precision errors Children with poorer EF at baseline showed the most treatment gainsTreatment gains maintained at 12 month follow up.

These findings may be due to the initial low rates of child problem behaviour prior to the intervention. It should also be noted that the ACES (Schultz et al., 2001) has low reliability (Cronbach’s = .59), although all other measures demonstrated sound psychometric properties. In addition, multi-level modelling at the classroom level may have been a more appropriate statistical test than using ANCOVAs conducted at the individual child level, however the study did not have sufficient statistical power to enable this.The findings from these three studies indicate that the PATHS curriculum may be a promising intervention for preventing and reducing child psychopathology. Strengths of these studies are the use of RCTs in order to evaluate the effectiveness of the PATHS program with an appropriate control group and adequate power. In addition, two of the three studies collected follow up data, which showed that treatment effects were sustained over time. The multi-methods of assessment and multiple reporters used in the studies also strengthen the findings. One limitation, however, is the reliance on teacher and parent reports of child behaviour rather than direct observations, which may have been biased by demand characteristics.The preschool PATHS curriculum has also been implemented as a component of the Headstart Research based Developmentally Informed (REDI) programme. This programme is designed for economically deprived children and targets social-emotional competencies and cognitive skills, including language and emergent literacy skills. To evaluate the efficacy of the Head Start REDI programme, Bierman and colleagues conducted two studies.In the first study, Bierman et al. (2008) randomly allocated 356 4-year-old children into intervention or a regular education control group. Multiple measures including teacher and parent reports and direct child assessments and observations were administered pre- and post-intervention. Hierarchical linear models found statistically significant improvements in child emotional competence and social problem solving among children who had participated in the REDI programme, although effect sizes were modest (range = .21-.35). In addition, parent rated child communication and observer rated task orientation also improved and a slight significant reduction in teacher-rated child aggression (p=.05, es=-.28) was observed in the intervention group, compared to controls. No other significant differences were found on any other measures. It should be noted that emotional competence was measured using the Assessment of Children’s Emotion Skills (Schultz, Izard, & Bear, 2004) and the Emotion Recognition Questionnaire (Ribordy, Camras, Stafani, & Spacarelli, 1988) which both have poor reliability (Cronbach’s = .57 and .63 respectively), however all other measures used were

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appropriate and psychometrically sound. The second study utilized the same sample and procedure as above, but collected five additional cognitive and behavioural measures of child EF, all of which possessed satisfactory psychometric properties, in order to investigate whether EF skill development moderated or mediated intervention effects (Bierman, Nix, Greenberg, Blair, & Domitrovich, 2008). Findings from hierarchical linear models indicated that children’s EF skills at baseline predicted both their language/emerging literacy ability and behavioural outcomes as rated by teachers on the Preschool Social Behavior Scale (Crick, Casas & Mosher, 1997) following the year long intervention. Children who participated in the REDI programme demonstrated improvements on two measures of EF (Dimensional Change Card Sorting; Frye et al., 1995 and the Preschool Self-Regulation Assessment; Smith-Donald, Raver, Hayes, & Richardson, 2007) that correspond to working memory, inhibitory control, attention shifting, and task orientation, although effect sizes were small (range between .20-.28). In addition, self-regulation was a significant mediator between the intervention and observer-rated social competence (29%) and aggression (43%). Furthermore, the intervention appeared to be of particular benefit to those children with greater EF deficits at baseline. These two studies have a number of strengths, including utilising a randomized controlled design and the use of multi-method assessments incorporating direct observations, which increases the validity of the results and reduces the potential bias found using questionnaire measures. However the use of multiple statistical tests applied in both studies is likely to have increased the risk of error. Follow up data would be useful to ascertain whether these findings are sustained following the intervention. Another programme shown to improve EF and reduce child conduct problems is the Early Risers conduct prevention programme. This two-year preventative programme was created for children at risk of developing conduct problems and targets multiple risk factors by improving child skills, parent skills, child school support, and family support. In a study by Piehler et al. (2013), formerly homeless families (n=223) and their children aged 6-12 years were recruited to take part in the programme.To examine the effects of the programme, conduct problems and EF was measured through parent-report using the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 2004) at four time points across three years. This longitudinal data collection allowed the researchers to assess the trajectory of child EF and conduct problems and to examine any mediating effects of EF or conduct problems. However, the reliance on parent-report to measure EF, and not neuropsychological tasks, may have limited the findings due to the subjective nature of self-report measures, which could have been influenced by demand characteristics. In addition EF was solely measured by a 10-point scale on the BASC, which may not fully access the

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complexity of EF, although it has been found to be a reliable and valid measure (Reynolds & Kamphaus, 2004). Results using a latent growth model indicated that participation in the Early Risers programme predicted EF growth (M= -.94), which predicted reduced growth in conduct problems (M= -.90). EF was found to fully mediate the relationship between intervention associated changes and conduct problems for the duration of the study. These findings indicate that developing skills in EF may help to prevent and reduce later conduct problems.The Tools for Getting Along (TFGA) curriculum is another intervention targeted at preventing and reducing child behavioural problems by developing social problem solving skills in children. Daunic et al. (2012) evaluated the efficacy of the TGFA programme in a large-scale matched RCT with 1296 school children. Mulitilevel modeling indicated that, post-intervention, students reported increases in rational problem solving and a greater tendency to approach problems positively. Students with poorer EF at baseline benefited most from the programme, with significantly increased problem-solving knowledge on the Problem-Solving Knowledge Questionnaire (Daunic et al., 2006) and teacher-reported EF skills using the Behavior Rating of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000). Significant reductions were also observed on measures of proactive aggression (g=.09), trait anger (g=.11) and anger expression (g=.04). However, no change was found in teacher-rated internalising or externalising behaviour measured using the Clinical Assessment of Behavior form (Bracken & Keith, 2004), as was hypothesized. An advantage of this study is the large sample size employed, however the use of multiple statistical tests may have increased the chance of error. In addition, teachers who implemented the intervention also completed the assessment measures, which may have led to bias due to expectancy effects. Furthermore, the Problem-Solving Knowledge Questionnaire (Daunic et al., 2006) had low reliability (Cronbach’s = .48 pretest and .67 posttest) in the current sample, which may have impacted on the results. All other measures used were appropriate and psychometrically sound.

An additional novel intervention designed to enhance EF skills among children is the Enhancing Neurobehavioral Gains with the Aid of Games and Exercise (ENGAGE) programme (Healey & Halperin, 2014). This programme aims to develop preschoolers’ self-regulation through the use of games and exercises played for at least 30 minutes daily with parents over a five-week period. In a preliminary study to test the efficacy of the programme, analysis of variance showed parents reported significant reductions in child hyperactivity (partial η2 =.397), attention problems (partial η2 =.248) and aggression (partial η2 =.240) on the BASC (Reynolds & Kamphaus, 2004) following the intervention (Healey & Halperin, 2014) . Significant improvements were also observed in working memory and visuomotor precision errors on two neurocognitive measures (Stanford Binet; Roid, 2003 & Developmental Neuropsychological Assessment; Korkman & Kirk, 2007). In addition, those who exhibited greater EF deficits at baseline appeared to benefit most from the ENGAGE program, and treatment gains were maintained at 12 month follow up. However, the findings are limited by the lack of a randomized matched control group, small sample size, and use of parent-report, which may have been subject to bias as parents were involved in the intervention.

Discussion

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The aim of this review was to focus on parental empathy and EF as two potential mediating factors in the relationship between CPS and child outcomes. It explored literature published within the last ten years to see whether interventions aimed at increasing parental empathy and enhancing child EF skills reduced child behavioural difficulties. Evidence from the reviewed studies suggests that interventions targeted at increasing parental empathy and enhancing EF skills led to improved behavioural outcomes among children and adolescents.

Parental Empathy There is a growing evidence base to suggest that low parental empathy is associated with poorer child outcomes (Curtner-Smith et al., 2006; Psychogiou et al., 2008; Rodriguez, 2013), whereas high parental empathy has been linked with child prosocial behaviour (Farrant et al., 2012; Strayer & Roberts, 2004). The findings from this review indicate that parenting interventions targeted at increasing parental empathy may help to improve child behaviour. Only one study evaluated an intervention that was focused solely on increasing parental empathy (Flory, 2004). This study found that just through changing parental negative attributions of child misbehaviour and increasing parental empathy there was a significant reduction in child psychopathology. The remaining studies reviewed interventions that focused on increasing parental empathy in addition to improving other parenting practices. The results from these studies found significant reductions in child behavioural problems following the interventions. Furthermore, Christopher et al. (2013) found that low empathy mothers may benefit most from parenting interventions. To date, there has been no study that has measured whether empathy increases among adults utilising the CPS approach, however, as this is one of the primary aims of CPS, this is presumed to be the case. In line with the literature above, if the CPS intervention increases parental empathy (as proposed by Ashworth et al., 2012), and evidence suggests that increasing parental empathy is associated with improved child behavioural outcomes, it follows that parental empathy may mediate the relationship between the CPS approach and child outcomes.

Executive Functioning There is currently a convincing evidence base to suggest that EF plays an important role in facilitating behavioural regulation in children (Schoemaker et al., 2013; Brunton & Hartley, 2013; Enns et al., 2007, 2008) and can be a causal factor in later problem behaviour (Martel et al., 2007; Hughes & Ensor, 2008). This is supported by the findings from this review, which indicate that interventions aimed at enhancing EF in children can result in significant reductions in child externalising and internalising behaviour. Studies also found improvements in child emotional and social competence, problem solving skills and EF skills including working memory, inhibitory control, attention shifting, verbal fluency and task orientation. Furthermore, several studies found that EF interventions appeared to be of most benefit for children with greater EF deficits at baseline. This supports the CPS theory that children who display externalising and internalising behavior do so because of skills deficits that prevent them from responding adaptively to a given situation. The authors of CPS propose that the regular use of ‘Plan B’ conversations helps children develop these lagging skills. Therefore, as CPS aims to enhance child EF, and evidence suggests that

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improvements in EF are associated with reduced child conduct problems, it is likely that EF development is also a mechanism of change in the CPS model.

Limitations There are a number of issues that must be considered when interpreting the findings from these studies. Firstly, only one of the parental empathy intervention studies reviewed targeted increasing parental empathy in isolation, and this study did not measure whether parental empathy actually increased as a result of the intervention, therefore the findings cannot be definitively attributed to this (Flory, 2004). All other intervention studies reviewed were targeted at increasing empathy in addition to improving other aspects of parenting. Therefore it is unclear whether increases in empathy led to the observed effects or whether these effects were due to other elements of the intervention. Secondly, the majority of the outcome measures used to evaluate interventions relied on parental- and self-report measures, which are open to bias as participants may wish to respond in a social desirably manner or report what they think is expected of them. This was highlighted by Rodriguez (2013), who found a discrepancy between empathy measured behaviourally and self-reported empathy, with lower empathy found behaviourally than was disclosed using a self-report measure. Future research would be advised to consider using behavioural methods instead of relying on self-report measures that may be misrepresentative. Thirdly, among the parental empathy literature, five different interventions were evaluated, all of which targeted a number of different parenting practices in addition to empathy, which made it difficult to make comparisons between studies. Similarly, due to the broad range of cognitive domains that EF covers, the interventions evaluated in this review differed in their focus. Some measured overall EF, whereas others focused on specific areas of EF such as working memory, planning and inhibition. Due to this, findings were often difficult to compare and generalize. Furthermore, examination of other mediating factors was beyond the scope of this review. A number of other possible mediators may also play a role in the outcomes of CPS. For example, other areas of adaptive functioning such as language processing, cognitive flexibility, emotion regulation and social skills, were all omitted for reasons of limited space. However all of these are expected to improve as a result of CPS and may mediate the relationship between intervention and outcome. It should be noted that within the CPS framework these five cognitive domains are viewed as separate functions, however in some studies included in this review, EF encompassed these skills. Empathy was also limited to studies of parental empathy, and did not consider teachers or mental health staff. In addition, parenting factors such as warmth, parenting style, or parenting stress may be influential. Research has found that CPS can lead to a reduction in parenting, teaching and mental health staff stress, which may help to reduce child conduct problems by creating a calmer, stress free environment (Greene et al., 2004; Epstein & Saltzman-Benaiah, 2010; Schaubman, et al., 2011).

Clinical Implications and Future Research The findings from this literature review have important clinical implications. Interventions aimed at increasing parental empathy and enhancing EF skills were both associated with improvements in child behaviour. In addition, previous research has indicated that both low parental empathy and EF deficits are related to increased child internalising and externalising behaviour problems. These findings indicate

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that increasing parental empathy and promoting EF development should be a critical target in interventions aimed at reducing or preventing conduct problems. Fostering empathy in parents helps a child to feel understood and valued (Kohut, 1977). The majority of intervention studies did not investigate whether parental empathy increased following the intervention, and the studies that did, did not explore whether this increase drove the reduction in child behavioural problems. Therefore future research exploring whether parental empathy mediates the relationship between intervention and child outcomes may be beneficial. In addition, despite the wealth of research to suggest that child EF plays an important role in child functioning, there is a scarcity of interventions focused on enhancing EF skills. EF deficits have been found to be independently associated with behavioural problems at the age of 4 years (Hughes & Ensor, 2008). Thus, identifying EF deficits in preschool children as a precursor to future aggressive or antisocial behavior, and developing more early interventions for these at risk children, may help to prevent future behavioural problems developing (Piquero, 2001). CPS is an intervention used with children and adolescents displaying internalising and externalising behaviour across a variety of different settings. Although there is a growing evidence base for the efficacy of CPS in reducing child behavioural problems, there is currently no research into what is driving these changes. This literature review proposed parental empathy and EF as two factors that may mediate the relationship between CPS intervention and child behavioural outcomes. However, as mentioned, a range of other factors may also be influential. Future research is required to explore possible mediators and moderators that influence CPS outcomes, in order to develop a greater understanding of the model. In addition, such studies may have clinical implications for other interventions aimed at reducing or preventing conduct problems, by identifying what key factors are required for healthy child functioning.

ConclusionReview of the evidence has indicated that interventions aimed at increasing parental empathy and enhancing child EF can lead to a reduction in conduct problems and improved outcomes among children and adolescents. As increasing parental empathy and developing EF skills are both targeted in the CPS model, it follows that these two factors ought to mediate the observed relationship between CPS intervention and improved outcomes. To date, no studies have been conducted into what factors may drive the observed effects of CPS. Future research exploring potential mediating factors will help increase understanding of the mechanisms of change underlying the CPS model and may identify critical aspects required for healthy child and adolescent development.

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Riggs, N. R., Greenberg, M. T., Kusche, C. A., & Pentz, M. A. (2006). The Mediational Role of Neurocognition in the Behavioral Outcomes of a Social-Emotional Prevention Program in Elementary School Students: Effects of the PATHS Curriculum. Prevention Science, 7, 91-102.

Rodriguez, C. M. (2013). Analog of Parental Empathy: Association with Physical Child Abuse Risk and Punishment Intentions. Child Abuse & Neglect, 37, 493-499.

Schaubman, A., Stetson, E., & Plog, A. (2011). Reducing Teacher Stress by Implementing Collaborative Problem Solving in a School Setting. School Social Work Journal, 35, 72-93.Schoemaker, K., Mulder, H., Deković, M., & Matthys, W. (2013). Executive Functions in Preschool Children with Externalizing Behavior Problems: A Meta-Analysis. Journal of Abnormal Child Psychology, 41, 457-471. Snow, N. E. (2000). Empathy. American Philosophical Quarterly, 37, 65-78. Stewart, S. L., Rick, J., Currie, M., & Rielly, N. (2009). Collaborative Problem-Solving Approach in Clinically-Referred Children: A Residential Program Evaluation. A Final Report Submitted to the Centre of Excellence in Children’s Mental Health, Children’s Hospital of Eastern Ontario, September 30, 2009. Strayer, J., & Roberts, W. (2004). Children's Anger, Emotional Expressiveness, and Empathy: Relations with Parents’ Empathy, Emotional Expressiveness, and Parenting Practices. Social Development, 13, 229-254.

Van Zeijl, J., Mesman, J., Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer, F., Stolk, M. N., . . . Alink, L. R. (2006). Attachment-Based Intervention for Enhancing Sensitive Discipline in Mothers of 1- to 3-Year-Old Children for Externalizing Behavior Problems: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, 74, 994-1005.

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Appendix AJournal of Child and Family Studies: Guidelines for Authors

Guidelines for Authors

Journal of Child and Family Studies

GeneralIn general, the journal follows the recommendations of the 2010 Publication Manual of the American Psychological Association (Sixth Edition), and it is suggested that contributors refer to this publication. The research described in the manuscripts should be consistent with generally accepted standards of ethical practice. The anonymity of subjects and participants must be protected and identifying information omitted from the manuscript.

Manuscript SubmissionThe Journal uses Editorial Manager™ as its submission and peer review tracking system. All authors are required to register as a new user with Editorial Manager the first time they login in to the system. Straightforward login, registration procedures and step-by-step instructions for submitting manuscripts can be found on the website. Authors can use the Editorial Manager to track the review of their manuscripts in real time.

All authors should submit their manuscripts online. Manuscript submissions to the Journal should be prepared electronically and submitted in a standard word processing format. Microsoft Word® is preferred. Electronic submission substantially reduces the editorial processing and reviewing times, and shortens overall publication times. Please connect directly to the site: http://jcfs.edmgr.com and upload all of your manuscript files following the instructions given on the screen.

Suggested Reviewers

Authors of research and review papers, excluding editorial and book review submissions, should provide the names and contact information for four possible reviewers of their paper. The suggested reviewers should be authorities in the research field of the submission who can provide unbiased and fair evaluation of the authors’ work. The authors may also request that a particular researcher may not be considered a reviewer because of a conflict of interest. Colleagues from the authors’ institution(s) may not be included as possible reviewers. One or more of these suggested reviewers may be selected by the Journal as reviewers, but the final choice of reviewers for any submission remains the prerogative of the Editor-in-Chief and the Associate Editors of the Journal.

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Publication PoliciesThe Journal considers manuscripts for publication with the understanding that they represent original material and have not been published, submitted or accepted elsewhere, either in whole or in any substantial part. Each manuscript should report sufficient new data that makes a significant contribution to its field of research; thus, the submission of small amounts of data from a larger study or research project for divided publications would be inappropriate. A statement transferring copyright from the authors (or their employers, if they hold the copyright) to Springer Science+Business Media, Inc. will be required before the manuscript can be accepted for publication. Such a written transfer of copyright, which previously was assumed to be implicit in the act of submitting a manuscript, is necessary under the U.S. Copyright Law in order for the publisher to carry through the dissemination of research results and reviews as widely and effectively as possible.

Authors can expect a decision usually within 8 to 10 weeks. Reviewers comments are sent with the decision. Accepted papers are subject to editorial revisions and copyediting. However, the contents of the paper remain the responsibility of the author.

Double-Blind Peer ReviewAll submissions are subject to double-blind peer review. In general, experimental/research studies are judged in terms of the following criteria: originality, contribution to the existing research literature, methodological soundness, and readability.

When you are ready to submit a manuscript to JCFS, please be sure to upload these 2 separate files to the Editorial Manager site to ensure timely processing and review of your paper:

• A title page with no running head, manuscript title, and complete author information. Followed by the Abstract page with keywords and the corresponding author e-mail information.

• The blinded manuscript containing no author information (no name, no affiliation, and so forth).

Manuscript StyleAll manuscripts should be formatted to print out double-spaced at standard 8" x 11" paper dimensions, using a 10 pt. font size and a default typeface (recommended fonts are Times, Times New Roman, Calibri and Arial). Set all margins at one inch, and do not justify the right margin. Double-space the entire manuscript, including title page, abstract, list of references, tables, and figure captions. After the title page, number pages consecutively throughout including the reference pages, tables, and figure legends. The average article length is approximately 30 manuscript pages. For manuscripts exceeding the standard 30 pages, authors should contact the Editor in Chief, Nirbhay N. Singh directly at [email protected].

The Journal encourages the publication of research that is virtually jargon-free and

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easy to read. Thus, a personalized manuscript, written in active tense, is preferred. For example, “This study examined . . .” could be stated as, “We examined . . .” The Journal encourages a conversational rather than an impersonal tone in the manuscripts. Hypotheses should be written as a part of the last paragraph of the Introduction and not in bullet form. All reference to the study being reported should be consolidated in the last (or, if necessary, the last and penultimate) paragraph of the Introduction and not scattered throughout the introductory section.

Title PageA title page is to be provided and should include: (1) the title (maximum of 15 words); (2) full names of the authors (without degree), with a bullet between the names of the authors; (3) brief running head; and, at the bottom of the title page, (4) the corresponding author’s initials and last name (without degree), affiliation, mailing address, and e-mail address. The initials and last name of all authors should be listed as well. All authors from the same institution should be listed together, with a bullet separating the names. For all, but the corresponding author, list the affiliation, city and state only.

AbstractThe abstract should be between 200 and 250 words. It should be concise and complete in itself without reference to the body of the paper. In addition to a general statement about the field of research as the first sentence, abstracts of experimental/research papers should contain a brief summary of the paper's purpose, method (design of the study, main outcome measures, and age range of subjects), results (major findings), and clinical significance. Abstracts of review papers should include a general statement about research area being reviewed as the first sentence, it should contain a brief summary of the review's purpose, method (data sources, study selection process), results (methods of data synthesis and key findings), and conclusions (summary statement of what is known, including potential applications and research needs). Do not use sub-headings and do not cite data or references in the abstract.

Key WordsA list of 5 key words is to be provided directly below the abstract. Key words should express the precise content of the manuscript, as they are used for indexing purposes.

TextText should begin on the second numbered page. Authors are advised to spell out all abbreviations (other than units of measure) the first time they are used. Do not use footnotes to the text. When using direct quotations from another publication, cite the page number for the quotation in the text, immediately after the quotation. When reporting statistically significant results, include the statistical test used, the value of the test statistic, degrees of freedom, and p values. In the discussion include an evaluation of implications (clinical, policy, training or otherwise) of the study when appropriate. Also, discuss limitations in study design or execution that may limit interpretation of the data and generalizability of the findings. Do not use any sub-headings in the Introduction or Discussion sections.

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FootnotesNo footnotes are to be used.References Cited Within the TextCite references in alphabetical order within the text.

ReferencesThe accuracy of the references is the responsibility of the authors.List references alphabetically at the end of the paper and refer to them in the text by name and year in parentheses. References should include (in this order):• last names and initials of all authors, year published (in brackets), title of article, name of publication, volume number and inclusive pages

Do not include issue numbers of journals unless each issue begins with page 1. For book chapters, include volume number (if applicable) and page numbers, as shown below.

Consult the Publication Manual of the American Psychological Association, 6th Edition (Chapter 7) for formatting references. The style and punctuation of the references should conform to strict APA style – illustrated by the following examples:

• Journal Article:Roelofs, J., Meesters, C., & Muris, P. (2008). Correlates of self-reported attachment (in)security in children: The role of parental romantic attachment status and rearing behaviors. Journal of Child and Family Studies, 17, 555-566.

Book:McBee, L. (2008). Mindfulness-based elder care: A CAM model for frail elders and their caregivers. New York: Springer.

Book Chapter:Singh, N.N., Winton, A.S.W., Singh, J., McAleavey, K., Wahler, R.G., & Sabaawi, M. (2006). Mindfulness-based caregiving and support. In J.K. Luiselli (Ed.), Antecedent assessment and intervention: Supporting children and adults with developmental disabilities in community settings (pp. 269-290). Baltimore, MD: Paul H. Brookes.

TablesTables follow the Reference section. Create tables using the table creation and editing feature of your word processing software (e.g., Word) instead of spreadsheet programs. Tables that are a single column are actually lists and should be included in the text as such. Number tables consecutively using Arabic numerals in order of appearance in the text. Cite each table in the text and note approximately where it should be placed. Type each table on a separate page with the title and legend included. Double-space the table and any footnotes to it. Set each separate entry in a single table cell. Do not use underlining. Properly align numbers, both horizontally

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and vertically. Use brief headings for columns. If abbreviations are necessary, define them in a key at the bottom of the table. Keep footnotes to a minimum; if necessary, use superscript letters to denote them.

FiguresFigures follow the tables. Figures must be submitted in electronic form. Figures and illustrations (photographs, drawings, diagrams, and charts) are to be numbered in one consecutive series of Arabic numerals.

Page ChargesThe Journal makes no page charges. Reprints are available to authors, and order forms with the current price schedule are sent with proofs.

Books for ReviewBooks for review should be sent to Nirbhay S. Singh, 7401 Editor/JCFS, Sparkleberry Lane, Chesterfield, VA 23832.

Does Springer provide English language support?Manuscripts that are accepted for publication will be checked by our copyeditors for spelling and formal style. This may not be sufficient if English is not your native language and substantial editing would be required. In that case, you may want to have your manuscript edited by a native speaker prior to submission. A clear and concise language will help editors and reviewers concentrate on the scientific content of your paper and thus smooth the peer review process.

The following editing service provides language editing for scientific articles in all areas Springer publishes in:

• Edanz English editing for scientists

Use of an editing service is neither a requirement nor a guarantee of acceptance for publication.

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Clinical Experience

1. Adult Community During my first year, I completed a year long placement in an adult community mental health team. My supervisor’s main model of therapy was Cognitive Behavioural Therapy (CBT) and this year enabled me to gain a good grounding in applying CBT to a range of different mental health disorders including schizophrenia, depression, panic disorder and OCD. I was also able to complete a piece of trauma work using imagery rescripting with an adult man with autism who had experienced a number of traumatic events as a child. During this placement I also gained experience co-facilitating a 10-week CBT for bi-polar group, which helped me to gain confidence in delivering group interventions. In addition I developed my abilities in conducting neuropsychological assessments, completing two WAIS-IV assessments with individuals who had suspected learning difficulties. I completed a presentation on insomnia to the team, which helped me to learn more about treating sleep difficulties.

2. Child and Adolescent My second placement was split between a Child and Adolescent Mental Health Team (CAMHS) a youth offending team and an assessment service. The assessment service was a new gateway service that assessed all children and adolescents referred for mental health difficulties in the catchment area. If mental health difficulties appeared mild upon referral children and their families were offered 1-3 sessions of brief solution focused therapy, and if more severe they were given a full assessment in which it would be decided wither to refer to CAMHS, or alternative services such as Tier 2, Tier 4, or charity services. This placement gave me confidence in completing thorough assessments and formulating with children and adolescents. I also gained experience in working within a reflective team providing brief solution focused therapy. Within CAMHS I gained experience working with children aged 6 to 17 years, using CBT to treat OCD, generalized anxiety and depression. The youth offending team helped me to gain experience working with youths who were hard to engage, in longer-term therapy, in which the main aim was to try to engage the youths and to develop a therapeutic alliance with them, to give them the space to talk about their difficulties. I also gained experience of using the WISC-IV and WIAT with children and adolescents with suspected learning difficulties.

3. Older AdultsMy older adults placement was in a challenging behaviour team. The majority of patient’s referred to the team had diagnoses of dementia and were presenting with challenging behaviour. Here I gained experience of working systemically with patient’s families and care homes. This involved leading staff therapeutic network meetings, consulting with staff individually, liaising with the patient’s families and also completing some individual narrative therapy with patients. I also gained experience of neuropsychological assessments used with patient’s with suspected dementia, including the WAIS-IV, WMS, RBANS and TOPF. On this placement I also gained experience of using narrative therapy with a woman with schizophrenia on an older adults inpatient ward. My older adults placement helped me to develop

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experience of working with people with physical difficulties that impact upon their mental health, and how to address this within assessments and intervention.

4. Specialist – Eating DisordersMy specialist placement was split between an adult outpatient and inpatient eating disorder service. Within the outpatient service the majority of my work was using CBT for eating disorders (CBT-E) with patients with bulimia. I also co-facilitated several sessions of a ‘Steps to Change’ group with patients with anorexia nervosa who were considering treatment. I gained experience of assessing individuals with eating disorders, and I also completed an extended assessment and formulation of a woman with co-morbid OCD and anorexia. On the inpatient ward, I worked individually with one patient with body image difficulties and used CBT with one patient who had anorexia with co-morbid OCD. I also conducted an extended assessment and attended daily therapeutic community meetings. In addition I completed an audit of how patients and staff view outcome measures on the ward. The outcomes of this audit were presented in a poster presentation at the Eating Disorder International Conference.

5. Learning DisabilityMy final placement was in a community learning disability team. During this placement I gained experience of working systemically with people with learning disabilities presenting with a range of difficulties including psychosis, depression, anxiety, and challenging behaviour. I completed individual therapy with two patients (one using narrative techniques and the other brief solution focused therapy). The rest of my work involved working systemically through facilitating network meetings with the system around the patient. I also gained experience of assessing patients with suspected autism and learning difficulties, and adapting my verbal and written communication to engage with patient’s with communication difficulties.

PSYCHD CLINICAL PROGAMMETABLE OF ASSESSMENTS COMPLETED DURING TRAINING

Year I Assessments

Assessmenttitle

WAIS-IIIShort report of WAIS-III data and practice administrationPractice Case ReportCognitive behavioural therapy with a man presenting with symptoms of obsessive compulsive disorderProblem Based Learning – Reflective AccountPBL Reflective AccountMajor Research Project Literature ReviewAre Parental Empathy and Executive Functioning Mechanisms of Change in the Collaborative Problem Solving Model? Adult – Case Report 1Behavioural Activation and Imagery Rescripting with an adult male presenting with

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symptoms of depressionAdult – Case Report 2Cognitive Behavioural Therapy with an adult woman presenting with symptoms of psychosisMajor Research Project ProposalInvestigating Mechanisms of Change in the Collaborative Problem Solving Model

Year II Assessments

assessmenttitle

Service Related ProjectA service evaluation investigating clinicians’ workload and the nature of cases seen within a child and youth mental health assessment serviceProfessional Issues EssayPeople with learning disabilities can experience institutional discrimination in health and social care services. How do you envisage changing this culture in your role as a clinical psychologist?Problem Based Learning – Reflective AccountPBL Reflective AccountChild and Family– Case ReportSystemic Family Consultation with the family of a 6 year-old boy with autism presenting with emotion regulation and behavioural difficultiesPersonal and Professional Learning Discussion Groups – Process AccountProcess Reflective AccountOlder People – Oral Presentation of Clinical ActivityStaff Consultation and narrative therapy with an elderly woman presenting with challenging behaviour in a care home

Year III Assessments

assessmenttitle

Major Research Project Empirical PaperInvestigating Mechanisms of Change in the Collaborative Problem Solving Model Personal and Professional Learning – Final Reflective AccountOn becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of trainingPeople with Learning Disabilities– Case ReportA cognitive and functional assessment of a woman in her late twenties with a suspected learning disability