parent and family skills training in targeted prevention programs for at-risk youth

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The Journal of Primary Prevention [jpp] HS091-100 July 4, 2000 14:29 Style file version Nov. 19th, 1999

The Journal of Primary Prevention, Vol. 21, No. 2, 2000

Parent and Family Skills Training in TargetedPrevention Programs for At-Risk Youth

John E. Lochman1,2

The first part of this paper provides an overview for targeted preventive interven-tions using parent and family skills training with high risk children. The typicalformat and goals of these programs are presented. Empirically-examined parenttraining programs have either been delivered to the parents alone, to the parentsand children in separate group meetings, or to the parents and children together insessions for at least part of the time. An overview of findings from research on theseprograms indicates that these programs have consistent and replicated effects onchildren’s behavior, on parents’ improved use of effective discipline strategies, andon improved family functioning.

The second major part of this paper describes gaps in existing research knowl-edge about indicated prevention programs are then identified, and the barriersand opportunities involved in the implementation of empirically-supported arediscussed. Finally, the paper provides a series of recommendations for future re-search, knowledge development and policy development.

KEY WORDS: parent training; prevention; substance abuse.

Parent management training is one of the most widely used and most ex-tensively tested of all the intervention techniques for children with aggressivebehavior and conduct disorder (Frick, 1998), and has emerged as a key methodfor indicated preventive intervention projects designed to reduce the risk for ado-lescent substance use and abuse. “Indicated prevention” programs are designedto identify individuals who are at risk for a later negative outcome, such as sub-stance abuse. These interventions are designed to alter the mutable processes (e.g.,social-cognitive processes, parenting skills) which mediate the expression of therisk marker and of the later negative outcome meant to be prevented (Institute of

1The University of Alabama.2Address correspondence to John E. Lochman, Ph.D., Department of Psychology, Box 870348, TheUniversity of Alabama, Tuscaloosa, AL 35487; e-mail: [email protected].

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0278-095X/00/1200-0253$18.00/0C© 2000 Human Sciences Press, Inc.

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Medicine, 1994) for targeted high risk children. Thus, the aim of targeted, indi-cated prevention programs using parent and family skill training is to reduce riskfactors for substance use by providing family members with new skills.

Risk factors for studies examining the effects of these programs have typicallyincluded aggressive, antisocial and other disruptive problem behaviors of children,and sometimes of their parents. Longitudinal research has indicated that children’saggressive behavior is a significant predictor of adolescent substance use (e.g.,Lochman & Wayland, 1994), and that interventions with aggressive, disruptivechildren may serve to prevent adolescent substance use. A critical strength of thisapproach to parent and family skills training is its basis in empirically-groundedunderstanding of parenting behaviors which influence children’s problem behav-ior. Research has consistently found that parents of aggressive children displaymore harsh punishment, poorer monitoring, and less warmth and involvementthan parents of nonaggressive children, and that these parenting factors change inimportance at different developmental periods for children (Lochman, in press).Harsh parenting is a highly significant contributor to the development of aggres-sive behavior patterns in early childhood, but once started, aggressive behavior atone point in time is a better predictor of children’s subsequent aggression than isparents’ harshness. By the middle school years, parental monitoring becomes themost significant parenting skill in helping children from becoming involved witha deviant peer group, and from engaging in progressively more substance use andother antisocial behavior (Fletcher et al., 1995).

Throughout the child and adolescent years, low levels of parental warmthand involvement are associated with children’s aggressive behavior. However, aschildren’s behavior becomes increasingly aversive, parents respond in part by be-coming progressively less positive towards their children (Kandel and Wu, 1995).Thus, these developmental changes in familial behaviors need to be incorporatedinto plans for parent and family training programs. Ultimately, the primary goalsof these programs are twofold: to decrease children’s disruptive behaviors, and toincrease children’s prosocial, competent behaviors.

TYPICAL FOCI OF PARENT AND FAMILY SKILLSTRAINING PROGRAMS

The parent and family training programs have evolved out of the prior inter-vention research of Patterson (Patterson, 1974, 1975), Forehand (Forehand & Long,1988; McMahon & Forehand, 1984), Wahler (Wahler, Cantor, Fleischman, &Lambert, 1993), Webster-Stratton (Webster-Stratton, 1990, 1994), Kazdin (Kazdin,Siegel, & Bass, 1992), Szapocznik (Szapocznik, Murray, Scopetta, Hervis, Rio,Cohen, Rivas-Vazquez, Posada, & Kurtines, 1989) and their colleagues. Theseprograms have relatively common foci, based in early behavior modification re-search. Typically, these programs begin with a focus on developing parent’s positive

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attention to their children during parent-child interaction and play times, and ondeveloping parents’ positive reinforcement for their children’s adaptive and proso-cial behavior. Then, the programs move to helping parents respond to children’snegative behaviors with discipline that is consistent, but not overly harsh. Thus,the parents are trained to use procedures such as time-out, response cost, removal-of-privileges, and work chores.

Interventions also typically focus on helping parents to present their expec-tations for their children’s behavior and their house rules in clearer, more directways, thereby enhancing their antecedent (or stimulus) control of children’s behav-ior, in addition to the earlier focus on consequence control of behavior. Programsalso include a focus on enhancing parents’ warm involvement with their children,while also enhancing parental monitoring of children’s behavior, and of the peerswith whom their children spend time. In addition to these behavioral parentingskills, parent and family training programs have increasingly also focussed onother foci such as parent-child comunication skills and parent stress management,which serve to reduce the impact of parenting programs unless they are addressed.Finally, programs have increasingly begun to incorporate training to help parentsfacilitate their children’s development of problem-solving skills and other skillswhich are included in collateral child training programs.

Scope of Programs

These parent training programs are usually conducted with groups of parents,and include active role-playing, discussion, and viewing of videotapes illustratingthe various parenting skills. Programs differ on whether they are directed: (1) atparents only, (2) have a separate child training component in addition to a parentgroup, or (3) have a family focus possibly in addition to parent training. The latterprograms with a family focus range from having parents and children interactingtogether, learning new skills during parent-child interaction sessions, to familysystems training that is more similar to family therapy approaches.

In the following section, the results of outcome research studies examin-ing these three types of parent training programs will be briefly overviewed. Thissummary of research findings is drawn from a recent CSAP-funded publication en-titled “Prevention Enhancement Protocols System (PEPS): Preventing SubstanceAbuse Among Children and Adolescents: Family-Centered Approaches” (Grover,1998), and is consistent with other recent reviews of parent training effectiveness(Brestan & Eyberg, 1998; Bry, Catalano, Kumpfer, Lochman, & Szapocznik, 1999;Gordon, in press; Kazdin & Weisz, 1998; Lochman, 1990; McMahon & Wells,1999; Wells, 1995). The reviewed indicated prevention-related studies includedeight parent training only studies, three parent plus child training studies, ten fam-ily skills training studies, and four parent training plus family skills training studies.These studies use controlled experimental designs as well as nonexperimental time

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series designs. Only the findings from the controlled studies will be noted in thenext section.

OUTCOME RESEARCH FINDINGS

The PEPS review distinguishes between outcome effects which have strongevidence and have been found in multiple studies versus those outcome effectswhich are suggestive in one study but where insufficient evidence exists to makedefinitive conclusions. Strong evidence has been found for three sets of outcomes.First, most outcome studies have reported improvements in children’s problem be-haviors at post treatment and at followups ranging from several months to six yearsor more. These reductions in problem behavior for children whose parents had re-ceived parent training include: (a) lower rates of aggressive problem behavior athome and at school at followups ranging from one year (Dishion & Andrews, 1995;Kazdin, Siegel, and Bass, 1992) to three to six years (Tremblay, McCord, Boileau,Charlebois, Gagnon, Le Blanc, & Larivee, 1991; Tremblay, Pagani-Kurtz, Masse,Vitaro, & Pihl, 1995), (b) lower rates of antisocial and delinquent behavior at aone-year followup (Kazdin, Siegel, & Bass, 1992), (c) fewer days confined in juve-nile correctional institutions (Bank, Marlowe, Reid, Patterson, & Weinrott, 1991),(d) lower rates of placement in special classes at school at a three-year followup(Tremblay et al., 1991), and (e) lower levels of child noncompliance and prob-lem severity up to a year after intervention (Dubey, O’Leary, & Kaufman, 1983;Webster-Stratton, Kolpacoff, & Hollinsworth, 1988; Webster-Stratton, Kolpacoff,& Hollingsworth, 1989). There are mixed findings about the effects of interventionon ADHD symptoms (Dubey, O’Leary, & Kaufman, 1983; Horn, Ialongo, Pascoe,Greenberg, Packard, Lopez, Wagner, & Puttler, 1991; Ialongo, Horn, Pascoe,Greenberg, Packard, Lopez, Wagner, & Puttler, 1993), and parent training mayhave most impact on those ADHD children who also display substantial levels ofaggressive, antisocial behavior.

Second, multiple studies have reported improvements in caretakers’ parent-ing behaviors following their involvement in parent training programs. Parentingbehavior improvements include reductions in parental aversive behavior and spank-ing (Wahler, Cartor, Fleischman, & Lambert, 1993; Webster-Stratton, Kolpacoff,& Hollinsworth, 1988), increases in contingent parental attention (McMahon,Forehand, & Griest, 1981), and increases in parental positive affect (Webster-Stratton, 1990) directed towards children. As parents become less harshly punitiveand more positive with their children, they also begin to use other, more effectivediscipline techniques. Parents also report greater satisfaction with their parentingfollowing intervention (Baum & Forehand, 1981).

Third, the outcome studies indicate that there are also broader improvementsevident in family functioning, including better problem-solving and communica-tion (Webster-Stratton, 1994), greater responsiveness between family members,

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clearer family structure and organization (Szapocznik, Santisteban, Rio, Perez-Vidal, Santisteban, & Kurtines, 1989), and reductions in observed family conflict(Dishion and Andrews, 1995) for families who have participated in parent andfamily skills training. Thus, the parents’ changes in their specific parenting tech-niques appear to be accompanied by broader changes in how they relate to theirchildren and to each other in a variety of everyday situations in family life.

Findings that are suggestive of intervention effects but where insufficient evi-dence currently exists include changes in adaptive functioning of parents and chil-dren. As future research examines these outcomes and intervention components,replications of these findings would strengthen our confidence in them. Reductionsin parental stress, depression and substance use have been noted following parenttraining (Anastopoulos, Shelton, DuPaul, Guevremont, 1993; Webster-Stratton,1990). Children have been found to not only increase their rates of prosocial be-havior, but also to have improvements in social problem-solving skills and in self-esteem following intervention (Szapocznik et al., 1989; Webster-Stratton, 1994).These gains in affective and social-cognitive functioning for parents and childrenillustrate the potential benefits of including children as well as parents in the inter-vention, and may indicate that the behavioral gains are more likely to be maintainedif these broader changes in functioning take place. Parents and children may be-come better at managing their own frustration and anger, and this may contributeto sustained improvements in parenting behaviors and child behaviors.

OUTCOMES FOR THE COPING POWER PROGRAM

Lochman and Wells (1996; Lochman, in press) have recently shown that thesechanges in risk markers and proximal outcomes can be accompanied by reductionsin the outcome to be prevented, namely adolescent substance use rates. The CopingPower Program has separate parent training and child training components. Thegroup interventions last for 15 months and are offered at the time of transition tomiddle school. This indicated prevention intervention is targeted at children whoare rated by teachers and parents as being highly aggressive.

At post intervention (for both cohorts) and at a one-year follow-up (for cohortone), intervention children, in comparison to untreated control children, had lowerrates of aggressive behavior and improvements in social-cognitive skills such aspositive cue encoding skills and higher level social-problem skills involving ne-gotiation. Intervention parents used physical punishment at lower rates followingintervention, and had improvements in parental satisfaction. Parents also had clearreductions in anger in hypothetical problem situations, and they had lower ratesof marital conflict, suggesting that the intervention parents were becoming betterat regulating their anger and emotional arousal. Perhaps most importantly, inter-vention children were found to have lower substance use rates than did untreatedcontrols at the one-year follow-up, suggesting that the proximal outcome effects

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were having a preventive influence on early-onset substance use. Parents’ reductionin harsh discipline, their enhanced anger regulation, and children’s social-cognitiveimprovements appeared to contribute to these children’s reduction in substance userates, in comparison to untreated high risk children. These findings illustrate howintervention programs’ effects on key, empirically-determined target processes canindeed have longer-term preventive effects on substance use and other antisocialadolescent outcomes (Lochman, in press).

GAPS IN KNOWLEDGE

These outcome effects are encouraging, but future research can usefully bedirected at a next set of questions which can further our empirical understandingof the outcome effects of parent and family skills training. Some of these questionsinvolve the following issues.

The available literature best indicates that parent and family oriented inter-vention programs can have immediate post-intervention and short-term follow-upeffects. However, much less is known about whether clear long-term preventioneffects will be evident. What are long term effects of parent and family trainingin carefully-controlled studies with longitudinal follow-ups? Do these trainingprograms prevent adolescent substance use and abuse? After these primary ques-tions are addressed, research can examine whether changes in proximal outcomesclearly mediate subsequent reductions in substance use and substance abuse rates.

Although a reasonably clear set of parenting deficits have emerged in theresearch literature on children at risk for substance abuse, these findings havetypically been used to create generic parent training interventions which havenot been carefully crafted to fit the developmental level of the target children.Research can now begin to examine whether interventions should address differentparenting skills at different developmental periods. For example, is it more effectiveto primarily focus on basic parenting skills in early childhood (e.g., parents use ofreinforcement and discipline strategies), and on communication skills and parentalmonitoring in the early adolescence years?

Two major difficulties in longitudinal prevention research involve the prob-lems involved in getting a sufficiently high initial response rate to insure that thesample is representative of the population being examined, and in successfullyfollowing subjects across assessment waves over time. High levels of attrition canlead to the sample at later follow-ups no longer being representative of the originalsample, and, in the worst case, attrition can occur differentially across conditions,thus threatening the internal validity of the study. Prevention studies, in compar-ison to treatment studies, are particularly prone to potential attrition problemsbecause the family and child are being approached by the preventionist to becomeinvolved in the research, rather than the family approaching the interventionistfor help. To improve prevention research, we need to better understand factors

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that contribute to recruiting and retaining high risk children and their families inpreventive interventions.

Research has begun to indicate that certain forms of parenting practices aredifferentially related to children’s adjustment, depending on the ethnic status offamilies (Deater-Deckard, Dodge, Bates, and Pettit, 1996). Such findings increasethe urgency of initiating studies which examine whether culturally-appropriate in-terventions more effective than generic parent training programs in reducing chil-dren’s risk behaviors. Current research suggests that cultural factors may moderateintervention effects, and thus that interventions should better address culturally-relevant beliefs.

Prior research on child-based interventions has suggested that length of inter-vention and inclusion of booster programs may help to produce stronger and morestable positive effects in children’s behavior (Bry et al., 1999; Lochman, 1985,1992). In research on parent interventions do booster sessions and longer-lastingprograms produce more lasting effects?

Research has begun to indicate that interventions having both parent compo-nents and child components can be effective, and that the multicomponent inter-ventions may produce better maintenance of effects at follow-up. However, otherresearch has raised cautions about possible iatrogenic effects with some formsof child interventions (e.g., Dishion and Andrews, 1995). In component analysisdesigns, what are the relative effects of parent training, parent plus child training,and child training plus enhanced parent training which includes a direct focus onparent-child interactions?

To produce maximum preventive effects on high risk children, it may becritical to expose children and their families to both intensive targeted, indicatedinterventions as well as broader universal interventions. Such an approach can notonly serve to reinforce multiple times the focal concepts within the interventionprograms, but can also begin to have an effect on the interpersonal environmentaround the high risk children (Conduct Problems Prevention Research Group,1999b; Lochman, in press). Does embedding indicated interventions within uni-versal interventions produce stronger prevention effects?

Finally, what are the longer-term systemic effects of parent and family skillstraining? How much of these interventions become embedded in ongoing familyfunctioning? Do agencies and agency staff continue to use these programs insubsequent years after the training period?

BARRIERS AND OPPORTUNITIES

There are a variety of barriers which affect the dissemination of empirically-supported into widespread implementation in community settings. Some of thesebarriers have to do with inadequate training processes, some have to do withcommunity agencies’ and groups’ lack of acceptance of programs, and some have

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to do, at the individual level, with disinterest, resistance and lack of involvementby the potential participants. Thus, potential barriers include the following.

Lack of community and agency perceived ownership of programs can bea central barrier to the dissemination and ongoing implementation of preventionprograms. If community members and agency/school staff perceive that a programis being forced on them without adequate input from them about their perceivedneeds, then it is unlikely they will feel they have ownership of the program, and theprogram will likely be implemented in a haphazard way, at best. It is imperative thatagency heads and relevant community leaders be brought into the implementationplanning process early, and that they have a potential influence on implementationplanning. It is also critical that agency staff be allowed to openly express concernsand support for the planned program, and that their concerns be addressed ifpossible in the planning process.

Inadequate training and supervision of intervention providers is another bar-rier to effective dissemination. Training that consists only of a one-shot workshop,without ongoing supervision or consultation, may not be sufficient for training staffin how to deal with expected and unexpected problems in the delivery of a parent-training program. Better models of training can include upfront workshop training,followed by regular consultation meetings at a prearranged rate (monthly; weekly;etc), and possibly including opportunities for immediate “crisis” consultation ifsignificant difficulties develop in the delivery of services.

Another barrier can involve the lack of attendance to the cultural appropri-ateness and cultural beliefs of the population to receive the intervention programs,and to resultant clashes between program goals and methods and the recipients’values. Programs that advocate forms of parenting that are counter to strongly-held, culturally-supported beliefs are at risk for failure. In addition, the empiricalbasis for some programs may have been restricted to investigations of only onecultural or ethnic group. Thus, some parenting practices may be more related tonegative outcomes in some cultural or ethnic groups, but less so in other cultural orethnic groups. However, if basic research on parenting practices has not examinedthe effects of moderating variables on the relationship between parenting practicesand children’s behavior, then parenting programs may erroneously attempt to trainparents of certain cultural or ethnic groups in inappropriate parenting skills.

Interventions are likely to have different effects with different subtypes ofrisk. Interventions are not likely to be equally effective with all participants, and itis important to understand relevant subtypes of children and of their parents whichpredict intervention effects. For example, research has suggested that for childrenwith certain types of temperament (low activity levels, low fear) and traits (callous-unemotional), the anticipated relationships between poor parental monitoring andharsh parenting and children’s aggression and conduct problems are not found(Colder, Lochman, & Wells, 1997; Wootton, Frick, Shelton, & Silverthorn, 1997).Thus, the same type of parent training may not be equally effective for childrenwith different types of temperaments and traits.

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Low levels of parent attendance at sessions and investment in the programsrepresent a substantial barrier to effective dissemination of programs. Parents ofhigh risk children may not attend any parent training sessions when invited, orif they do come, their attendance may be highly sporadic. Low levels of par-ent attendance and investment may be influenced in turn by a set of personaland familial barriers, including: (a) caregiver dysfunction and medical problems,(b) parents’ discomfort in group meetings, (c) psychosocial stressors such asfinancial crises, upcoming divorces or abandonment by spouses, and (d) par-ents’ feelings that a “training” program implies they are being criticized andblamed. However, parental attendance and investment could be positively influ-enced by certain opportunities such as: (a) parent meetings which are conductedin community settings, (b) provision of child-care and transportation for meet-ings, (c) facilitation of cohesion-building in parent groups, through appropriatesharing of personal experiences, creation of informal support networks withinthe group, and efforts to fine-tune parents’ own ideas rather than rigidly impos-ing the program’s “ideas,” and (d) use of “enhanced” parent interventions whichaddress family communication and personally-relevant topics such as parentalstress.

RECOMMENDATIONS FOR FUTURE RESEARCH, KNOWLEDGEDISSEMINATION, AND POLICY DEVELOPMENT

The following recommendations are derived from this preceding overviewof research gaps and barriers to the implementation of programs. The substantialempirical support for these parent and family interventions should serve as a basisfor broader dissemination efforts, and for the creation of coherent social policy inthis area.

At the state and local levels, prevention researchers and preventive interven-tion staff can promote the need for, and the empirically-supported success of, earlypreventive interventions. Research findings indicating the effectiveness of preven-tive interventions might usefully become part of the state and local policy agendas,leading to more proactive, constructive efforts to carefully and systematically im-plement proven prevention programs.

Preventive interventions could be provided in early childhood and at keydevelopmental transitions, using developmentally-appropriate interventions. Pre-vention programming would then focus on prevention in the children’s early yearsin the infancy, preschool and early elementary school years. Preventive interven-tions might also be provided at key subsequent developmental points, such as thetransitions to middle school and to high school, when there are marked normativechanges in peer and family relationships, in the increasingly independent nature ofacademic and study skills and in the increased pressure and opportunity to engagein antisocial and substance-using behavior.

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Research could examine how proximal intervention effects mediate distalprevention effects. If interventions have demonstrated long-term effects, we needto more clearly understand how changes within children and families have ledto these prevention effects. Thus, outcome research on programs would routinelyexamine whether interventions have had immediate, proximal impact on the sup-posed targets of the intervention, such as certain key parenting processes, and thenexamine whether these immediate proximal changes lead directly to the major pre-vention outcome indicators, such as onset of substance use and substance abuse.These analyses not only further understanding of how interventions actually work,but they can also provide support for the theory underlying the intervention.

It would be worthwhile to examine factors in the training process and in thehost systems (schools; community agencies) which affect dissemination. This is acentral focus for the next generation of prevention research. There is a critical needto understand what are the key factors within communities and within agencieswhich can lead that community or agency to be more or less accepting of a newintervention. Often, agency acceptance may be affected by the level of supportfor the program by key administrative staff, and by the staffs’ ability to criticallyreview the program before its acceptance. Elements of the training process also mayhave profound effects on the effectiveness of the implementation of the program.Research needs to examine these processes and factors with the same degree ofscientific rigor as is apparent in clinical trial research.

Intervention research would benefit by examining moderator factors (e.g.,neighborhood, family and child factors) which influence parent training programs’level of success. Just as we need to understand with greater clarity how mediationalprocesses operate, and thus how programs work, we need to understand whichtypes of individuals benefit greatly from a particular intervention, and which don’trespond well. Prior research on risk factors leading to substance abuse can be auseful source for identifying possible moderating factors. Thus, children who havelow levels of fear, high levels of psychopathy or high levels of sensation seekingmay not be as responsive to positive parenting practices (e.g., Colder, Lochman,and Wells, 1997; Wooton, Frick, Shelton, and Silverthorn, 1997), and may be lessinfluenced by parenting interventions than children without these risk factors.

Preventive intervention programs for parents need to actively plan for a parentgroup’s ending, promoting the supportive roles of relevant community resourcesfor families. An often overlooked aspect of intervention development and im-plementation involves the planning for how parents can effectively find ongoingsupport for problem-solving after the program has ended. Program implementersshould be intimately aware of community resources and they should begin to rein-force parents for accessing those local community parenting resources and centers.A central subtext of preventive interventions for parents is that parents should pro-gressively begin to feel that they can handle difficult situations with their children,and that when they need assistance in problem-solving during a crisis that theycan access community help groups or centers in a resilient fashion.

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Preventive interventions that have both parent and child components can ad-dress a broader set of risk and protective factors that can an intervention withsingle components (Kazdin, Siegel, & Bass, 1992; Lochman, in press; Webster-Stratton and Hammond, 1997). Comprehensive, multicomponent intensive pre-vention programs have been shown to have particular potential for interventionswith high risk children and adolescents who are already displaying signs of sig-nificant conduct distubance (e.g., Conduct Problems Prevention Research Group,1999a).

Relevant cultural contexts should be incorporated into parent and family skillstraining programs. To be relevant and effective, programs need to be based onunderstanding of family processes and family change strategies within families ofvarious socioeconomic, ethnic and community backgrounds.

ACKNOWLEDGMENTS

The completion of this article was supported by grants from the NationalInstitute of Drug Abuse (R01 DA 08453), and from the Center for SubstanceAbuse Prevention, Substance Abuse and Mental Health Services Administration(URG SP 07956; URG SP 08633).

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parent and family skills training in targeted prevention programs for at-risk youth

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