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QUESTION: Does an additional parent problem-solving treatment component, aimed at reducing non-child related stress, enhance the effects of usual care (problem-solving skills training plus parent management training) in the treatment of families with a child referred for aggressive and antisocial behaviour?
Quasi-randomised controlled trial, with alternate allocation to treatment groups. Time frame not specified.
Out-patient child conduct clinic, New Haven, USA.
127 families with children aged 6–14 years (mean age 9.8 years, 27 girls, 100 boys) referred for aggressive and antisocial behaviour (40.2% diagnosed with oppositional defiant disorder, 29.9% with conduct disorder, 9.4% with major depressive disorders, 3.1% with attention-deficit/hyperactivity disorders, 12% with other disorders and 4.1% with no diagnosable Axis 1 disorder using DSM-III-R criteria).
In both groups, children received 20–25 sessions of cognitive problem skills training and parents received 16 sessions of parent management training. The intervention group parents also received five sessions of a parent problem-solving intervention. This intervention was designed to tackle sources of stress in parents’ everyday life (e.g. work problems) that were not specifically related to their children.
Main outcome measures
Primary outcomes were child antisocial behaviours, parental stress and family interaction, measured with the Interview for Antisocial Behavior, Parent Daily Report and Child Behavior Checklist questionnaires. For child and parent measures, a reduction in score indicated improvement; for family measures, an increase in score indicated improvement for family outcomes. The changes in these scores from baseline were combined to produce a therapeutic index of change for each outcome.
Improvements in child and parent scores were significantly greater in the intervention group compared with the control group (p<0.001). There was no significant difference between groups for family improvement scores.
Helping parents tackle stress during treatments for child behaviour problems enhances the outcomes for parents and children, at least in the short term.
Low parental involvement and inconsistent parenting have been shown to be the main risk factors for aggressive behaviour in children.1 It is important to recognise and treat aggressive behaviour as this leads to serious secondary problems.2 Improving parenting skills through appropriate programmes such as parent management training and problem solving skills training is effective in modifying children’s aggressive behaviour.3–,4
Stress, in particular, is a variable risk factor in any individual at any point in time. There is no established stress score for the “normal” population. Thus Kazdin et al should be congratulated for attempting to show that “add-on” therapy for stress reduction in parents (parent problem solving) helps. We share the frustrations that multi-component interventions raise with research design, ceiling-effect, drop-outs and cost effectiveness.
However certain aspects of this study raise questions about the validity of the results.5 The study and control groups are not well defined (all children self-referred to the clinic were enrolled, no pre-defined inclusion/exclusion criteria, no comparison between groups prior to intervention). Method of randomisation is unclear and authors have allocation bias as they assigned a slightly larger proportion of families to receive the intervention based on their pilot study. Exclusion of drop-outs from analysis introduces another element of bias. There was no blinding in this study.
The authors have shown that immediate post-treatment scores are statistically significant. But was the intervention successful in bringing about clinically important levels of reduction in anti-social behaviour? Are these benefits sustained in the long-term? – follow up would have answered this. We need more blinded RCT studies on parent problem solving to prove its effectiveness.
Future research on interventions should focus on outcome predictors and to identify which intervention is “best-fit” for a given child. It should also focus on “drop-outs” as these are the children most in need.
Source of funding: This work was funded by the Leon Lowenstein Foundation, the William T Grant Foundation and the National Institute for Mental Health.
For correspondence: A Kazdin. Child Study Center, Yale University School of Medicine, PO Box 207900, New Haven, Connecticut 06520-7900