Effects of parent management training programs on disruptive behavior for children with a developmental disability: A meta-analysis

Research in Developmental Disabilities 38 (2015) 272–287

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Research in Developmental Disabilities

Effects of parent management training programs on disruptive behavior for children with a developmental disability: A meta-analysis Laura Skotarczak a,*, Gloria K. Lee b a b

University at Buffalo – State University of New York, United States Michigan State University, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 9 September 2014 Received in revised form 1 December 2014 Accepted 3 December 2014 Available online 8 January 2015

This meta-analysis determined the effects of parent management training (PMT) on disruptive behaviors in children with a developmental disability. Parent management training programs, based on behavioral theories of psychology, are commonly used in addressing disruptive behavior in children. Eleven studies met inclusion criteria with a total of 540 participants, with 275 in experimental groups and 265 in control groups. The effect of PMT on the disruptive behavior in children with a developmental disability was significant (g = 0.39). The moderator effects of type of PMT, delivery type and setting, and administrator level of education were also significant. The moderator effects of child age, and session number and duration were not significant in this meta-analysis. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Meta-analysis Parent management training Parenting Child behavior Developmental disability

1. Introduction 1.1. Developmental disability and children According to the Centers for Disease Control and Prevention (CDC, 2011), 13.9% of children between the ages of 3 and 17 years in the United States are diagnosed with a developmental disability. In the period between 1996 and 2008, the prevalence of developmental disabilities has increased 17% (Boyle et al., 2011). Boyle et al. (2011) suggest that developmental disabilities as a whole may be more prevalent due to increased rates of infants surviving from preterm birth and genetic disorders, such as Down syndrome. Regardless of cause, more children than ever are diagnosed with a developmental disability such as Autism Spectrum Disorder (ASD), Down syndrome, Cerebral Palsy and Special Learning Disability. In addition to the functional and intellectual delays resulting from a developmental disability, a child with a developmental disability is more likely than a typically developing child to engage in maladaptive behaviors (Gadow, DeVincent, Pomeroy, & Azizian, 2004; Holden & Gitlesen, 2006), and also more likely to be diagnosed with a psychiatric disorder, such as anxiety disorder, depression, and conduct disorder (Emerson, 2003; Gadow, Guttmann-Steinmetz, Rieffe, & DeVincent, 2012). Furthermore, the disruptive behaviors of children with a developmental disability are more severe than those behaviors with children who only have a mental health diagnosis (Gadow et al., 2004).

* Corresponding author. Tel.: +1 7162383845. E-mail address: [email protected] (L. Skotarczak). http://dx.doi.org/10.1016/j.ridd.2014.12.004 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.

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1.2. Disruptive behaviors and effects on children Maladaptive behaviors associated with children with developmental disabilities include yelling, screaming, aggression, and self-injurious behavior, such as head banging (Lecavalier, 2006). Lecavalier (2006) reports that over a two-year period, school-age children with pervasive developmental disorders experience high rates of emotional and behavior problems as compared to typically developing students. In their systematic review, Davies and Oliver (2013) report that aggression and self-injury increase with age in children with developmental disabilities even into adulthood. Maladaptive behaviors are often inadvertently reinforced by parents seeking to reduce the severity of behavior and giving into such behavior, and thereby offering a perceived reward (Eddy, Leve, & Fagot, 2001). 1.3. Disruptive behaviors and effects on parents Parents of a child with a developmental disability are at greater risk for increased stress related to parenting when compared to typically developing children (Baker et al., 2003). Margalit, Shulman, and Stuchiner (1989) found that an increase in disruptive behaviors is correlated with a higher level of parent stress. Neece, Baker, Blacher, and Crnic (2011) report symptoms of comorbid attention-deficit hyperactivity disorder (ADHD) in children with a developmental disability were emergent earlier in childhood and that this, in part, is perhaps due to increased parent stress, which can exacerbate ADHD-related and disruptive behaviors in children. Besides causing stress, these disruptive behaviors also have a detrimental impact on maternal mental health. Gray et al. (2011) found that maternal depressive and anxiety symptoms are higher for mothers of children with a developmental disability than mothers of typically developing children and such symptoms worsen over time. Zablotsky, Anderson, and Law (2012) report that the more severe behaviors the child with autism displays, the higher the risk of depression for the mother, and maternal quality of life is also reported to be lower. In addition to depression, anger is also higher in parents of children with a developmental disability. The anger also causes increased depression and stress in parents (Benson & Karlof, 2009). The wide range of negative emotions and effects on parents resulting from the stress of raising a child with a developmental disability are evident. Increasing positive and proactive parenting practices is likely to reduce negative behaviors in children (Kazdin, 1997) which in turn is likely to reduce parent stress, thereby reinforcing more positive parenting practices. In addition, this will promote positive parental mental health outcomes. 1.4. Parent management training Parent management training (PMT) is one of the different types of intervention that is commonly used by health care professionals working with families and individuals with emotional and behavioral disorders by teaching parents/families the necessary skills in managing children’s disruptive behaviors. PMT programs are based on the following three theoretical approaches – social learning theory, coercion model of interaction, and applied behavior analysis, all of which are considered behavioral schools of psychological theory. Social learning theory (SLT), developed by Albert Bandura, maintains that children learn how to behave as observations are made about the behavior of others in reaction to their own behavior (Bandura, 1969; Grusec, 1992). In addition, a child learns how to behave based on how others behave. The ability of a child to manipulate and process the environment in which he/she lives changes as the child matures. One explanation for why such behavior might be continuously allowed by parents can be explained by the coercion model first described by Patterson (Patterson, 1980). In this model of family interaction, a child receives reinforcement for negative behavior by the response of the parent to this behavior. If this interaction occurs often, the family process might deteriorate to the point where the child receives more negative reinforcement for maladaptive behaviors than positive reinforcement for preferred behaviors and a coercive family process might become the norm (Eddy et al., 2001). A central aim of most PMT programs, such the Triple P Positive1 programs (Sanders, 1999) is to alleviate or eliminate this coercive process. Many PMT programs also utilize principles and practices of Applied Behavior Analysis (ABA). Applied Behavior Analysis is an approach to understanding behavior and encouraging the improvement of behaviors (Cooper, Heron, & Heward, 2007) especially those behaviors that are personally important to participants’ everyday activities. Behavior change occurs when stimuli, such as reinforcers (to encourage desired behavior) and punishment (to discourage maladaptive behavior) directly follows the behavior. The key to change is timing the stimuli to directly follow the behavior. The application of ABA in PMT programs occurs through techniques such as observing and recording behavior, modeling, rewarding of appropriate behavior, and planned ignoring. Just as there is overlap between PMT programs’ theoretical bases, intervention strategies across PMT programs are often similar. These include the building of parent strengths and communication style to increase problem solving (Sharry, Guerin, Griffin, & Drumm, 2005); using role-playing and video-taped modeling (Sharry et al., 2005; Webster-Stratton & Herman, 2008); using descriptive praise and rewarding positive behavior and planned ignoring (Kazdin, 1997; Sanders, Mazzucchelli, & Studman, 2004). While processes and details sometimes differ between different PMT programs, all aim to improve child behavior via changing parental response to behaviors (Lucas, 2011). Thus far, some evidence exists in supporting the benefits of PMTs for parents and children with developmental disabilities. For instance, Matson, Mahan, and LoVullo (2009) included ‘‘training packages’’ in a review of parent training methods for children with a developmental disability and concluded that parent trainings are cost effective, may reduce the

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need for psychopharmacological interventions, and have great potential to generalize behaviors to other areas of life. Roberts, Mazzucchelli, Taylor, and Reid (2003) examined the effects of early interventions, including PMT programs, on the behaviors of young children with a developmental disability and suggest that interventions based on social learning theory and applied behavior analysis held particular potential. Brookman-Frazee, Stahmer, Baker-Ericze´n, and Tsai (2006) examined parenting interventions, including parent training, for both children with developmental disabilities and typically developing children. These authors suggest that behaviors of both groups ‘‘overlap’’ and that research gained in both groups might inform future research as well as improve treatment. Typically, the specific PMT programs developed by the authors are evaluated and assessed over time and assembled in a treatment manual. Facilitators are trained to administer the programs and the fidelity to the manual is assessed to ensure that facilitators are completing programs as prescribed. 1.5. Previous reviews and rationale for current study Much research has been conducted on PMT programs on the behavior of children with a developmental disability, mainly with three different types of studies. The first type, efficacy studies, has studied the effects of PMT when the child has a developmental disability. Such studies include the effect of PMT on parental mental health and/or parenting skills (Tonge et al., 2006; Todd et al., 2010; Davidson, 2011; Gammon & Rose, 1991; Neff, 2012; Niccols & Mohamed, 2000); or child outcomes (Drew et al., 2002); or parent and child outcomes (Chadwick, Momcˇilovic´, Rossiter, Stumbles, & Taylor, 2001; Coughlin, Sharry, Fitzpatrick, Guerin, & Drumm, 2009; Feldman & Werner, 2002; Fujiwara, Kato, & Sanders, 2011; Griffin, Guerin, Sharry, & Drumm, 2010; Hand, Raghallaigh, Cuppage, Coyle, & Sharry, 2013; Hudson et al., 2003; McIntyre, 2008a, 2008b; Research Units on Pediatric Psychopharmacology [RUPP] Autism Network, 2007; Roberts & Pickering, 2010; Quinn, Carr, Carroll, & O’Sullivan, 2006; Tellegen & Sanders, 2014; Whittingham, Sofronoff, Sheffield, & Sanders, 2009). The second type are systematic and literature reviews which also have been conducted on PMT programs for children with a developmental disability (Brookman-Frazee et al., 2006; Gavidia-Payne & Hudson, 2002; Hastings, Robertson, & Yasamy, 2012; Matson et al., 2009; Roberts et al., 2003; Singer, Ethridge, & Aldana, 2007), and review the outcomes of efficacy studies. The third type of study is meta-analysis, many of which have examined the effect of PMT on disruptive behavior in children who are typically developing (Maughan, Christiansen, Jenson, Olympia, & Clark, 2005; Harris, 2007) and parent outcomes for typically developing children (de Graaf, Speetjens, Smit, de Wolff, & Tavecchio, 2008), including one examining the effects of fathers in particular (Fetcheri, Freeman, & Matthey, 2011); and parent and child outcomes (Nowak & Heinrichs, 2008). However, less was done on evaluating the effectiveness of PMT programs on the reduction of the child’s disruptive behaviors when the child has a diagnosis of developmental disability. For instance, the Triple P Positive1 program has been evaluated in several meta-analyses (de Graaf et al., 2008; Fetcheri et al., 2011; Nowak & Heinrichs, 2008). However, Nowak and Heinrichs (2008) included samples where both typically developing children and children with a developmental disability were mixed in the intervention but did not investigate the effect on children with a developmental disability as a unique group. In de Graaf et al.’s study (2008), the researchers focused on the effect of the program on parenting skills but not on any child outcomes. Similarly, Fetcheri et al.’s study (2011) also only studied the effects on fathers’ parenting skills as the outcome but did not include any child outcomes. Singer et al. (2007) examined the effects of group parent trainings on depression and stress of parents of children with a developmental disability, but did not examine the effects of these on child behavior. To date, there has been one meta-analysis published on a specific PMT program for children with a developmental disability. Tellegen and Sanders (2013) examined the effects of Stepping Stones Triple P (SSTP), an adapted form of Triple P Positive1 for children with a disability, on the behavior of children with a developmental disability. The outcome of this meta-analysis is generally encouraging, with a medium effect size for child behavior change (d = 0.54). Tellegen and Sanders broke down the effect not only by child behavior but also by level of SSTP, and all effect sizes are moderately significant. While the Tellegen and Sanders meta-analysis indicates SSTP has a positive effect on disruptive behavior on children with a developmental disability, there are, however, a few limitations to note. Specifically, all of the studies included in the Tellegen and Sanders meta-analysis are located in Australia, making generalization to other countries and ethnic groups problematic. In addition, many SSTP studies were included in the meta-analysis, but these were from all levels of SSTP, which vary in intensity of intervention, from brief psycho-education to seminars. Also, the only moderator effect examined was the effect of the different levels of SSTP and outcomes and the findings were inconclusive. 2. The current meta-analysis Although PMT programs have existed for decades and have been heavily researched on for their efficacy, there have been no meta-analyses published to determine the direct effects of PMT programs on the disruptive behaviors of children with a developmental disability especially, as well as investigating at the various pertinent moderating effects of the different variations and modes of the programs (e.g. age of child, individual vs. group format, etc.). Developmental disability is a chronic condition and the behaviors and mental health diagnoses of children with a developmental disability tend to be more severe than those of typically developing children. PMT programs have been developed specifically to increase the parenting skills necessary to reduce such behaviors of children. This meta-analysis seeks to determine the effect of PMT programs on reducing disruptive behaviors on children with a developmental disability, with specific focus on various moderating effects in order to understand how they may affect the outcome.

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3. Methods 3.1. Search A comprehensive search of the literature was conducted in the following research databases – Academic One File, Access Medicine, Alt Health Watch, Articles Plus, ERIC, ProQuest Dissertations and Theses, and PsychInfo. The following key words, and combinations of the key words were used: autism, developmental disability, intellectual disability, parent management, parent training, spectrum, Asperger, pervasive developmental, emotional disturbance, behavior, disruptive behavior, child disintegrative, Autism Society of America, Triple P, The Incredible Years1, Noncompliant Child, and Common Sense Parenting. Authors who have contributed significantly to the field of PMT were also searched individually by their names. In addition, authors who have multiple publications or strong connections to specific PMT programs were contacted via email to determine if unpublished studies were available. Earlier reviews and meta-analyses concerning parent management or parent training were manually reviewed for relevant studies. These searches returned thousands of articles and studies. After eliminating articles and manuscripts that were not experimental studies (i.e. were literature reviews or reports) and all duplicate returns, 52 studies related to PMT and developmental disability remained. 3.2. Inclusion/exclusion criteria All promising studies were initially examined to determine if the following inclusion criteria were met: (a) the PMT programs evaluated were in line with the operational definition of PMT programs – parenting programs researched and developed to educate parents on how to increase positive behavior and decrease negative behaviors in an organized and meaningful manner (Kazdin, 2005); (b) examined the behavior of children with a developmental disability, which was defined as genetic or acquired disabilities that result in delays across several areas of functioning and are chronic (Neidert, Dozier, Iwata, & Hafen, 2010); (c) the developmental disability originated before the age of 18; (d) the impairment affected the functional ability in the areas of conceptual, social and practical skills as well as intellectual functioning (Schalock et al., 2010). These impairments cause difficulties in many areas of daily living, such as school, work, and self-care; (e) studies were evaluated using randomized controlled trials; (f) studies had pre-test and posttest measures that were administered immediately before the beginning of the intervention and immediately after the end of the intervention; (g) studies had control groups that were either no treatment or treatment as usual (TAU) but not a specialized treatment such as medication; and (h) studies were conducted no earlier than 1990. Mental and/or physical disorders that are not associated with intellectual or cognitive impairment were excluded, which excluded ADHD and other conduct-related disorders (Singer et al., 2007). 3.3. End studies With the stated inclusion and exclusion criteria, we yielded 29 papers. Of these papers, eight papers were excluded because only parent outcomes were evaluated or reported (Bristol, Gallagher, & Holt, 1993; Drew et al., 2002; Neff, 2012; Niccols & Mohamed, 2000; Pelchat, Bisson, Ricard, Perreault, & Bouchard, 1999; Schultz et al., 1993; Tonge et al., 2006; Wang, 2008). One paper was excluded because the control group was a ‘‘medication only’’ group (Farmer et al., 2012). Two papers were excluded because behaviors of children with developmental disability were not evaluated separately but as part of a larger group including typically developing children (Gammon & Rose, 1991; Griffin et al., 2010). As a result, the evaluation of the effect size for children with a disability as a distinct group was impossible. Another paper lacked a control group for child behavior (Hudson et al., 2003). One paper did not evaluate changes in disruptive behavior as child outcomes and thus was excluded (Oosterling et al., 2010). Another paper did not report appropriate scale psychometrics and information on the scale was not able to be identified (Feldman & Werner, 2002). Two papers (Chadwick et al., 2001; Strauss et al., 2012) were excluded because study design included a teacher training component. A final paper was excluded because the posttest assessments were not gathered immediately after the intervention but six weeks after (Sofronoff, Jahnel, & Sanders, 2011). When possible, authors were contacted when necessary data was missing, inadequate, or required clarification. When authors were able to provide the necessary data, those papers were included. Of the remaining 12 papers, three contained two experimental groups, leading to issues of dependency in which control groups were shared (Plant & Sanders, 2007; Sofronoff, Leslie, & Brown, 2004) or program trainers were shared (Roberts, Mazzucchelli, Studman, & Sanders, 2006). To eliminate the issue of dependency, the study (in each of these papers) with the larger number of participants in the experimental group was chosen, and the second group was excluded. In one paper (Sofronoff et al., 2004) both studies had the same number of participants in the experimental group (18) therefore both were excluded to eliminate any issue of dependency. As a result, 11 final study groups remained. 3.4. Data coding The coding of the original 29 papers meeting inclusion criteria was conducted by the first and second authors. One variable was calculated – child behavior change per parent report, with intercoder agreement being 90%. This resulted in 11 studies included, 15 excluded, and three disputed. The three disputed articles were examined more closely and determined to not fit the inclusion criteria thus excluded. A flow chart of the inclusion/exclusion process is located in Fig. 1.

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♦ ♦ ♦ ♦

♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

♦

Fig. 1. Inclusion/exclusion process flow diagram.

3.5. Measures used to determine child behavior change The purpose of this meta-analysis is to determine the effects of PMT programs on disruptive behaviors in children with a developmental disability as reported by parents. The following instruments were used to measure child behavior change in those studies with generally one instrument per study, but some studies used two measures. 3.5.1. Child Behavior Check List (CBCL, Achenbach & Rescorla, 2000) The CBCL was developed by Achenbach and Rescorla (2000) that assesses the severity of negative behaviors in children as well as indicates the possibility of a diagnosis. There are two versions of the CBCL, the CBCL – 1½ to 5 (years of age), a 99 item measure and the CBCL 6 to 18 (years of age), a 113 item measure. Both are rated based on the same 3-point scale (0 = not true, 1 = somewhat or sometimes true, or 2 = very true or often true). Parents are asked to consider behavior over the last six months. Both versions measure behavior on two different areas – syndrome and DSM-IV-oriented scales. The CBCL 1½ to 5 is used for preschoolers and the syndrome scales include emotionally reactive, anxious/depressed, somatic complaints, withdrawn, sleep problems, attention problems and aggressive behavior. The DSM-IV oriented scales include affective problems, anxiety, pervasive developmental problems; attention deficit/hyperactivity, and oppositional defiant. The CBCL 6 to18 is for school aged children, the syndrome scales are anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior and aggressive behavior. The DSM-IV oriented scales are affective problems, anxiety, somatic, attention deficit/hyperactivity, oppositional defiant and conduct. The CBCL is used in the evaluation of three studies (McIntyre, 2008b; Quinn, Carr, Carroll, & O’Sullivan, 2007; Wilson, 2011).

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3.5.2. Eyberg Child Behavior Inventory (ECBI, Eyberg & Pincus, 1999) The ECBI was developed by Eyberg and Ross (1978) and revised in Eyberg and Pincus (1999) to assess both the types of behavioral problems and their intensity. The ECBI is a 36-item measure consisting of two sub-scales – behavior intensity scale and behavior problem scale. Parents are asked to rate a number of behaviors in two ways (Eyberg & Pincus, 1999). First, parents are asked to specify if a list of behaviors is a problem with a yes or no. The yes responses are summed to determine the behavior problem scale score, which ranges from 0 to 36 (each yes is worth a value of one). Second, for each behavior the behavior intensity scale is determined via a 7-point Likert Scale, from 1 (never occurs) to 7 (always occurs). Scores on the behavior intensity scale range from 36 to 253. The ECBI does not include a total score, but frequency and intensity are calculated as separate scales. The ECBI was used in five studies (Leung, Fan, & Sanders, 2013; Plant & Sanders, 2007; Roux, Sofronoff, & Sanders, 2013; Tellegen & Sanders, 2014; Whittingham et al., 2009). 3.5.3. Strengths and Difficulties Questionnaire (SDQ, Goodman, 1997) SDQ was developed by Goodman (1997) to assess various problematic behaviors for children ages 4–17 years. The SDQ is a 25-item measure consisting of five subscales. There are four difficulty subscales – conduct problems scale, hyperactivity scale, emotional scale and peer problems scale plus one prosocial scale. Each item is rated on a 3-point Likert scale (0 = not true, 1 = somewhat true, or 2 = certainly true). Each of the subscale scores ranges from 0 to 10. The sum of the four difficulty subscales is added to determine the Total Difficulties Score which ranges from 0 to 40. There is also a five item impact section of the SDQ, intended to measure the impact of these behaviors on child stress, home life, school, leisure activities and peer relationships. Items in the Impact section are also rated on a 3 point Likert Scale (0 = not at all/only a little, 1 = a medium amount, and 2 = a great deal). A total score is not measured in the impact section; instead the score for each item is considered individually and ranges from 0 (not at all/only a little) to 2 (a great deal). There are three versions of the SDQ – parent report, teacher report and child/adolescent report. The parent version of the SDQ was used in three studies (Coughlin et al., 2009; Hand, McDonnell, Honari, & Sharry, 2013; Hand, Raghallaigh, et al., 2013; Quinn et al., 2007). 3.5.4. Developmental Behavior Checklist (DBC, Einfeld & Tonge, 2002) The DBC was developed by Einfeld and Tonge (2002) to assess various maladaptive behaviors of children with intellectual and developmental disabilities of age 4 to 18. There are five versions of the DBC – Parent/Carer (DBC-P), Teacher (DBC-T), Adult (DBC-A), Parent Short Form (DBC-P24), and Monitoring (DBC-M). The DBC-P is a 96-item measure consisting of six subscales – anxiety, communication disturbance, social relating, self-absorbed, and disruptive/antisocial. Each item is rated on a 3-point Likert scale (0 = not true as far as you know, 1 = somewhat or sometimes true, or 2 = very true or often true). The scale can be used for a total score/mean score, to evaluate overall behavior (range 0–192); for individual items; or any or all subscales (each ranges from 0 to 32). The Roux et al. (2013) study used the DBC-P parent scale. The disruptive/antisocial subscale of the DBC-P parent report was used in the Plant and Sanders (2007) study. 3.6. Moderator variables The following moderators were identified during the coding process of the studies included in this meta-analysis. 3.6.1. Types of PMT The first moderator examined was the impact of specific PMT program. The different types of PMT programs evaluated in the meta-analysis are described below. 3.6.1.1. Parents’ Plus. The Parents’ Plus Programmes are evidence-based programs delivered in small groups and use a videobased format to illustrate both negative and positive family interactions. The sessions also include group discussions and assigned homework (Quinn et al., 2007). Two types of Parents Plus Programmes evaluated in this meta-analysis – Children’s Programme (Coughlin et al., 2009; Quinn et al., 2007) for children ages 6–12 years of age, and a modified version of the Children’s Programme, adapted to accommodate children with a developmental disability, examined by Hand, Raghallaigh, et al. (2013). 3.6.1.2. Stepping Stones Triple P Positive1 (SSTP). Stepping Stones Triple P Positive1 considers the function of the child’s behavior as well as focusing on positive behavior in an effort to increase parent efficacy and confidence (Whittingham et al., 2009). Stepping Stones Triple P1 is a module of the Triple P1 program that was developed specifically for use with children with a developmental disability. The Triple P1 program consists of different levels of intervention, from a public awareness campaign to interventions for parents at risk of abusive behaviors. The SSTP program level in this study is Level 4, which is for children with serious behavioral problems. Stepping Stones Triple P1 was used in six studies (Leung et al., 2013; Plant & Sanders, 2007; Roberts et al., 2006; Roux et al., 2013; Tellegen & Sanders, 2014; Whittingham et al., 2009). 3.6.1.3. The Incredible Years1. The Incredible Years is a PMT that has three different foci of curricula – parents, teachers and children. The program has been developed for children with conduct problems for ages 2–12 years. The Incredible Years1 uses video, group discussion and problem solving to encourage more positive behaviors over the course of 22–24 weekly sessions (Reid & Webster-Stratton, 2001). The topics taught include ignoring, natural and logical consequences, anger

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management, and tangible reinforcement. Parents are also assigned homework to reinforce lessons. The Incredible Years1 program was evaluated in McIntyre (2008b) and Wilson (2011). 3.6.2. Session number and duration Program dosage was examined in both the number of program sessions and length of session. Number of sessions ranged from 4 (Tellegen & Sanders, 2014) to 16 (Plant & Sanders, 2007). Session duration ranged from 60 (Tellegen & Sanders, 2014; Whittingham et al., 2009) to 150 min (Hand, Raghallaigh, et al., 2013; McIntyre, 2008a, 2008b; Wilson, 2011). 3.6.3. Program delivery setting and delivery type The moderator effects of delivery setting (site or home-based) were examined as well as three different types of program delivery methods – group, individual and mixed. In the case of mixed delivery methods, participants attended groups and received some of the curriculum individually or as a couple in person or by phone. 3.6.4. Administrator level of education The moderator effect of the PMT trainers’ level of education was examined. The level of education fell into one of two categories – bachelor or graduate. 3.6.5. Child age The moderator effect of child age was examined. The mean age of children assessed ranged from 4.11 (McIntyre, 2008b) to 8.54 years (Coughlin et al., 2009). 3.7. Data analysis Posttest differences between control (Group Mean 1) and experimental (Group Mean 2) were examined, calculating standard mean difference, d: d¼

X1  X2 SDwithin

Where X 1 and X 2 are Control Group Mean and Experimental Group Mean respectively and SDwithin is the within groups standard deviation, calculated as: sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ðn1  1ÞSD21 þ ðn2  1ÞSD22 SDwithin ¼ n1 þ n2  2 Where n1 and n2 are the sample sizes of Group 1 and Group 2, respectively and SD1 and SD2 are the standard deviations of Group 1 and Group 2, respectively. Effect sizes (d) were then converted Hedges g (Borenstein, Hedges, Higgins, & Rothstein, 2009) to reduce the possibility of bias that might result from small sample size: g ¼Jd Where the correction factor J is: J ¼1

3 4df  1

Only effects directly following treatment were evaluated. Longitudinal effects of treatment (i.e. those measured weeks or months following treatment end) were not analyzed in this meta-analysis. Quinn et al. (2007) evaluated child behavior using both the CBCL and the SDQ. In this case the effect sizes were standardized and averaged. Two studies (Leung et al., 2013; Tellegen & Sanders, 2014) used the ECBI, which measures behavior on two scales – intensity and problem; in these studies the effect sizes were also standardized and averaged. One study (Roux et al., 2013) used the ECBI and the DBC, and these effect sizes (ECBI behavior intensity, ECBI behavior problem and DBC score) were also standardized and averaged. 4. Results 4.1. Main effects The primary purpose of the current meta-analysis study was to evaluate the effectiveness of PMT for children with a developmental disability, with the main outcome on the reduction of disruptive behaviors. A total of 11 studies were included in this meta-analysis, resulting in a total of 540 participants. Among all, 275 parents participated in PMT and 265 were in a control group. The effect size for each study is located in Table 1. Overall and moderator effects were analyzed using the software R (R Core Team, 2012) and the data analysis package Metafor (Viechtbauer, 2010). Various statistics were used to assess the overall effect size, confidence intervals, heterogeneity

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Table 1 Individual study effect sizes. Author(s)

Type of PMT

Exp n

Con n

Delivery

g

v

SE

Coughlin et al. (2009) Hand, Raghallaigh, et al. (2013) Leung et al. (2013) McIntyre (2008a, 2008b) Plant and Sanders (2007) Quinn et al. (2007) Roberts et al. (2006) Roux et al. (2013) Tellegen and Sanders (2014) Whittingham et al. (2009) Wilson (2011)

Parents’ Plus Parents’ Plus Stepping Stones Triple Incredible Years Stepping Stones Triple Parents’ Plus Stepping Stones Triple Stepping Stones Triple Stepping Stones Triple Stepping Stones Triple Incredible Years

13 16 42 21 26 22 17 28 35 29 26

32 13 39 23 24 19 15 24 29 30 17

Combined Group Group Group Individual Group Group (mothers) Combined Individual Combined Group

0.07 0.06 0.25 0.40 0.22 0.38 0.66 0.83 0.12 0.97 0.95

0.16 0.00007 0.05 0.08 0.08 0.10 0.12 0.08 0.06 0.07 0.10

0.40 0.01 0.22 0.29 0.29 0.31 0.02 0.29 0.25 0.27 0.32

P P P P P P

test, and sensitivity test. In addition, a forest plot and a funnel plot were generated. The main effect size was determined using a random effects model. The overall main effect of PMT programs on the behavior of children with a developmental disability is significant (g = 0.39, p = .001, 95% CI = 0.15, 0.63), which indicates that PMT is effective in the reduction of disruptive behaviors among children with developmental disabilities. In addition, a sensitivity test showed that, after removal of the highest and lowest effect sizes, the overall effect ranged from g = 0.32 (p = 0.006; 95% CI = 0.09, 0.56), and g = 0.48 (p < 001; 95% CI = 0.26, 0.67) respectively, indicating neither of these effect sizes caused a large change in the main effect size. A forest plot displaying study effect sizes and overall effect, including 95% confidence intervals, is located in Fig. 2. A trim fill test indicates that there are six studies missing on the left side, and, were these missing studies included, the overall effect would be g = 0.06 (p < .001), indicating that publication bias is a threat. Finally, a funnel plot (Fig. 3) was also used to analyze the presence of publication bias did indicate a slight skew to the right, also indicating the possibility of publication bias in a positive direction. The use of studies published in journals contributes to this threat, as studies that are published tend to show significant positive effects (Cooper, 2010). The Q test for heterogeneity was significant (Q = 46.680, p < .001) indicating that there is between-study variability and which may be better understood with the exploration of moderator effects.

Fig. 2. Forest plot with 95% confidence intervals for effect sizes of included studies and main effects.

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Fig. 3. Funnel plot with missing studies indicating threat of publication bias.

4.2. Moderator effects Moderators were analyzed using a mixed effects model (R Core Team, 2012; Viechtbauer, 2010) to determine the effects of each moderator on disruptive behavior. The following were examined as categorical moderators – type of PMT, delivery setting, delivery type and level of trainer education. Categorical moderators and effects sizes are located in Table 2, and the results are as follows: 4.2.1. Type of PMT The type of PMT used was significant (QM (df = 3) = 17.828, p  .001). Stepping Stones Triple P1 (g = 0.48, p < 001, 95% CI = 0.20, 0.76) and The Incredible Years1 (g = 0.65, p = .013, 95% CI = 0.14, 1.17) were both significant as a moderator of child behavior. Parents Plus Programme had no effect on child behavior (g = 0.05, p = 77, 95% CI = 0.29, 0.39). 4.2.2. Delivery setting The site where PMT was administered was significant (QM (df = 2) = 12.30, p = .002). A combined (home and site) delivery setting (g = 0.63, p = .012, 95% CI = 0.14, 1.12) had a larger effect on child behavior than did PMT attended at an agency only (g = 0.32, p = .01, 95% CI = 0.06, 0.58). 4.2.3. Delivery type The manner in which a parent received PMT was significant (QM (df = 3) = 15.27, p = .002). The combined delivery type (g = 0.69, p < .001, 95% CI = 0.29, 1.09) had a significant effect on child behavior, in contrast to those administered solely by Table 2 Categorical moderator effects. Moderator

# Effect sizes (k)

Effect size (g)

p-Value (g)

95% CI LL

Type of PMT Incredible Years Parents’ Plus Stepping Stones Triple P Delivery setting Site based Combined Delivery type Individual Group Mixed Facilitator education Bachelors or less Graduate * p < 0.05.

Test of difference (Q test) UL

2 3 6

0.65 0.05 0.42

0.01 0.79 0.01

0.15 0.28 0.12

1.16 0.37 0.71

7 3

0.32 0.63

0.02 0.01

0.06 0.14

0.58 1.12

2 6 3

0.17 0.28 0.69

0.51 0.07 0.001

0.34 0.02 0.29

0.69 0.57 1.09

2 4

0.62 0.54

0.01 0.01

0.19 0.13

1.06 0.95

QE

QM *

10.91

14.00*

31.22*

12.30*

20.25*

15.27*

9.48

14.34*

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group (g = 0.20, p = .07, 95% CI = 0.22, 0.57), and individually (g = 0.17, p = .51, 95% CI = 0.34, 0.68), neither of which had a significant effect on child behavior. 4.2.4. Administrator level of education The level of education of the person conducting the training was a significant moderator (QM (df = 2) = 14.34, p > 0.001). Both trainers with a graduate degree (g = 0.62, p = .005, 95% CI = 0.19, 1.06) and those who did not (g = 0.54, p = .01 95% CI = 0.13, 0.95) had an effect on child behavior, although the effect was larger for those with a graduate degree. The following were run as continuous moderators – child age, session number, and session duration, all of which were non-significant. The results of these are – child age (QM (df = 1) = 1.40, p = .24); session duration (QM (df = 1) = 0.38, p = .54); and, session number (QM (df = 1) = 1.15, p = .28). Continuous moderator effect sizes are located in Table 3. 5. Discussion 5.1. Main effects This study aimed at evaluating the effectiveness of parent management training programs that assisted parents of children with developmental disabilities in reducing children’s disruptive behaviors. Using random effects model, the main effects of this meta-analysis indicated that, among the 11 randomized clinical trial effect sizes included, PMT programs have a positive and significant effect on the behavior of children with a developmental disability. The effect g = 0.32 is in the moderate range (Cohen, 1988). This result, although not quite as large, is not dissimilar from the effect of Tellegen and Sanders’ (2013) meta-analysis of Stepping Stones Triple P1 (d = 0.54). As noted previously, the Tellegen and Sanders metaanalysis is the only meta-analysis to date that examines the effects of PMT on the behavior of children with a developmental disability. 5.2. Moderator effects There is significant heterogeneity between the 11 studies, some of which can be attributed to moderator effects. In examining the potential moderators, some moderators have an effect in contributing to the differences in the main effects while others did not. In this study, the moderator effects of type of PMT, number of sessions, session duration, child age, delivery type, delivery setting, and facilitator education were examined. Of these moderators, number of sessions, session duration, and child age had no effect on child behavior. Type of PMT (Stepping Stones Triple P1, The Incredible Years1, and Parents Plus Programme), delivery type (individual, group, or mixed), delivery setting, and facilitator education (graduate degree, no graduate degree) all have significant effects on child behavior outcomes. 5.2.1. Types Among the three different PMT programs studied, Stepping Stones Triple P1 and The Incredible Years1 both had a significant effect on child behavior, while Parents’ Plus Programmes did not. As all of the PMT programs have similar theoretical bases and techniques, the effect of PMT type may not be attributed to differences in the theoretical approach. In addition, all have many years of research and ample published evidence to support their efficacy. The effect size for Stepping Stones Triple P1 in this study is similar to the effect size for Stepping Stones Triple P1 as found in the Tellegen and Sanders’ (2013) meta-analysis. The Tellegen and Sanders’ meta-analysis is the only published metaanalysis studying the effect of any PMT on the effect of PMT on the behavior of children with a developmental disability. The range of individual effects size for the included studies in this meta-analysis is g = 0.12 (Tellegen & Sanders, 2013) to g = 0.97 (Whittingham et al., 2009). The diverse range of effect size among the 11 studies on the reduction of children’s disruptive behaviors among children with a developmental disability could be due to other moderator effects. In general, literature showed that the Incredible Years1 also has robust evidence in supporting its efficacy, although such studies were conducted for children with other types of disorders in typically developing children, not for children with a developmental disability. More specifically, the effects of The Incredible Years1 on child behavior for typically developing children is much more robust (Larsson et al., 2009; McGilloway et al., 2012). Larsson et al. (2009) found The Incredible Years1 reduced aggression (d = 0.58) and McGilloway et al. (2012) reported improved total behavior (d = 0.48) in typically Table 3 Continuous moderator effects. Moderator

# Effect sizes (k)

Effect size (g)

p-Value (g)

Session duration Session number Child age

11 11 10

0.65 0.04 0.94

0.54 0.28 0.24

* p < 0.05.

95% CI

Test of difference (Q test)

LL

UL

QE

QM

0.19 0.86 0.14

1.49 0.78 1.75

0.13 36.82* 10.78

0.38 1.15 1.40

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developing children. Furthermore, The Incredible Years1 does not provide a training specifically designed for children with a disability, including developmental disability (McIntyre, 2008b), as does Stepping Stones Triple P1 and there are no metaanalysis studies examining the effects of The Incredible Years1 on the behavior of children with a developmental disability. In the current meta-analysis we examined two efficacy studies using The Incredible Years1 for children with a developmental disability with effect sizes from 0.40 (McIntyre, 2008b) to 0.95 (Wilson, 2011). Although there are no metaanalyses for examining outcomes for children with a developmental disability, Sougstad (2012) reported that the Incredible Years1 has a large (g = 0.70) effect on clinically significant child conduct behaviors. Menting, de Castro, and Matthys (2013), however, found the effect of The Incredible Years1 to be smaller (d = 0.27) than the effect size generated by this study. Parents’ Plus Programmes did not contribute significantly to the outcome of child behavior. This nonsignificance is likely due to the varying effect sizes for the studies included; specifically, d = 0.06 (Hand, Raghallaigh, et al., 2013) to 0.38 (Quinn et al., 2006). Although the three studies (Coughlin et al., 2009; Hand, Raghallaigh, et al., 2013; Quinn et al., 2007) included in the current meta-analysis were conducted on children with developmental disability only, an earlier study published by Quinn et al. (2006) did compare outcomes of children with a developmental disability with children who were otherwise typically developing (both had problems related to conduct). In the Quinn et al. (2006) study, children with a disability had larger improvements in behavior than that of typically developing children. 5.2.2. Methods of delivery The combined format of PMT, which includes both a group format with some individual consultation, had a significant and large effect on the outcome of child behavior. This is in contrast to formats delivered solely by group or on an individual basis, neither of which had a significant effect on child behavior. Results related to methods of delivery have been mixed in other meta-analyses. Serketich and Dumas (1996) find no differences in individual or group methods of delivery for PMT on antisocial behavior in young children (preschool to elementary age). Other studies, on the contrary, find individual formats to have an effect, or a greater effect, on child behavior than do group formats (Maughan et al., 2005; Nowak & Heinrichs, 2008). The effect of a group format with individual support may bridge the gap between the efficacies of both formats. 5.2.3. Administrator level of education Results from this meta-analysis indicated that those trainers who were students or had a bachelor’s degree who provided the PMT had a moderate effect on the reduction of the child’s maladaptive behavior. However, trainers with a graduate degree who provided the PMT had a large effect on the child’s maladaptive behavior. This differential outcome in relations to varying levels of education and training may be explained by nuances in the client–therapist relationship. The client–therapist relationship consists of three factors (Lambert & Barley, 2001) – therapist related (i.e. interpersonal style); facilitative conditions (such as warmth and congruence); and the therapeutic alliance. Kazdin, Whitley, and Marciano (2006) find that both therapist/child and therapist/parent alliances were related to improved child outcomes. In addition, therapist/parent alliance predicted improvements in personal interactions at home on the part of parents. Karver, Handelsman, Fields, and Bickman (2006) find that the therapeutic alliance is vital to family and youth outcomes in interventions. Furthermore, as PMT affects child behavior through working with parents, the effect of the therapist/parent alliance may impact child behavior. The concept of therapeutic alliance can be affected by therapist expertise, the therapeutic alliance is a complex dynamic and a full understanding of how it evolves has yet fully understood (Karver et al., 2006; Lambert & Barley, 2001). Although the clinician’s ability to develop and maintain the working alliance is crucial to therapeutic outcomes, there exists very little research on how specific therapist characteristics, such as their training level or education, influence this alliance (Del Re, Flu¨ckiger, Horvath, Symonds, & Wampold, 2012). It can be speculated that both novice and experienced therapists have different, but unique, attributes that contribute to the therapist/client-relationship, and thereby outcomes how the client–therapist relationship changes with the education and experience of the therapist may contribute to the difference in effect on child behavior. In relating to trainer’s level of expertise to therapeutic outcomes, many factors in the client–therapist alliance contribute to client success (Michelson, Davenport, Dretzke, Barlow, & Day, 2013) such as warmth and acceptance on the part of the therapist, client directed sessions, and a strong therapeutic relationship (Swift & Callahan, 2010). Other factors that many impact the effect on experience may include a novice therapist’s openness to learning and sympathy with client vulnerability (Angus & Kagan, 2007). Lorentzen et al. (2012) reported that there is a relationship between task and goal establishment and clinical experience which may explain the relationship between when a trainer acquires a graduate degree and outcomes. It can be speculated that both novice and experienced therapists may contribute to the positive effect on child behavior, but in different ways. The current metaanalysis does indicate that level of education does have a effect on client outcomes. More research, however, on the effects of experience and education on the part of the therapist in the administration of PMT would be needed to better explain the effect on child behavior. 5.2.4. Session number and duration Neither number of sessions nor session duration had an effect on child behavior in this current meta-analysis. For session number, however, existing literature showed mixed results. Consistent with the resutls of this meta-analysis, Serketich and Dumas (1996) also found that session number had no effect on child behavior. In contrast, Maughan et al. (2005) found that

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programs that have between two to five sessions were most efficacious. In terms of duration of sessions or intensity of treatment, Tellegen and Sanders (2013) report that more intensive treatments intended to have larger effect sizes for children exhibiting more severe behaviors. As all of the PMTs included in this study were intended for children with serious difficulties, there is the possibility that heterogeneitity between studies may not be different enough to determine the effect of session number and duration. 5.2.5. Child age Results of the current meta-analysis indicated no significance in the age of the child and the effect of PMT on child behavior. Existing literature, however, showed mixed results. A meta-analysis by Lundahl, Risser, and Lovejoy (2006) had a similar outcome, reporting that outcome of PMT is not affected by the age of child. Other studies have shown that child age has an effect on the efficacy of PMT on child behavior. Serketich and Dumas (1996) and Maughan et al. (2005) found that PMT was more effective on older children (age 9–10), although the latter had only two groups in this age level. Conversely, Nowak and Heinrichs (2008) found that the benefit of PMT was stronger for younger children. These studies, however, do not attempt to explain the impact of child age on outcomes related to child behavior. 5.3. Generalization The findings reported in this meta-analysis can generalize to children with a developmental disability. There are some factors contributing to the generalizability of the results of this meta-analysis. First, the studies included in this metaanalysis represented PMTs conducted in four countries – The United States, Australia, Ireland, and China. Half of the studies, however, were located in Australia, and 90% were located in ‘‘Western’’ societies. Generalizing the effects of PMT on child behavior, therefore, still may not be practical to non-Western cultures. Second, the evidence in this meta-analysis indicates that, although PMT was originally developed for children with conduct disorder related behaviors (Kazdin, 1997), PMT also appears to have an effect on disruptive behaviors related to developmental disabilities. The implication of the moderate effect size of PMT on the behavior with children with a developmental disability is encouraging because of the chronic and generally more severe disruptive behaviors related to developmental disabilities. 5.4. Strengths While systematic review and randomized clinical trials existed in supporting the effectiveness of PMT for parents of children with developmental disabilities, this study represented the second study, after the Tellegen and Sanders’ (2013) study, to collate a meta-analysis in evaluating the effectiveness of PMT on the direct effect of reduction of children’s disruptive behaviors. A meta-analysis allows for the synthesis of multiple but smaller studies, thereby increasing statistical power. In addition, this study also investigated the potential moderating variables that may explain the differences in the main effects. Furthermore, this meta-analysis also investigated three different PMT programs to determine if PMTs in general have an effect on child behavior, rather than a specific program. 5.5. Limitations Although the current study has some strengths, it has some limitations and the conclusions of the results should be interpreted with caution. First, there are relatively few randomized clinical trial studies available that were conducted using parent management training programs for parents of children with developmental disabilities, therefore, limited the number of studies that could be included in the current meta-analysis. Second, in terms of the moderators, limited studies had variations that allowed the coding and calculations of such effects on the effectiveness of PMT on the reduction of children’s disruptive behaviors. For example, socioeconomic or community (i.e. urban, rural, or suburban) data was not reported consistently. One reason this may be of particular interest is due to Lundahl et al.’s (2006) finding that those from a lower socioeconomic status benefitted less from PMT when the method of delivery was via group participation. More detailed reporting of relevant data would allow for a better understanding of PMT and demographics such as socioeconomic status. Third, as indicated in Fig. 2, the funnel plot showed some threats to publication bias. Although using dissertations and unpublished studies did allay the threat of publication bias, only a limited amount of such studies were located. Fourth, there were more studies using the Stepping Stones Triple P1 programs as compared to other PMT programs. While this may be due to the ample amount of research done on this particular program, a less homogenous group of studies may allow for more robust effects. Fifth, collecting data on what aspects, such as information on diagnosis or development, better understanding of behavioral techniques, role play was not reported. Although client satisfaction surveys are often reported in the data more specific qualitative information on specific, positive aspects of PMT would allow for a better understanding of client satisfaction. Finally, a majority of the studies used total scales as a measure of children’s overall disruptive behaviors. While many of the measures have subscales that represent distinct domains or areas of disruptive behavours, the efffect of PMT on such specific domains of disruptive behaviors cannot be studied because subscale scores were not reported. Therefore, it is not clear whether PMT would make a distinct differences in terms of the effect on different types of disruptive behaviors.

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5.6. Research implications Results of the current study provided evidence that PMT programs do have a significant effect on the improvement of behavior of children with a developmental disability. However, future research studies can improve and provide more conclusive outcomes that can guide practice. First, measuring and reporting the specific subscales of measures used to quantify child’s behavior outcomes would allow the evaluation of whether PMT may affect the specific types of disruptive behaviors. Second, an examination of the effects of PMT programs on parenting stress and sense of self-efficacy as well as parenting practices would allow an understanding of how such programs could affect other parenting outcomes. Analyses of the effects of PMT programs on the behavior of children who have a developmental disability are warranted as a likely research topic. A more rigorous reporting of demographics such as race, socioeconomic status, type of community (urban, suburban, or rural), and trainers’ variables such as gender and years of experience would help with studying moderator effects. Replication studies are also necessary in better understanding the effect of moderators such as child age and session number and duration on child outcomes. 5.7. Clinical implications Results of this study provided some clinical insights to practitioners who work with families of children with developmental disabilities. Results showed that PMT, particularly the Stepping Stones Triple P1 and The Incredible Years1 programs, were effective in reducing the disruptive behaviors of children with developmental disabilities. Parent Management Training that includes a method of delivery including both group and individual formats are especially effective. 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