Does parent training with young noncompliant children have long-term effects?

ooO5-7967194$6.00 + 0.00 Copyright (Q 1993 Pergamon Press Ltd

Behim. I&x. Ther. Vol. 32, No. 1, pp. 101-107, 1994 Printed in Great itritain. All rights reserved

DOES PARENT TRAINING WITH YOUNG NONCOMPLIA~ CHILDREN HAVE LONG-TERM EFFECTS? PATRICIA LONG,' REX FOREHAND, 2* MICHELLE WIERSON~

and ALLISON MORGAN*

’ Department of Psychology, Oklahoma State University, Stillwater, OK 74075, U.S.A., 2Department of Psychology, University of Georgia, Athens, GA 30602, U.S.A. and ‘Department of Psychology, Pomona College, Claremont, CA 91711, U.S.A. (Receiued 16 October 199.2)

Summary-The current study was a long-term follow-up (approx. 14 yr following treatment) of 26 late adolescents/young adults (17 yr and older) who had participated in parent training with their mothers when they were young (2-7 yr old) noncompliant children. Parent training, consisting of teaching mothers to use attends and rewards for appropriate behavior, clear commands and time-out, had reduced deviant behavior and increased compliance immediately following treatment. At this follow-up, these individuals were compared to a matched community sample on various measures of delinquency, emotional adjustment, academic progress and relationship with parents. No differences emerged between the two groups on any of the measures, suggesting that noncompliant children who participated in parent training during their early years are functioning as well as nonclinic individuals as they move into adulthood.

Kazdin (1985) delineated the different approaches to the outpatient treatment of actingout children. Based upon the literature, he concluded that parent management training was the most thoroughly evaluated and the most effective procedure. However, Kazdin also noticed that follow-up assessments of this intervention technique typically were limited to 1 yr posttreatment. Forehand and Long (1988) reviewed studies which had collected follow-up data with parent training participants 8 or more months after treatment. They identified 12 studies and concluded that changes were generally, but not always, maintained from posttreatment to follow-up. Forehand and Long then proceeded to provide long-term follow-up data for a sample of 21 parents and children who had participated in parent training some 7iyr (range 4h-10 yr) earlier. At the time of the follow-up assessment, the children were in the early adolescent age range (1 l-14 yr). A variety of assessment procedures was employed, including parent-report data, teacher-report data, child-report data and observational data. When the data for these participants were compared to a community sample, very few differences emerged. For example, there were essentially no differences across multiple measures of externalizing problems, internalizing problems and prosocial competence. However, data from the school indicated that the parent training group was performing less well academically. The study by Forehand and Long is important in that it provided long-term follow-up data at a point in time when former participants in parent training were transitioning into the adolescent years. The purpose of the present evaluation was to extend this follow-up interval for a sample of children who previously had participated in a parent training program and who were now 17 yr or older. At the current time the sample was facing another transition: movement from late adolescence to early adulthood. The latter life stage is a time when critical decisions about education, relationships and conventionality (vs engagement in deviant behavior) are being made (Jessor, Donovan & Costa, 1991). To the best of our knowledge, no follow-up studies of parent training have been completed with a sample entering adulthood. Thus, the present study provides the first opportunity to compare earlier participants in parent training to a nonclinic control group when the participants are leaving home and assuming autonomy in life. *Author for correspondence. 101

102

PATRICIA LONGet

al.

METHOD

Subjects An attempt was made by telephone and mail to contact 47 young people who were transitioning from late adolescence to early adulthood (i.e. ages between 17 and 22 yr) and who had participated with their parents in a parent training program at least 14 yr earlier. Of these, 26 were contacted successfully and agreed to participate. The remaining 21 were not possible to locate (n = 17), refused to participate (n = 2) or failed to return measures (n = 2). The initial presenting problem and the reason for referral to parent training for all of these children was noncompliance to parental requests, although secondary problems ranged from aggression toward others to firesetting. Problem severity ranged from disruption in the home setting only to disruptions requiring community involvement (e.g. Department of Family and Children’s Services). Children’s ages at the time of program participation ranged from 2 yr 4 months to 7 yr 10 months. In most cases only the mother and child participated in the parenting program. A matched community comparison group also was examined in the current study. These participants were selected from a larger group of individuals who were transitioning to adulthood and who volunteered to participate in a follow-up project of an earlier community-based study of parent-adolescent relationships. Twenty-six young adults from this sample were equated with the parent training Ss on age, gender and family socioeconomic status. All Ss in both groups were Caucasian in ethnicity. Table 1 presents the demographic breakdown for each group. When t-tests were applied to continuous variables (i.e. age, socioeconomic status, number of children) and chi-square analyses to dichotomous variables (i.e. marital status, parental marital status), no significant demographic differences emerged between the two groups (see Table 1). Socioeconomic status was assessed using the Myers and Bean (1968) two-factor index of social position, calculated according to the individual with the highest educational and occupational level in the household. In this sample, parental position scores were calculated for both groups. The Myers and Bean system yields possible scores ranging from 1I to 77, with lower scores indicating higher social position. Present scores ranged from 11 to 62, with a mean score across groups of 24.0, indicating the average family was middle to lower middle class status. Parent training The parent training program has been presented in detail by Forehand and McMahon (198 1) and, thus, will be only briefly summarized here. The program consists of 8-10 clinic sessions in which a parent is initially taught to attend to and reward appropriate behavior and to ignore minor inappropriate behavior (e.g. whining, tantrums). The parent is then taught how to issue commands Table 1. Demoeraohic

variables

for Parent Training and Comparison

Parent Training group Current age Gender No. males No. females Socioeconomic status* Marital status No. married No. unmarried Number of children No. w/l child No. w/no child Parental marital status No. married No. divorced

Comparison group

groups

12 or x2 value’

a!f

20 yr

19 yr 8 months

0.95

49

17 9

18 8

0.09

1

24.1

23.8

0.05

50

1 25

1 25

0.00

1

2 24

0 26

1.44

50

22 4

20 6

0.50

1

‘Current age, socioeconomic status, and number of children are I values and the remaining are x2 values. ZDetermined based upon the Myers and Bean Index of Socioeconomic status.

Parent training with noncompliant children

103

and to utilize reinforcement for compliance and time-out for noncompliance. Didactic instruction, modeling, role-play, interaction with the child in the clinic and structured times to practice skills in the home are employed as teaching procedures. Parent training measures

The following behavioral observation measures, collected during four 40 min home observations at pretreatment and posttreatment, were utilized to assess the immediate impact of parent training (i.e. ascertain if parent training was effective): Child compliance to total commands issued by the mother; Child compliance to alpha commands (a command to which compliance can be initiated); and Child deviant behavior (whining, crying, yelling tantrums, aggression and deviant talk). Details on the definition of these behaviors and on the scoring system are available in Forehand and McMahon (198 1). Details on reliability and validity of the coding system are available from the same source. Follow -up measures

The following measures were utilized to assess the functioning of individuals as they transitioned from late adolescence to early adulthood. Four broad-based areas of functioning were assessed: relationship with parents, delinquency, emotional adjustment and academic performance. Relationship with parents. The quality of the young adult’s relationship with his or her parents was assessed with the Conflict Behavior Questionnaire (CBQ; Prinz, Foster, Kent & O’Leary, 1979). The CBQ consists of 75 dichotomous items pertaining to family communicationconflict behavior. Example items include: “My mother (father) doesn’t understand me”, “I enjoy spending time with my mother (father)“. This instrument has yielded alpha coefficients of above 0.88 and has been shown to discriminate between clinical and nonclinical populations (Prinz et al., 1979). A short form of the CBQ, consisting of the 20 items with the highest item-total correlations and phi coefficients, also has been developed. The short form correlates with the longer version at 0.96 (Robin & Foster, 1989). The short form of the CBQ was used in the current study and was completed by the young adults in reference to both their mothers and their fathers, thus yielding a measure of relationship quality with each parent. Delinquency. A measure of delinquent behavior was determined using two measures. First, a self-report measure developed for the National Youth Survey (NYS; Dunford & Elliott, 1984) was completed by the young adult. The scale consists of 47 items designed to represent the full range of criminal acts that can lead to a juvenile’s arrest. The items are grouped together based upon the nature and severity of the acts, corresponding to eight offense-specific scales. For purposes of this study, three scales were of interest. First, the Hard Drug Use scale was examined. On this scale individuals are asked to report the number of times they used five hard drugs (i.e. hallucinogens, amphetamines, barbiturates, heroin, cocaine derivatives) in the past year. Each item with a response greater than zero was assigned a ‘l’, such that totals ranged from 0 to 5. The other two measures were an Index Offenses scale (e.g. aggravated assault, sexual assault, gang fights, stole motor vehicle, broke into building, broke into a vehicle) and a General Delinquency scale (e.g. bought stolen goods, stole something valued at greater than $50, gang fights, sold marijuana, hit parent, disorderly conduct, strongarmed others). The former represented severe forms of delinquency, while the latter, which also included index offenses, encompassed more varied and less severe forms of delinquency. The presence/absence in the past year of each of the above behaviors constituting Index Offenses (possible range of scores &9) and General Delinquency (possible range of scores O-22) were summed to obtain a score for each of the two scales. All scales on the NYS have demonstrated acceptable levels of reliability and have some data to support their validity (Elliott, Ageton, Huizinga, Knowles & Canter, 1983; Huizinga & Elliott, 1986). All young adults completed this measure. In addition to the NYS, the Michigan Alcohol Screening Test (MAST), a self-report scale, was administered in order to obtain a specific measure of drinking behavior. The MAST (Selzer, 1971) consists of 25 ‘yes-no’ items and yields total sum scores which can range from 0 to 24. Normative data suggest that a score greater than 4 indicates possible alcoholism (Selzer, 1971). Validity and

104

PATRICIA LONGet al.

reliability of the MAST have been demonstrated on multiple occasions (e.g. Selzer, 1971; Selzer, Vinokur & Van Roijen, 1975). emotional a~~stment. The Rosenberg Self Esteem scale (RSE) and the Brief Symptom Inventory (BSI) were administered as measures of the young adult’s emotional adjustment. The RSE (Rosenberg, 1965) was designed to assess an individual’s global sense of self-esteem and worth. The RSE consists of 10 items scored according to a four-point response format (strongly agree, agree, disagree, strongly disagree). A mean value is obtained, such that scores range from 1 to 4, with higher scores associated with higher overall esteem. The RSE has been shown to have test-retest reliability of 0.82 over a I-wk period (Fleming & Courtney, 1984), and several externai validity studies have demonstrated adequate correlations (coefficients from 0.55 to 0.72) with other self-esteem inventories (e.g. Savin-Williams & Jaquish, 1981). The BSI (Derogatis & Spencer, 1982) is a 53-item self-report instrument that was developed as a global screening measure for psychological symptoms, Individuals are asked to rate items according to level of distress, ranging from ‘not at all’ to ‘extremely’. The scale yields nine symptom dimensions and three global indices. For the purposes of the present study, the Global Severity Index was the primary follow-up measure. This index is considered a measure of general adjustment and distress. However, the following nine subscales also were examined: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. Higher scores reflect greater adjustment difficulties. Derogatis, Rickels and Rock (1976), among others, have demonstrated adequate reliability and validity. Academic achievement. Highest academic grade achieved was used as a measure of academic progress and achievement for the young adults. This was obtained via a single-item self-report. For years of education in high school, a numerical value was assigned, such that ninth grade = 9, tenth grade = 10 and so forth. For years of education beyond high school, a numerical value was assigned, such that 1 yr of college = 13, 2 yr of college = 14 and so on. Follow -up procedure An attempt was made to contact by telephone all families who had participated in the parenting program at least 14yr earlier. For those who were unreachable by phone, a letter requesting the young adult’s participation was mailed to the most recent address availabte for that family. For those from whom there was no response, a second letter was mailed. For families who had moved with no forwarding address or telephone number, an attempt was made to iocate a phone number through information services or relatives, or to obtain a new address through the post office. With these efforts, 30 individuals were contacted, of which 26 both agreed to participate and completed a mail-out packet of measures. For completing and returning these measures, each participant was mailed a check for $40, The comparison group was drawn from a larger community sample, participating in a follow-up study from their early adolescent years. Original recruitment of these Ss was conducted through posted notices, distribution of fliers, newspaper announcements and, for some adolescents from divorced families, local courthouse records. These participants were recontacted by telephone 5-7 yr after the initial assessment and asked to complete follow-up questionnaires which would be mailed to them. They also were paid $40 for their participation. RESULTS In the current study numerous statistical comparisons were conducted. As in the Forehand and Long (1988) study, in order to at least partially control for the multiple comparisons, the P level for significance was set at 0.01 for all analyses. One-tail t-test values were utilized as we were only interested in dete~ining if the clinic group was functioning less well than the comparison group. Participunts vs nonparticipants Initially, comparisons were made between the parent training families who participated in the follow-up and those who did not participate. This comparison allowed us to determine if the participants were representative of the overall sample. The means for the two groups and the results of t-tests conducted are presented in Table 2. There were three categories of dependent variables:

Parent

training

with

noncompliant

Table 2. Means and results of r-tests for participants Parent Training

and non-participants

Particiaants

Demographics Age (months) SES’ Pretreatment Compliance total Compliance alpha Deviant behavior Posttreatment Compliance total Compliance alpha Deviant behavior

at the time of P-value

NonMeasure

105

children

oarticioants

t

df ’

sicmificant* no

66.2 24.1

76.0 39.3

1.7 2.8

47 47

28% 83% 10%

30% 81% 9%

0.6 0.4 0.4

47 47 36

no

42% 90% 4%

38% 85% 6%

1.3 2.1 2.1

46 46 36

no no no

‘df vary primarily because all measures were not collected *Yes=P
with all parent

yes no no

training

cases.

demographic, pretreatment and posttreatment. The results of these analyses indicate that participants were of higher SES than nonparticipants. No other differences emerged.

Participant

improvement

at posttreatment

Previous findings have shown that, as a group, the behavior of children who participated in this parent training program improved from pretreatment to posttreatment (e.g. Forehand & McMahon, 1981). Before analyses were conducted on follow-up information, analyses were conducted to insure that the participants in this follow-up, who are a subgroup of those included previously, did improve from pre- to post-parent training. The means for the participants at pretreatment and posttreatment and the results of the t-test conducted are presented in Table 3. Results indicate that these participants showed improvement over the course of treatment.

Table 3. Means and results of analyses for Parent Training posttreatment Measure Compliance total Compliance alpha Deviant behavior

Pretreatment 28% 83% 10%

Posttreatment 42% 90% 4%

participants

from pre- to

t

df ’

P-value significant2

4.5 2.9 3.4

48 48 26

yes yes ves

’ df vary due to corrections for unequal variance between groups and because all measures were not collected with all parent training cases. *yes = P < 0.01.

Follow -up results

The follow-up data consisted of a comparison of the Parent Training participants and the Comparison group. Four categories of dependent variables were investigated: relationship with parents, delinquency, emotional adjustment and academic performance. A series of t-tests was conducted to identify differences between the groups for all variables except grade. For grade achieved, an analysis of covariance was conducted, controlling for the effect of current age. This was viewed as necessary because individuals of different ages would vary in the number of grades they had the opportunity to complete. Means for the Parent Training Ss who participated in the follow-up and for the Comparison Ss, as well as the results of the t- and F-tests, are presented in Table 4. As evident in these tables, no differences emerged between the groups. Initially, for the emotional adjustment measure BSI, the two groups were compared only on the Global Severity Index. However, given that the difference between the scores of the Parent Training participants and the Comparison group approached significance (P < 0.09), additional comparisons were conducted on the nine subscales to insure that any true differences were not overlooked. Results of these t-tests show that the two groups did not differ on any subscale (see Table 5).

106

PATRICIA LUNG et al, Table 4. Means and statistical analyses for relationship with parent, delinquency, emotional adiustment and academic nroaress for Parent Trainina and Comnarison mouns Denendent variable Relationship with parent CBQ-M’ CBQ-F’ Delinquency Hard drug use? Index offenses6 No. general delinquences’ MAST’ Emotional adjustment RSI? BSI’s Dependent variable Academic Grade’ ’

Parent Traininn

Comoatison

t

df

’

P-value sinnificant*

4.12 3.23

2.06 3.00

1.9 0.2

37 45

no “o

0.23 0.19 1.31 2.60

0.40 0.16 0.88 1.96

0.8 0.3 1.1 0.1

41 49 49 42

no “o

I .80

1.48

0.62

0.41

2.2 1.7

50 50

no “o

“0

tl0

P-value

Parent Training

Comparison

F

df’

significant2

12.2

12.9

2.8

1.48

no

’ d/varies due to corrections for unequal variance between groups and because all measures were not completed by all Ss. ~Yes=PiO.Ol. ‘CBQ-M = Conflict Behavior Questionnaire, completed by young adult about mother. High scores indicate poorer communication. ‘CBQ-F = Congict Behavior Questionnaire, completed by young adult about father. High scores indicate poorer communi~tion. $Number of hard drug uses in last year as reported on the NYS. *Number of index offenses in last year reported on the NYS. ‘Number of general delinquency items in last year reported on the NYS. sMAST, a score of 4 or more indicates possible alcoholism. ‘RSE scale; higher scores indicate better self-esteem. ‘sBSI: Globa Severity Index; higher scores indicate greater distress. “Differences in highest grade achieved were tested by means of an ANCQVA controlling for current age. Adjusted means are reported.

DISCUSSION

The present study replicates, and extends to the beginning of adulthood, the findings previously reported by Forehand and Long (1988). That is, children who had participated in parent training with their parents some years earlier were now functioning as well as late adolescents/young adults from the community. Generally, there were no differences in functioning across multiple areas, including delinquency, emotional adjustment, academic performance and relationship with parents. One particular interest in the study is the failure to find differences in grade obtainment by the two groups. The previous study by Forehand and Long (1988) suggested that the parent training group was functioning significantly lower in terms of grade point average than the community control group. However, the current results suggest that the two groups had made similar educational progress. The reason for the discrepancy in findings is uncertain but suggests that academic performance of treated behavior problem children may eventually ‘rebound’ and, thus, may not be a long-term negative consequence of early behavioral difficulties. However, it should be noted that grade point average and years of academic progress are two different measures that

Table 5. Means and statistical analyses for BSI subscale scores for Parent Training and Comtwison arouns Dependent variable Somatization Obsessivbcompulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism

Parent Training

Comparison

r

Q ’

signifIcant2

0.33 0.86 0.88 0.69 0.63 0.75 0.31 0.86 0.46

0.29 0.58 0.48 0.48 0.39 0.48 0.13 0.45 0.32

0.3 1.7 1.7 1.1 1.5 I.? 1.4 2.2 I.1

50 50 35 so 40 50 37 50 50

“o “Cl

P-value

IlO tl0

no “o nc no no

‘I were corrected for several analyses due to unequal variances, resulting in df less than the expected 50. syes= P
Parent training with noncompliant children

107

may produce different outcomes and, thus, there may not actually be a discrepancy in the Forehand and Long findings and the current results. Of particular importance in this study is the fact that we assessed multiple areas of functioning. Some data suggest that the transition from one developmental period to another can selectively accelerate problems in various areas (Forehand & Wierson, 1993). Thus, it is important, particularly when conducting long-term follow-up, to assess multiple areas of functioning. Although this was done in the present study, it is important to point out one limitation of our assessment procedure. That is, the particiants were assessed only by self-report questionnaires. However, this was necessary as many of them were independent from their parents and were at distances far removed from the site of initial participation. The present results suggest that children who were identified and treated by parent training early in childhood for behavior problems are functioning as well as a nonclinic group during the transition to adulthood. Obviously, without an untreated control group, one cannot draw the conclusion that participation in parent behavioral training is the reason for their current functioning. That is, it is conceivable that the treated children would have improved since initial assessment without treatment. However, as noted by Forehand and Long (1988), there are substantial data to indicate that the behavior of acting-out, antisocial children is stable over time (Olweus, 1979; Kazdin, 1985). Such data suggest that the clinic-referred children in the present study may not have resembled the community sample at the current assessment without intervention. In conclusion, the present evaluation provides support for the continued existence of treatment effects associated with an earlier implementation of a parent training program. Future assessments of the participants should provide information about their functoning in additional areas, such as marital/family life and occupation, which cannot yet be assessed for the majority of individuals entering adulthood. Acknowfedgemenfs-This research was supported in part by the William T. Grant Foundation Georgia’s Institute for Behavioral Research.

and the University of

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Short Michigan Alcoholism Screening Test