predictors of parent training efficacy for child externalizing behavior problems – a meta-analytic...

Predictors of parent training efficacy for childexternalizing behavior problems – a

meta-analytic review

Sandra M. Reyno1 and Patrick J. McGrath1,2

1Dalhousie University, Halifax, Nova Scotia, Canada; 2IWK Health Centre, Halifax, Nova Scotia, Canada

Background: The differential effectiveness of parent training has led researchers to examine a variety ofchild, parent, and familial variables that may predict treatment response. Studies have identified adiverse set of child, parent psychological/behavioral and demographic variables that are associatedwith treatment outcome and dropout. Method: The parent training literature was examined to isolatechild, parent, and family variables that predict response to parent training for child externalizing be-havior problems. A literature review was conducted spanning articles published from 1980 to 2004 ofindicated prevention (children with symptoms) and treatment (children with diagnosis) studies. Meta-analyses were conducted to determine standardized effect sizes associated with the identified predic-tors. Results: Many of the predictors of treatment response examined in this meta-analysis resulted inmoderate standardized effect sizes when study results were subjected to meta-analytic procedures (i.e.,low education/occupation, more severe child behavior problems pretreatment, maternal psycho-pathology). Only low family income resulted in a large standardized effect size. Predictors of drop-outresulted in standardized effect sizes in the small or insubstantial range. Conclusions: Response toparent training is often influenced by variables not directly involving the child, with socioeconomicstatus and maternal mental health being particularly salient factors. Keywords: Predictor, efficacy,parent training, externalizing behavior problems, meta-analysis.

Disruptive or externalizing behavior problems char-acterized by aggressive, noncompliant and opposi-tional acts are commonly observed in young children(Campbell, 1995; Campbell, Shaw, & Gilliom, 2000).Based on maternal report, approximately 5 to 13% ofpreschool children exhibit moderate to severe exter-nalizing behavior problems (Lavigne et al., 1996).The percentage is much higher (approximately 22%)in young children from low-income, welfare families(Webster-Stratton & Hammond, 1998). In a smallerpercentage of older children or adolescents (2.7 to3.4%), disruptive behavior problems reach a level ofseverity that warrants a diagnosis of oppositionaland/or conduct disorder (Breton, Bergeron, Valla,Berthiaume, & Gaudet, 1999; Romano, Tremblay, &Vitaro, 2001). Untreated behavior problems increasethe risk of negative outcomes in adulthood includingalcoholism and drug abuse, poor work outcomes,poor marital outcomes and a range of psychiatricdisorders (Champion, Goodall, & Rutter, 1995;Offord & Bennett, 1994). Child behavior problemsare influenced by a number of factors includingparental alcohol and drug abuse, maternal mentalhealth problems, and low socioeconomic status(Webster-Stratton, 1990). Additionally, an associ-ation has been found between adverse parentingpractices and child misbehavior (Dishion & An-drews, 1995).

The identification of parental behaviors asimportant influences on child misbehavior led to thedevelopment of parent training programs that

typically fall into three main categories basedon the reflective, Adlerian, and behavioral philo-sophical orientations. Although differing in orienta-tion, parent training programs exhibit commonimplementation characteristics (Kadzin, 1997). Thetherapist works mainly with the parent(s) teachingalternative ways to identify and conceptualize childproblem behaviors. Parents are encouraged in posit-ive parenting practices and given the opportunity toobserve how techniques are implemented. Furthertraining is often provided through role-playing andfeedback. Many programs also include homeworkexercises designed to promote further skill develop-ment and application.

Overall, therapist-led parent training has proveneffective in promoting positive changes in parent andchild behaviors (Barlow & Stewart-Brown, 2000;Graziano & Diament, 1992; Kazdin, 1997; Sampers,Anderson, Hartung, & Scambler, 2001; Serketich &Dumas, 1996). Therapist-led parent training hasbeen found to improve parent–child communication,increase parenting self-esteem, alleviate maternaldepression and parenting stress and reducechild behavioral problems (Anastopoulos, Shelton,DuPaul, & Guevremont, 1993; Barkley, Guevremont,Anastopoulos, & Fletcher 1992; Kazdin & Wassell,2000a). Studies examining follow-up status indicatethat positive effects of the parent training are main-tained over time (Dadds & McHugh, 1992; Long,Forehand, Wierson, & Morgan, 1994; Routh, Hill,Steele, Elliot, & Deweys, 1995; Webster-Stratton,

Journal of Child Psychology and Psychiatry 47:1 (2006), pp 99–111 doi:10.1111/j.1469-7610.2005.01544.x

� Association for Child and Adolescent Mental Health, 2006.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

1985a, 1990, 1992; Webster-Stratton & Hammond,1990).

Self-administered or minimal intervention parenttraining methods have also been effective in pro-moting positive behavioral changes in parents andchildren. Webster-Stratton, Kolpacoff, and Hollings-worth (1988) found success with a minimal inter-vention parent training program that involvedvideotaped modeling of skills. Similarly, Connell,Sanders, and Markie-Dadds (1997) found positiveoutcomes for a parent training intervention consist-ing of written materials and weekly telephoneconsultations. Self-administered or minimal inter-vention parent training programs have been usedto successfully treat such diverse problems aswhining, conduct problems, and noncompliance(Endo, Sloane, Hawkes, & Jenson, 1991; Webster-Stratton, 1992; Webster-Stratton et al., 1988; Sut-ton, 1995).

Not all research, however, supports the efficacy ofparent training. Non-significant treatment gainsand/or failure to maintain gains at follow-up havebeen reported (Wahler, 1980). Additionally, manyparents who stand to benefit the most from thistraining (i.e., those who are economically disadvan-taged or socially isolated) display limited attendancewith clinic-based programs and are less likely tocomplete treatment (Dumas & Wahler, 1983; Hol-den, Lavigne, & Cameron, 1990; Kazdin, 1990;Kazdin, Mazurick, & Bass 1993; Webster-Stratton &Hammond, 1990). In a review of studies examiningpremature termination from parent training, Fore-hand, Middlebrook, Rogers, and Steffe (1983) re-ported an overall dropout rate of 28%. Someresearchers have reported a rate approaching 50% ofparents (Oltmanns, Broderick, & O’Leary, 1977;Prinz & Miller, 1994). Studies have found that lim-ited attendance in parent training programs is as-sociated with poorer outcomes (Kazdin, Mazurick, &Siegel, 1994; Prinz & Miller, 1994) and poorer statusat follow-up, presumably because without atten-dance the relevant parenting skills are not learned.

Observed differential effectiveness in parenttraining has led to studies attempting to identifyparent and child attributes that influence treatmentoutcome in parent training. A range of variables thatpredict response to parent training have been iden-tified, including socioeconomic and marital status,intensity of child symptoms, maternal psycho-pathology, and life stress (Knapp & Deluty, 1989;Oltmanns et al., 1977; Strain, Young, & Horowitz,1981; Webster-Stratton & Hammond, 1990). Thefactors found to influence dropout rate are similar tothose found to affect treatment response (Kazdinet al., 1993; Prinz & Miller, 1994).

The purpose of this literature review and meta-analytic study was to isolate family, parent, andchild variables related to poor outcomes in parenttraining for child externalizing behavior problemsand to determine the strength of the association

between identified predictors of parent trainingefficacy and treatment outcome/dropout in indic-ated prevention and treatment studies.

Method

Literature search

A literature search was conducted for all publishedstudies from 1980 to September 2004 on child, parent,and family variables that influence response to parenttraining. A computer search on PsycINFO, Medline andthe Science Citation Index was performed using thefollowing key words: parent training and prediction,predictor(s), predicted, influence, factors, response,treatment outcome, characteristics, externalizing, con-duct problems, oppositional, aggressive, antisocial,assessment, and response. In addition, reference listsfrom empirical studies and review articles were perusedfor other relevant information. Leading researcherswere contacted for assistance in locating related work.To be included in the meta-analysis, studies had tomeet the following inclusion criteria: a) the samplepopulations were indicated prevention or treatment; b)primary child behavior concern was oppositional oraggressive behaviors or conduct problems; c) studiesreported a quantifiable measure of the association be-tween the predictor variable(s) and dropout/treatmentoutcome; d) studies employed a valid and/or reliablepredictor and outcome measure; e) studies were pub-lished in a peer-reviewed journal and written in theEnglish language. Due to the high levels of co-morbiditybetween oppositional and conduct problems andAttention Deficit – Hyperactivity Disorder (ADHD),samples including children with co-morbid ADHD wereincluded in the meta-analysis provided a primary con-cern for the child participants was externalizing be-havior problems such as aggression or oppositionalbehavior. Parent training book chapters and disser-tations or abstracts were not included in the meta-analysis.

Meta-analyses

Meta-analyses were conducted to examine theassociation between predictor variables and dropout/treatment outcome. All studies meeting inclusion cri-teria reporting sufficient information to calculate effectsizes were included in one or more meta-analyses. Thecharacteristics of these studies examining the associ-ation between predictors and dropout are detailed inTable 1, while the characteristics of studies examiningthe association between predictor variables andtreatment outcome are detailed in Table 2. Tables 1and 2 include information on participants (number,age and gender), mode of delivery (individual or group)and theoretical orientation of the parent training,predictor and outcome measures employed andtransformed effect sizes (rs). Of the studies examined,31 studies provided sufficient data to conduct meta-analyses on 15 predictors. Data was combined for the31 studies, with homogeneity of effect sizes found formost predictors despite differences in study charac-teristics. As identification of predictors of parent

100 Sandra M. Reyno and Patrick J. McGrath

Table 1 Characteristics of studies on parent training and dropout

Study Participants Method Outcome measure N r

Copage, Bennett,& McNeil, 2001

3 to 7.5 yrs,M 5.3 yrs

Behavioral/Individual(14 sessions)

Number of treatmentsessions completed

56 .302a

.302b

.166c

.027d (ECBI-IS)

.011e (PSI-PDT)Firestone & Witt,1982

5 to 9 yrs Behavioral/Individualand group (16 sessions)

Premature termin-ation of treatment

6160546062

.36f

.20g

.06h (LWMAT)

.19b

.05i

Frankel &Simmons, 1992

M 7.7 yrs Social-behavioral/Indi-vidual (10 sessions)

Termination after 6 orfewer sessions

119 .17g

Kazdin, 1990 15 girls, 66boys, 7 to13 yrs, M10.3 yrs

Parent managementtraining/Individual andconcurrent cognitive-based child treatment(4–5 mths)

Dropping out withfewer than 25% ofsessions completed

81 .23b

.34g

.15d

0j (SCL-90)0k (BDI).27l

.23e

Kazdin, Holland,& Crowley, 1997

54 girls, 188boys: 3 to14 years, M8.5 yrs

Parent managementtraining/Individual andconcurrent cognitive-based child treatment(16 sessions)


242 .20a

.12b

.14g

.19c

.12f

.10d (RDI# childconduct disordersymptoms DSM-III-R).08l (PSI -LSS).21m (RFI).40n (BTPS-PC)

Kazdin, Holland,Crowley, & Breton, 1997

59 girls,201 boys, 3to 14 yrs, M8.4 yrs



260 .39n (BPTS-PC)

Kazdin, Mazurick,& Bass, 1993



Completing six orfewer sessions

160 .18a

.32b

.25g

.25f

0d (CBCL-TBPS)0j (SCL-90)0k (BDI).26l (PSI - LSS).22e (PSI -PDT).28m (RFI).24c

Kazdin, Mazurick,& Siegel, 1994

14 girls, 61boys, 4 to13 yrs, M10.0 yrs

Parent managementtraining/Individual andconcurrent cognitivebased child treatment(16 sessions)

Termination after10 weeks of treat-ment

50 .28f

.26c

.40d (CBCL – TBPS) –Teacher completed

Kazdin, Stolar, &Marciano, 1995



Premature termin-ation of therapy

279 .17c

Kazdin & Wassell,1998

71 girls,233 boys, 3to 13 yrs, M8.2



302 .18a

.16b

.18f

0d (CBCL-TBPS)0e (PSI – PDT).06l (PSI-LSS).23m (RFI).47o (no-show sessions).17i

.17n (BTPS-PC)

Predictors of parent training efficacy 101

training response was not the primary researchquestion in many of the studies, effect sizes asso-ciated with negative findings were not always repor-ted. This may have resulted in an overestimationof the standardized weighted effect sizes for the pre-dictors.

Calculation of effect sizes

All analyses were performed using a meta-analysisprogram written by David A. Kenny, PsychologyDepartment, University of Connecticut (Kenny, 1999).The studies were weighed by sample size and the FisherZ transformation was employed. The effect size calcu-lations were based on correlation coefficients. Stan-dardized effect sizes were classified as follows; .0–.1insubstantial, .1–.3 small, .3–.5 moderate, and .5–1.0large (Cohen, 1988).

Results

For clarity of presentation, the variables examined aspotential predictors of parent training response havebeen separated into four categories: family demo-graphics, child variables, participation variables andparent psychological/behavioral factors. Many of thereviewed studies examined variables across multiplecategories.

Outcome measures were self-report and/orobservational. Parent perceptions either alone orcombined with observational measures were themost frequently used treatment outcome measures(63% or 12/19 studies). An observation of child be-havior was used as the sole outcome measure inapproximately one-third of treatment studies andexamination of file review was employed in onestudy.

Tables 3 and 4 summarize the results of the meta-analyses for dropout and treatment outcomerespectively. These tables list the predictor variables,the number of studies that examined each variable,the overall N of the meta-analysis, the mean weigh-ted effect size for each predictor, and the significanceof the meta-analytic result. The results of the Fishertest of homogeneity of the effect sizes for each meta-analysis is also included (v2 findings). A fail safe N

value is reported if the t-test examining the meta-analytic result was statistically significant (theoverall effect size was significantly different fromzero). Fail safe Ns estimate the total number ofunpublished studies with nonsignificant results thatwould need to exist for the overall mean effect size tobecome nonsignificant.

Family demographics

Socioeconomic disadvantage has frequently beenassociated with poor outcomes in parent training(Dumas, 1984a, 1984b; Knapp & Deluty, 1989;Kazdin & Wassell, 2000b; Routh et al., 1995;Webster-Stratton, 1985a, 1992; Webster-Stratton& Hammond, 1990). Researchers have used dif-fering methods to determine socioeconomic status(SES) based on measures of occupation, educationlevel, income, marital status, gender, membershipin a minority group, and area of residence. Edu-cation level/occupation and income were the mostfrequent measures used to determine SES. A meta-analysis examining the association between familyincome and treatment outcome resulted in a largestandardized effect (r ¼ .52) that was significantlydifferent from zero (t ¼ 8.23; p < .001), while ameta-analysis examining the association between

Table 1 Continued


McMahon,Forehand, Griest,& Wells, 1981

Young children Behavioral/Individual Termination after 5 orfewer sessions

48 .48g

0d (PAT ).30k (BDI)

Prinz & Miller,1994

4 to 9 yrs Social learning –enhanced treatmentaddressing adultissues (flexiblepace – 12 modularcontent areas)

Failure to completeall treatmentsessions

147 .08a

.29g

.04d (CBCL)

.02h (DAS)

.02j (SCL-90)

.66o (missedappointments)

Spaccarelli,Colter, &Penman, 1992

23 girls, 30 boys,M 6.1 yrs

Cognitive sociallearning – problemsolving enhancement/Group

Premature terminationfrom treatment

7672

.28g

.25d (ECBI)

Note: ECBI-IS – Eyberg Behavior Inventory – Intensity Score; PSI-PDT – Parenting Stress Index – Parent Domain Total; LWMAT –Locke Wallace Marital Adjustment Test; RDI – Research Diagnostic Interview; PSI-LSS – Parenting Stress Index-Life Stress Scale;RFI – Risk Factor Interview; BTPS-PC – Barriers to Treatment Participation Scale –Parent Completed; CBCL-TBPS; Child BehaviorChecklist – Total Behavior Problems Score; BDI – Beck Depression Inventory; PAT – Parent Attitude Test; DAS – Dyadic Parent-ChildInteraction Coding System.aSingle parent status; blow family income; cminority group status; dseverity of child behavior; eparenting stress; fyounger maternalage; glow education/occupation; hmarital satisfaction; ifamily size; jmaternal psychopathology; kmaternal depression; lnegative lifeevents/stressors; madverse parenting; nbarriers to treatment participation; otreatment attendance; psource of referral.


Table 2 Characteristics of studies on parent training and treatment outcome


Dumas, 1984a 36 boysand 16girls, 2 to11 years,M 6.22 yrs

Behavioral/Individual (7sessions)

Program completion, no requestfor further services,observations show 50%reduction in median levelof child aversive behavior(adequate inter-raterreliability reported)

52 .15a

.58b

.56c

.49d

.03e

Dumas, 1984b 80 boys, 29girls, 2 to16 yrs, M7.27 yrs

Behavioral/Individual(Minimum of 6 sessions)

Successful program comple-tion/file review (adequateinter-rater reliability reported)

109 .264a

.466b

.376c

.325d

.433f (history of psy-chological/psychi-atric symptoms)

.233e

Dumas & Wahler,1983

36 boys,13 girls,14 mths to12 yrs,M 6.55 yrs

Behavioral/Individual (4–6 weeks)

Program completion,observations show 50%reduction in median levelof child aversive behavior(adequate inter-raterreliability reported)

49 .282a

.522b

.479c

.454d

.301e

Hartman, Stage, &Webster-Stratton,2003

81 boys,4 to 7 yrs,M 61.2 mths

Cognitive social learning–videotape modeling/Group(22 to 24 sessions)

CBCL - ExternalizingScale T-Score

81 20c

.34h (BDI)

.17i (LES)Holden, Lavigne, &Cameron, 1990

114 boys,44 girls,18 mths to5 yrs, M 3 yrs

Behavioral/Individual andgroup (Open-ended to program completion – average25 sessions)

Program completion,cooperative child behaviorobserved 85% of the timeacross 3 consecutivesessions (adequate inter-rater reliability reported)

90 .42g (Cooperative be-havior during base-line-behavioralobservations*)

Horne & Dyke,1983

Male children,M 8.45 yrs

Social learning/Individual(22 sessions)

FICS – Total AggressiveBehavior Score

70 .64g (FICS – TotalAggressive BehaviorScore)

Kazdin, 1995 30 girls, 75boys, 7 to13, M10.3 yrs


Total problem CBCL scoreless than or equal to 60 andsocial competence score t lessthan or equal to 39

105 .35g (RDI# of non-conduct symptomsDSM-III-R).31f (SCL-90).25h (BDI).21i (PSI - LSS)

Kazdin & Wassell,1998

71 girls,233 boys,3 to 13 yrs,M 8.2

Parent managementtraining/Individualand concurrentcognitive-basedchild treatment(16 sessions)

Items on the BPTS-PCmeasuring the extent towhich the parent felt thechild improved

302 0a

0b

.18g (CBCL-TBPS)

.06i (PSI-LSS)

.11j (no-show ses-sions).07e

.22k (BTPS -PC)Kazdin & Wassell,1999

45 girls,155 boys,3 to 13 yrs,M 7.9

Parent managementtraining/Individualand concurrent cognitive-based child treatment(16 sessions)

Index of therapeutic change(combination of IAB, PDR,CBCL)

187198200

.40g (RDI –# conductdisorder symptoms,history of antisocialbehavior, othersymptoms).13j (overall mean ofcancelled, no showsand late session).42k (BTPS – PC)

Kazdin & Wassell,2000a

61 girls,189 boys,2 to 14 yrs,M 7.8 yrs



245249

.27g (RDI –# conductdisorder symptoms,history of antisocialbehavior, othersymptoms).25k (BTPS – PC)

Kazdin & Wassell,2000b

61 girls,189 boys;2 to 14 yrs,M 7.2 yrs



169164

.47g (RDI –# conductdisorder symptoms,history of antisocialbehavior, othersymptoms).32k (BTPS – PC)


family income and dropout resulted in a smallstandardized effect size (r ¼ .21; t ¼ 6.32; p <.002). The overall mean effect size for education/occupation and treatment outcome was nothomogeneous. Examination of the data revealedthat the heterogeneity was due in part to an out-lying value in one of the studies (Mackenzie, Fite,& Bates, 2004). The association between educa-tion/occupation and treatment outcome in thisstudy differed from the expected direction. Theauthors attribute this unexpected finding to alimited representation of different SES levels acrossthe sample (e.g., a larger proportion (close to threequarters) of the study participants fell in the twohighest levels of the Hollingshead categories) andresistance from higher SES mothers to the type ofintervention offered (structured, educational formatwith the focus on increasing parenting knowledge

and skill training and little emphasis on emotionalsupport and stress reduction). When this studywas removed from the meta-analysis, the resultingmean effect size for the remaining six studies (r ¼.34; t ¼ 4.97; p < .004) continued to be statistic-ally heterogeneous (v2 ¼ 11.83; p < .05). Wheneducation/occupation was examined as a predictorof treatment dropout, a small standardized effectsizes was obtained (r ¼ .26; t ¼ 9.65; p < .001).

Single parent and minority group status, youngermaternal age, and increased family size have alsobeen examined as demographic predictors of parenttraining outcomes (Copage, Bennett, & McNeil,2001; Dumas 1984b; Webster-Stratton & Ham-mond, 1990). The combined data examining the as-sociation between these variables and treatmentoutcome/dropout resulted in small mean standard-ized effect sizes. The mean weighted effect sizes were

Table 2 Continued


Mackenzie, Fite, &Bates, 2004

4 girls, 21 boys, 3to 8 yrs, M 5.3 yrs

Behavioral/Individual ECBI -PS 21 .47c

Routh, Hill,Steele, Elliott, &Deweys, 1995

Under 9 yrs Behavioral/Group (10–16 sessions)

ECBI -IS 33 .39b

.47g (ECBI)

.38f (GHQ)

.45e

Strain, Young, &Horowitz, 1981

12 to 71 mths Behavioral/Individual Cooperative behavior insessions (85% or above in3 consecutive sessions)(adequate inter-rater reliabilityreported),cooperative behaviorat home

109 .319a

.28j (# ofappointmentsmissed)

Webster-Stratton,1985a

9 girls, 25 boys, M5.2 yrs

Cognitive sociallearning/Individual(9 sessions)

CBCL – TPBS < 42 34 .44i (LES).

Webster-Stratton,1985b

9 girls, 21 boys, 3to 8 yrs

Cognitive sociallearning/Individual(9 sessions)

DPICSChild deviant/non-compliantbehaviors reduced 50%,mother criticism and negativephysical behaviors reduced50% (adequate inter-rater reli-ability reported)

29 .24a

Webster-Stratton,1990

3 to 7 yrs Cognitive sociallearning–videotapemodeling/Group(10 to 12 sessions)

CBCL – Parent and teacherTBPS < 42

828181

.25h

.23a

.42b

Webster-Stratton,1992

28 girls, 72 boys,3 to 8 yrs, M60.2 mths

Cognitive sociallearning–videotapetraining/Individual(10 sessions)

CBCL – TPBS 59 .32a

.20c

.34h (BDI)

.17i (LES)Webster-Stratton& Hammond,1990

35 girls, 79 boys,3 to 8 yrs

Cognitive sociallearning/Individual(app. 9 sessions)

CBCL – TPBS 101 .16a

.22c

.31h (BDI)

.22i (LES)

Note: FICS – Family Interaction Coding System; RDI – Research Diagnostic Interview; SCl-90 – Hopkins Symptom Checklist – 90;BDI-Beck Depression Inventory; PSI-LSS – Parenting Stress Index – Life Stress Scale; BPTS – PC – Barriers to TreatmentParticipation –Parent Completed; CBCL-TBPS – Child Behavior Checklist – Total Behavior Problem Score; IAB – Interview forAntisocial behavior; PDR – Parent Daily Report; RDI – Research Diagnostic Interview; ECBI-PS – Eyberg Child Behavior Inventory –Problem Score; ECBI-IS – Eyberg Child Behavior Inventory – Intensity Score; GHQ – General Health Questionnaire; LES – LifeExperience Survey; DPICS – Dyadic Parent-Child Interaction Coding System.aSingle parent status; blow family income; clow education/occupation; dsource of referral; efamily size; fmaternal psychopathology;gseverity of child behavior; hmaternal depression; inegative life events/stressors; jtreatment attendance; kbarriers to treatmentparticipation.


significantly different from zero in all but one of thecases (family size and dropout).

More severe pretreatment child behavior has beenlinked to negative outcomes in parent training in anumber of studies (Kazdin 1995; Kazdin & Wassell,2000b; Routh et al., 1995). Of the child variablessuggested as predictors of response to parent train-ing, severity of child behavior problems at pretreat-ment assessed primarily by parent report measures(71% of studies) was the most commonly examined.The combined data examining the association be-tween severity of child behavior and dropout/treat-ment outcome resulted in an insubstantial effect sizefor dropout and a moderate effect size for treatmentoutcome. The mean weighted effect size for dropoutwas not significantly different from zero. The effectsizes examining the association between severity andtreatment outcome were not homogeneous. Exam-ination of the data revealed that the heterogeneitywas due to an outlying value in one of the studies(Kazdin & Wassel, 1998). Kazdin employed two itemson the Barriers to Treatment Participation Scale(BTPS) to measure improvement following treatmentrather then a more commonly employed parent re-port measure such as the Child Behavior Checklist(CBCL). Although Kazdin found the BPTS improve-ment measure to be moderately correlated with

parent-completed CBCL total score (r ¼ .41), the useof the BTPS to assess treatment improvement mayhave led to heterogeneity of the effect sizes. Whenthis study was removed from this meta-analysis, theresulting mean effect size for the remaining sixstudies (r ¼ .41; t ¼ 8.3; p < .001) was statisticallyhomogeneous (v2 ¼ 6.45; p > .05).

Referral by a school or social agency as opposed toself-referral has also predicted poorer parent train-ing outcomes (Dumas 1984a, 1984b; Dumas &Wahler, 1983). The combined data examining theassociation between source of referral and treatmentoutcome resulted in a moderate standardized effectsize that was statistically significant.

Participation variables

Attendance at parent training sessions has beenexamined as a predictor of treatment outcome (Kaz-din & Wassell, 1998; Prinz & Miller, 1994; Strainet al., 1981). A meta-analysis examining attendanceas a predictor of treatment outcome resulted in asmall effect size. Kazdin, Holland, Crowley, andBreton (1997) developed a Barriers to TreatmentParticipation Scale (BTPS) to measure a number offactors that may influence treatment outcome,including practical obstacles to treatment parti-

Table 4 Association between predictor variables and treatment outcome

Predictor # of studies Total NMean weightedeffect size (SD)

t-test(p-value)

Chi square(p-value)

Failsafe N

Single parent 9 891 .20(.11) 5.52(.001) 14.97(.06) 63Family size 4 493 .21(.07) 6.40(.01) 7.18(.07) 39Low family income 5 324 .52(.14) 8.23(.001) 1.91(.75) 84Low education/occupation 7 472 .27(.30) 2.4(.054) 23.9(.00) –Barriers to treatment 5 1175 .33(.09) 8.38(.001) 9.17(.07) 87Treatment attendance 3 609 .16(.05) 6.01(.04) 2.51(.28) 26Source of referral 3 210 .44(.03) 26.3(.003) 1.49(.48) 537Severity of child behavior 8 1201 .40(.12) 9.18(.002) 27.6(.00) 168Maternal psychopathology 3 247 .39(.14) 4.75(.042) 1.0(.60) 1Maternal depression 5 428 .23(.15) 3.45(.03) 7.06(.13) 11Negative life events/stressors 6 682 .16(.09) 3.97(.01) 7.96(.16) 19

Table 3 Association between predictor variables and dropout

Predictor # of studies Total NMean weightedeffect size (SD)

t-test(p-value)

Chi square(p-value)

Failsafe N

Single parent status 5 907 .18(.07) 5.91(.005) .25(.65) 42Family size 2 364 .13(.15) 1.3(.48) .73(.39) –Low family income 6 901 .21(.08) 6.32(.002) 5.4(.37) 57Low education/occupation 8 933 .26(.08) 9.65(.000) 8.23(.31) 186Younger maternal age 6 924 .21(.07) 7.65(.001) 4.69(.46) 86Minority group status 5 787 .20(.07) 7.77(.003) .80(.94) 55Barriers to treatment 2 544 .29(.15) 2.65(.31) 8.43(.00) –Severity of child behavior 8 1086 .08(.10) 2.18(.07) 9.16(.24) –Adverse parenting 2 544 .22(.03) 9.80(.13) .06(.81) –Maternal psychopathology 3 388 .007(.01) 1.00(.44) .04(.98) –Maternal depression 3 289 .08(.13) 1.00(.44) 3.62(.16) –Marital satisfaction 2 389 .04(.04) 1.70(.41) .14(.70) –Negative life events/stressors 4 785 .15(.08) 3.73(.038) 6.65(.08) 11Parenting stress 4 599 .11(.12) 1.75(.19) 7.18(.07) –


cipation, treatment demands, perceived treatmentrelevance, and parent–therapist alliance. Thesebarriers are thought to influence participation andtreatment adherence. A moderate standardized effectsize was found for the meta-analysis examining theassociation between barriers to treatment parti-cipation (the overall score on the BTPS) and treat-ment outcome. The mean weighted effect sizeexamining the association between overall BPTSscore and dropout fell very close to the moderaterange (r ¼ .29).

Parent psychological/behavioral variables

Researchers have investigated a variety of parentpsychological and behavioral variables as predictorsof parent training outcome. Among these variables,frequently examined predictors of parent trainingefficacy were marital distress/dissatisfaction,maternal psychopathology, maternal depressivesymptoms, negative life events/parenting stress,and adverse parenting behaviors pretreatment (Co-page et al., 2001; Dadds & McHugh, 1992: Kazdin &Wassell, 1998; Routh et al., 1995; Webster-Stratton,1992).

While low marital satisfaction has been associatedwith more negative parenting behaviors and higherlevels of maternal depression (Rickard, Forehand,Atkeson, & Lopez, 1982), a number of studies failedto find an association between marital distress/dis-satisfaction and parent training outcomes (Brody &Forehand, 1985; Firestone & Witt, 1982). The com-bined data examining the association between mar-ital satisfaction and dropout resulted in aninsubstantial effect size. Insufficient data wereavailable to examine the association between maritalsatisfaction and treatment outcome.

Symptoms of maternal psychopathology and de-pression are frequently associated with parenttraining outcomes (Dumas 1984b; Kazdin, 1995;Webster-Stratton, 1992; Webster-Stratton & Ham-mond, 1990); however, many studies do not showan association with dropout (Kazdin, 1990; Kazdinet al., 1993; Prinz & Miller, 1994). The combineddata examining the association between maternalpsychopathology and treatment outcome resultedin a mean weighted effect size in the moderaterange, while the data examining the associationbetween maternal depression and treatment out-come resulted in a small effect size. One of thestudies included in the meta-analysis of maternaldepression and treatment outcome found a negat-ive association between these variables (Hartman,Stage, & Webster-Stratton, 2003). This unexpectedfinding was attributed to the relatively low levels ofdepression found in the sample pretreatment.When this study was removed from the meta-ana-lysis, the resulting mean effect size for the re-maining four studies fell close to the moderaterange (r ¼ .29). There was an insubstantial

association between maternal mental health pre-dictors and dropout.

Some studies found parent training to be lesseffective, with families reporting increased negativelife events and/or parenting stress (Kazdin, 1995;Webster-Stratton, 1985a; Webster-Stratton & Ham-mond, 1990), while others failed to find a significantassociation (Webster-Stratton, 1992). The combineddata examining the association between negative lifeevents and parenting stress and dropout resulted insmall mean weighted effect sizes. The mean weightedeffect size examining the association between negat-ive life events and treatment outcome also resultedin a small effect size.

Adverse child rearing practices at pretreatmenthas been consistently associated with treatmentoutcome and dropout in the studies examining thispredictor (Kazdin, 1995; Kazdin, Holland, & Crow-ley, 1997; Kazdin & Wassell, 1998). A small meanweighted effect size was found between adverseparenting and dropout; however, insufficient datawas available to examine the association betweenadverse child rearing practices and treatmentoutcome.

Discussion

Although parent training is effective in treating avariety of child behavior problems (Barlow & Stew-art-Brown, 2000; Graziano & Diament, 1992; Kaz-din, 1997; Sampers et al., 2001; Serketich & Dumas,1996), not all families benefit from this form oftreatment. Studies have identified a diverse set ofparent psychological/behavioral and demographicvariables that negatively influence treatment out-come (Dumas 1984b; Kazdin, 1995; Webster-Strat-ton & Hammond, 1990). This study examined fourmain clusters of predictors: demographic variables(single parent status, family size, low income, edu-cation/occupation, maternal age, minority status),child variables (source of referral – referred by schoolor social agency rather than self-referred, severity ofchild behavior), participation variables (treatmentattendance, perceived barriers to treatment parti-cipation) and parent variables (maternal psycho-pathology/depression, negative life events/stressors).Many of the predictors of treatment response exam-ined in this meta-analysis resulted in moderatestandardized effect sizes when study results weresubjected to meta-analytic procedures. Predictors ofdropout resulted in standardized effect sizes in thesmall or insubstantial range.

Of the demographic predictors of treatment out-come, only low family income resulted in a largestandardized effect size. A related predictor, loweducation/occupation, was a moderate predictor oftreatment outcome. The family stress model ofeconomic hardship has been proposed to explainthe relationship between low income, parenting


practices, and child adjustment (Conger et al., 1992,2002). The model postulates that economic pressureincreases parental psychological distress. This dis-tress precipitates a decline in parental mental healththat negatively influences parenting (e.g., adverseparenting practices increase). In the model, socio-economic disadvantage has an indirect effect on par-enting by increasing maternal depression (Simons,Lorenz, Wu, & Conger, 1993). Maternal depressionimpacts mother–child interaction quality, maternalperceptions of child behavior, and discipline re-sponses. Child adjustment is primarily impactedthrough the disruption in effective child rearingpractices, with use of harsh discipline practices thestrongest predictor for the development of external-izing child behavior problems (Dodge, Pettit, & Bates,1994). Preliminary findings support this model(Conger et al., 1992, 2002; Jackson, Brookes-Gunn,Huang, & Glassman, 2000), suggesting that en-hancements to parent training addressing parentaldistress and mental health concerns may positivelyinfluence treatment outcomes.

Pinderhughes, Dodge, Bates, Pettit, and Zelli(2000) also examined the relation between SES andparental discipline responses. The authors foundthat parenting beliefs about the efficacy of physicaldiscipline to manage child misbehavior and intensecognitive-emotional processes about the child (i.e.,negative perceptions of child and worries about thefuture implications of child misbehavior) mediatedthe relationship between low-income and physicaldiscipline responses. Higher stress levels associatedwith economic disadvantage were associatedwith increased cognitive-emotional reactivity. Theauthors suggest that helping parents monitor cog-nitions and affect, teaching parents effective problemskills, and increasing parents’ knowledge aboutalternative discipline strategies may reduce the useof harsh discipline practices.

When examining parent predictors of treatmentoutcome, the only moderate predictor of treatmentoutcome was maternal psychopathology. Studiesincluded in this meta-analysis employed a range ofmeasures (history of psychological/psychiatricsymptoms, SCL-90 and the GHQ) to assess maternalpsychopathology. Along with number of psychiatricsymptoms, the SCL-90 and GHQ assessed depres-sive symptomatology. The fact that maternal mentalhealth influences treatment response to parenttraining is not surprising given the task demandsinvolved in implementing behavioral interventions. Ahigh level of motivation and consistent implementa-tion of behavior modification techniques are requiredfor successful outcomes.

Many of the variables that predict parent-trainingresponse are associated to varying degrees withmaternal mental health, particularly maternaldepression. Maternal depression has been found tohave a high correlation with other forms of mater-nal psychopathology, socioeconomic disadvantage,

single parent status, and reports of life stress andnegative life events (Forehand, Furey, & McMahon,1984; Webster-Stratton, 1985a; Webster-Stratton &Hammond, 1988, 1990). Mothers with depressionreport increased parenting stress (Jackson & Haung,2000; Sarason, Johnson, & Seigel, 1978; Simonset al., 1993) and more severe child behavior prob-lems (Forehand, Lautenschlager, Faust, & Graziano,1986; Gross, Conrad, Fogg, & Wothke, 1994; Jack-son et al., 2000; Jackson & Huang, 2000; Webster-Stratton & Hammond, 1988). Additionally, financialstrain and low educational attainment have pre-dicted an increase in depressive symptoms (Jacksonet al., 2000).

Researchers have found that increased levels ofdepressive symptoms negatively influence parentingquality (Conger et al., 1992; Forehand et al., 1986;Jackson et al., 2000; Querido, Eyberg, & Boggs,2001; Simons et al., 1993, Voydanoff & Donnelly,1998; Webster-Stratton & Hammond, 1988), withthe association between parenting difficulties anddepressive symptoms similar in studies employingself-report measures and studies using interview-based clinical diagnosis of depression (Lovejoy,Graczyk, O’Hare, & Neuman, 2000).

Some of the studies in this meta-analysis as-sessed treatment outcome using maternal reportmeasures alone (47% of studies). Using maternalreport measures to assess treatment outcome mayhave resulted in a treatment bias effect, wherebypositive ratings of child behavior post-treatmentoccurred primarily as a function of having partici-pated in treatment. Alternatively, maternal depres-sion may have influenced maternal perceptions ofchild behavior. Webster-Stratton and Hammond(1988) found that depressed mothers perceivedtheir child as significantly more disturbed than didnon-depressed mothers. Additionally, Griest, Wells,and Forehand (1979) found maternal ratings ofchild problem behavior correlated higher withmaternal self-ratings of depression than withobservations of child problem behavior. Reductionsin maternal dysphoria and stress levels are associ-ated with improved maternal reports of childadjustment (Webster-Stratton, 1994). Parent train-ing interventions have resulted in improvements inparenting self-esteem and reductions in maternaldepressive symptomatology and parenting stress(Anastopoulos et al., 1993; Kazdin & Wassell,2000a).

In a more recent study, Querido, Eyberg, andBoggs (2001) also found a discrepancy between ma-ternal reports of child behavior and observations ofchild behavior at lower levels of depression. Motherswith higher levels of depressive symptomatology,however, provided child behavior ratings that wereconsistent with behavioral observations. The studyfindings suggest that for mothers with low levels ofpre-treatment depression, reported improvementsin child behavior following treatment may have


reflected a decrease in depressive symptomatologyrather than changes in child behavior (Rickard,Forehand, Wells, Griest, & McMahon, 1981).Unfortunately, insufficient data was available toexamine predictors based on different outcomemeasures (e.g., observational vs. parent-report);however, homogeneity of effect sizes was found inmost cases.

Conclusion

It is clear that many variables that influence re-sponse to parent training for child externalizingbehavior problems do not directly involve the child,with maternal mental health being a particularlysalient factor. This has led to studies examiningthe efficacy of enhanced parent training programson child outcomes. Most of these studies havefound modestly improved child outcomes whentreatment has addressed maternal problems inaddition to parenting concerns (Dadds, Schwartz,& Sanders, 1987; Griest et al., 1982; Sanders,Markie-Dadds, Tully, & Bor, 2000; Sanders &McFarland, 2000). In contrast, Webster-Stratton(1994) did not find improved child outcomes (as-sessed through parent reports or independent be-havioral observation) with the addition of acomponent teaching parents to cope with inter-personal distress. Further study is needed todetermine the extent to which concurrent treat-ment of parental difficulties increases treatmentefficacy. Improved outcomes from enhanced parenttraining programs may result from more specificmatching of parental difficulties with appropriateinterventions and through determining the bestsequence for administering the interventioncomponents.

Matching the format or setting of parent trainingprograms to parent/family characteristics has alsoimproved outcomes. For example, open-endedprograms requiring mastery before advancementhave led to positive parent training outcomes for lowSES parents (Rogers, Forehand, Griest, Wells, &McMahon, 1981). Cunningham, Bremner, and Boyle(1995) found economically disadvantaged familiesand families with children with more severe beha-vior problems were more likely to enroll in andcomplete community-based than clinic-based par-ent training programs. Additionally, parents in thecommunity-based groups reported greater reduc-tions in child behavior problems. Similarly, Baydar,Reid, and Webster-Stratton (2003) demonstratedthat maternal mental health risk factors and lowsocioeconomic status did not influence programengagement or treatment outcome for mothersinvolved in a preventative community-based par-enting program (Incredible Years) offered in HeadStart schools. This community-based parent train-ing program has also been effective for ‘high risk’

Head Start children (e.g., those with relativelyhigher rates of child conduct problems pretreat-ment) (Webster-Stratton, Reid, & Hammond, 2001;Reid, Webster-Stratton, & Beauchaine, 2002). Infact, mothers of ‘high risk’ children enrolled in HeadStart programs show increased engagement andimproved outcomes in parent training relative tomothers of ‘low risk’ children (Reid, Webster-Strat-ton, & Baydar, 2004).

Although the participants in these community-based studies included at-risk families rather thanchildren diagnosed with behavioral disorders orfamilies who sought treatment for child behaviorproblems, the study findings suggest that offeringparent training in the community and providingadditional supports to encourage attendance mayreduce logistic and psychological barriers toattendance and positively influences outcomes.Eyberg, Edwards, Boggs, and Foote (1998) suggestthat adding strategies to promote maintenance oftreatment gains can also improve outcomes. Theyrecommend increasing parental self-monitoringbehaviors, fading treatment sessions and boostersessions. The Incredible Years Program includesparent and teacher training components, boosterparent sessions, optional in-home booster sessions,standardized materials and comprehensive leadertraining (Webster-Stratton et al., 2001). Furtherstudy is needed to determine the extent to whichaltering program design to match parent/familycharacteristics increases positive outcomes.

The meta-analytic approach of this paper investi-gated the simple association (correlations) betweenisolated predictors and parent training outcomes.Studies are needed that examine the interrelation-ships among identified predictor variables and par-ent training outcomes in order to better understandhow these variables influence parent training out-comes. The findings from this research may lead tofurther modification and enhancement of parenttraining programs to better address the needs ofparticipating families.

Acknowledgements

Patrick McGrath was supported by a DistinguishedScientist Award from the Canadian Institutes ofChild Health.

Sandra Reyno is supported by a TransdisciplinaryUnderstanding and Training on Research – PrimaryHealth Care Program Award from the CanadianInstitute of Health Research.

Correspondence to

Patrick J. McGrath, Psychology Department, Dal-housie University, Halifax, NS, Canada, B3H 4J1;Tel: (902) 494-3581 Fax: (902) 494-6585; Email:[email protected]


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Webster-Stratton, C., & Hammond, M. (1988). Maternaldepression and its relationship to life stress, percep-tions of child behavior problems, parenting beha-viors, and child conduct problems. Journal ofAbnormal Child Psychology, 16, 299–315.

*Webster-Stratton, C., & Hammond, M. (1990). Pre-dictors of treatment outcome in parent training forfamilies with conduct problem children. BehaviorTherapy, 21, 319–337.

Webster-Stratton, C., & Hammond, M. (1998). Conductproblems and level of social competence in Head Startchildren: Prevalence, pervasiveness, and associatedrisk factors. Clinical Child Psychology and FamilyPsychology Review, 1, 101–124.

Webster-Stratton, C., Kolpacoff, M., & Hollingsworth, T.(1988). Self-administered videotape therapy forfamilies with conduct-problem children: Comparisonwith two cost-effective treatments and a controlgroup. Journal of Consulting and Clinical Psychology,56, 558–566.

Webster-Stratton, C., Reid, M.J., & Hammond, M.(2001). Preventing conduct problems, promotingsocial competence: A parent and teacher trainingpartnership in head start. Journal of Clinical ChildPsychology, 30, 283–302.

Manuscript accepted 15 March 2005


predictors of parent training efficacy for child externalizing behavior problems – a meta-analytic...

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