Exploration of predictors, moderators and mediators of change in parent skills training programmes for externalising behaviour problems in children – who benefits most and how do they work?
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Date
01/07/2014Author
Jones, Holly
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Abstract
Background: A key driver for early years strategies is the reduction of oppositional
and defiant behaviour in childhood to prevent a negative life course of poor
educational attainment and criminality. Despite a robust evidence base, manualised
parent skills training programmes (PT) for externalising behaviour problems are only
effective for approximately two-thirds of families. A limited number of variables
that account for variance in outcome have been discovered. Finding further
predictor, moderator and mediator variables will explain who benefits most, and how
change occurs. This will ensure that families receive the most appropriate treatments
for their profile of needs, and services deliver the available interventions in an
efficient and effective way.
Objectives: A systematic review of the literature was conducted to explore progress
in this area since two key meta-analyses published in 2006.
A primary study was carried out to examine whether parent attachment style,
parenting self-efficacy and dysfunctional parental attributions predict, moderate or
mediate the levels of externalising child behaviour problems reported by parents
attending the Incredible Years PT.
Methods: Studies exploring variables influencing outcome in child behaviour
following attendance at a manualised, evidence-based PT group for parents of
children and adolescents aged 0-18 years were sought. Psychinfo, Medline, ERIC
and Embase databases were searched for articles published between August 2004 and
March 2013 with keywords ‘parent’, ‘child’, ‘training’, ‘indirect effects’ and
‘oppositional behaviour’ or related terms. 2853 articles were retrieved, from which
12 studies fulfilled criteria. Study quality was appraised and co-rated.
A pre-post, within subjects design was conducted with 79 parents attending the
Incredible Years PT delivered in a Child and Adolescent Mental Health Service.
Participants completed a battery of pre-treatment questionnaires measuring
attachment style, attributions, self-efficacy and child behaviour. 52 parents
completed the same battery post-treatment, and missing data was carried forward in
an intent to treat analysis. Data was analysed using multiple regression techniques,
and mediation and moderated mediation analyses.
Results: The recent evidence base is populated by secondary analyses of
intervention RCTs, and less robust non RCTs. The selection of maternal mood,
parenting stress, parenting style and child demographics dominate, and the
exploration of unique variables is limited. Significant findings are mixed and add no
new variables to our understanding.
Significant changes in parenting self-efficacy and dysfunctional attributions were
found post-treatment, and attachment style remained stable. A main treatment effect
size of d=.3 was estimated, and a significant number of children fell below sub-clinical
levels of problem behaviour (n=13, 15.7%). Baseline child-responsible
attributions and self-efficacy accounted for up to 40% of the variance in baseline
child behaviour. Attachment style did not contribute significantly to the model, but
moderated parent-causal attributions. Post-treatment, attachment avoidance had a
moderating effect on self-efficacy and child-responsible attributions, and a
significant direct effect on outcome. The indirect effect of parental-attributions on
child behaviour through self-efficacy was moderated by attachment avoidance which
reduced the number of significant paths.
Conclusions: The call for PT studies delivered with fidelity in real world settings
has been recognised, and more sophisticated statistical models of mediation are being
adopted. There remains an exhaustive list of novel potential variables that future
research needs to select and explore in primary research designs.
An evidence based PT is achieving statistically and clinically significant results for
children referred for problem behaviour. Dysfunctional parent attributions and self-efficacy
are predictors of both pre- and post-treatment levels of child behaviour,
which could be screened for in the referral process. The evidence for a direct and
indirect role of attachment style on parent training outcomes adds a new candidate
variable to the literature that warrants further exploration.