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Open Access 09-10-2018 | Original Article

# Enhancing Outcomes of Low-Intensity Parenting Groups Through Sufficient Exemplar Training: A Randomized Control Trial

Auteurs: Melanie L. Palmer, Louise J. Keown, Matthew R. Sanders, Marion Henderson

Gepubliceerd in: Child Psychiatry & Human Development | Uitgave 3/2019

• Optie A:
• Optie B:
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## Abstract

Low-intensity parenting groups, such as the Triple P-Positive Parenting Program Discussion Groups, appear to be a cost-effective intervention for child conduct problems. Several studies evaluating a Triple P Discussion Group on disobedience found promising results for improving child and parent outcomes. However, a sufficient exemplar training approach that incorporates generalization promotion strategies may assist parents to more flexibly apply positive parenting principles to a broader range of child target behaviors and settings, leading to greater change. We compared the effects of sufficient exemplar training to an existing narrowly focused low-intensity intervention. Participants were 78 families with a 5–8 year-old child. Sufficient exemplar training resulted in more robust changes in child behavior and superior outcomes for mothers on measures of parenting behavior, parenting self-efficacy, mental health, and perceptions of partner support at post-intervention and 6-month follow-up. These results indicate that teaching sufficient exemplars may promote generalization leading to enhanced intervention outcomes.

## Introduction

There is a high prevalence of mild to moderate levels of conduct problems displayed by young children in the population with estimates ranging from 19 to 65% [1, 2]. Costs associated with child conduct problems include stress and concern for the child and their caregivers [2, 3], poorer short- and long-term academic, peer, health, and behavioral outcomes [4, 5] and demands on public services [6]. Survey data also indicate a high prevalence of ineffective parenting practices among parents of young children with between 10–70% reporting that they shout at or use physical punishment with their child [2, 7, 8] highlighting a need for effective interventions. Although there appears to be a substantial proportion of families who would benefit from a parenting program, participation is low [2]. A possible reason for low participation in parenting programs is that available programs are not meeting the needs or preferences of all parents. For some families, an 8–18 week intensive program may be required, however in other families a long-term intervention may be neither feasible nor needed [9].
Low-intensity parenting programs play an important role in a public health approach to parenting support that aims to reduce the prevalence of child conduct problems at a population level [10]. Such programs require less practitioner time, are more cost-effective [11] and range from single session programs to several sessions of topic-focused intervention [9]. Typically, low-intensity parenting programs focus on a narrow range of specific child problems or parenting strategies. For parents of a child with mild to moderate conduct problems, a low-intensity program may be sufficient to prevent the development of more serious problems [12]. There is evidence that low-intensity parenting programs lead to positive changes in children and parents. A recent systematic review of low-intensity parenting programs, delivered individually and in group settings, reported reductions in disruptive child behavior and ineffective parenting behaviors, as well as improvements in parenting self-efficacy and satisfaction at post-intervention [13].
The potential benefits of low intensity interventions could be further enhanced by building in strategies that promote generalization, transfer of learning, and psychological flexibility effects. One strategy to promote more flexible application of parenting skills that is particularly well suited to the delivery of low-intensity topic-specific parenting groups is teaching a sufficient number of training exemplars. Teaching a sufficient number of exemplars involves providing enough examples and illustrations of how to apply positive parenting and contingency management principles so that the transfer of skills across diverse contexts is promoted [14]. Single exemplar training may result in change of the exemplar taught, but more limited generalization to other child or parent behaviors or settings. For example, a low-intensity parenting program that teaches parents skills to manage specific forms of misbehavior (e.g., disobedience) may not be sufficient for parents to generalise parenting skills to manage other difficult child behaviors such as aggression, or to manage difficult behaviors in a range of settings. Teaching a second or third exemplar may facilitate the spread of intervention effects across a broader range of child and parent outcomes. Sufficient exemplar training (SET) also incorporates other generalization promotion strategies, such as training loosely [14] to enhance parents’ ability to flexibly apply positive parenting and behavior management principles skills across a broader range of contexts (behaviors and settings) leading to more robust changes across a diverse range of child and parent outcomes.
The principle of teaching sufficient exemplars can be readily applied to the Triple P Discussion Groups (TPDG) [15], which are low-intensity parenting programs. It would involve parents attending a series of topic-specific low-intensity parenting groups, where core parenting principles and skills are taught using a diverse range of exemplar topics. Those who receive teaching in sufficient exemplars learn how core behavioral parenting strategies (e.g., praise, applying logical consequences) are applied to a range of specific behaviors (e.g., disobedience, fighting and aggression, chores, self-esteem).
In the current study, SET comprised participating in four TPDGs, which are 2-hour group interventions that teach parents skills to manage a specific child behavior problem or developmental issue. Each group session introduced core parenting skills and principles including application of anticipatory antecedent events (e.g., discussion of rules, planned activities, giving clear instructions) and consequent events (e.g., praise, logical consequences) and their application to a diverse range of topics that include increasing prosocial behaviors, building resilience and reducing problem behaviors. We predicted that this kind of training would help consolidate the learning of these skills and result in more robust intervention effects across a broader range of child and parent outcomes. We also predicted that SET would lead to more robust changes at multiple levels of the family system, such as parental mental health and their partner relationship, than narrowly focused training.
In testing this new intervention, we wanted to benchmark its effects against an existing evidence-based low-intensity program, the Triple P Dealing with Disobedience Discussion Group (DDDG). We chose this low-intensity program because it has an established evidence base, is widely disseminated, has high levels of consumer satisfaction, could go some way to control for expectancy effects associated with receiving an evidence-based intervention, and would avoid the ethical concern of having parents wait to receive an intervention. In choosing this single session intervention as a comparator condition we were mindful of the fact that the two conditions had differing amounts of contact time, albeit a relatively small difference of 2 versus 8 hours. Both are low-intensity interventions in the parent training field. Three evaluations using randomized control trial (RCT) designs have found that following DDDG parents report significant reductions in child behavior problems and less use of ineffective parenting practices at post-intervention [1618] in comparison to a waitlist control condition and that effects are maintained at 6-month follow-up. Significant reductions in parenting self-efficacy, poor parental mental health and inter-parental conflict have also been found at 6-month follow-up [16, 18]. However, a lack of follow-up data for the waitlist control group limits conclusions. In Mejia et al. [17], follow-up data was obtained from both groups at follow-up and effects on parenting practices and mental health were found. High levels of satisfaction with the DDDG have also been reported.
This study also targeted a research gap on the effects of low-intensity parenting programs for fathers [13, 19], by attempting to engage fathers as well as mothers in the study. We aimed to explore the extent to which fathers’ participation has similar outcomes to mothers’ participation on child and parenting outcomes. An additional focus of the study was to examine the effects of the Triple P Discussion Groups among parents with young school-aged children (defined in this study as 5–8 year olds) by addressing key topics relevant to this developmental phase, including fighting and aggression, chores, and self-esteem. This emphasis is important given key changes in parenting tasks during middle childhood, which relate to an increase in children’s regulation of their own behavior and an increase in interactions with others (e.g., non-familial adults, peers [20]). For parents, the increasing number of external influences on their children’s development may result in changes in parental monitoring and create new challenges around promoting positive development (e.g., getting along with peers at school). In contrast, the previous research evaluating the DDDG has used samples of parents with preschool aged children.

## Method

### Trial Registration

The trial was registered on the Australian New Zealand Clinical Trials Registry (Reference ACTRN12613000100796).

### Participants

Participants were 75 mothers and 58 fathers from 78 families with a 5–8 year old child residing in Auckland, New Zealand (see Table 1 for the demographic characteristics of the participants). The majority of families in the sample were two-parent families (84.6%, n = 66). There were 55 mother-father pairs from the same family, 20 mothers participated alone (nine of which were from two-parent families), and three fathers participated alone (two of which were from two-parent families). The majority of the target children were male (n = 50) and of New Zealand European/New Zealander ethnicity (71.8%, n = 56). A high proportion of the families reported that their total family income was greater than $50,000 per annum. Many mothers and fathers in the current sample had a university degree (56.8% and 49.1% respectively). All fathers, except one, and about two-thirds of mothers were in paid employment. There were no significant differences between the two conditions on any demographic variable or pre-intervention measures. Thus, randomization to condition resulted in two groups that were similar at pre-intervention. Table 1 Demographic details of participating families by condition Variable DDDG Families: N = 35 Mothers: N = 34 Fathers: N = 27 SET Families: N = 43 Mothers: N = 41 Fathers: N = 31 n % n % Child gender Male 23 65.7 27 62.8 Female 12 34.3 16 37.2 Child ethnicity New Zealand European/New Zealander 28 80.0 28 65.1 Maori 1 2.9 0 0.0 Pacific Islander 1 2.9 1 2.3 Asian 1 2.9 3 7.0 Other 4 11.4 11 25.6 Type of family Two-parent biological or adoptive 26 74.3 31 72.1 Two-parent step family 2 5.7 7 16.3 Single parent family 7 20.0 5 11.6 Marital status Married 22 62.9 29 67.4 Cohabiting 6 17.1 9 20.9 Divorced 0 0.0 1 2.3 Separated 6 17.1 3 7.0 Single 1 2.9 1 2.3 Total family income <$30,000
3
8.6
5
11.6
$30,001–$50,000
5
14.3
6
14.0
$50,000–$70–75,000
2
5.7
7
16.3

### Attendance

Generally, attendance was high with the majority of families in the DDDG condition attending the session (88.6%), and a large portion of families in the SET condition attending two or more of the four sessions (81.4%). More mothers in the DDDG condition (85.3%) attended the session than fathers (59.3%). For those in the SET condition, a similar proportion of mothers and fathers attended two or more sessions (73.1% and 67.8% respectively), although more fathers did not attend any sessions (25.8%) when compared to mothers (14.6%). Among two-parent families, many families in both conditions attended a session together (DDDG: 45.2%; SET: 51.3%), however there was also a large proportion of families in which only the mother attended and had direct contact with the intervention material (DDDG: 41.9%; SET: 25.6%).

### Mother Short-Term Effects

#### Child Outcomes

Table 2 presents the descriptive statistics, univariate F values, relative effects sizes, and 95% confidence intervals for the short-term condition effects for mothers. A significant multivariate condition effect was observed for disruptive child behavior, F(2, 70) = 6.94, p = 0.002. Medium sized univariate condition effects were found for both the ECBI Intensity (d = 0.54) and ECBI Problem subscales (d = 0.65). Mothers in the SET condition reported a significantly lower number and frequency of disruptive child behaviors at post-intervention when compared to mothers in the DDDG condition. The MANCOVA for target and non-target negative child behaviors (PDR) and the ANCOVA for child psychosocial problems (SDQ) did not show significant condition effects for mothers at post-intervention.
Table 2
Descriptive statistics and univariate condition effects for mothers at post-intervention and 6-month follow-up
Measure
DDDG (N = 34)
SET (N = 41)
Condition effects
Pre-intervention
Post-intervention
6-month follow-up
Pre-intervention
Post-intervention
6-month follow-up
Post- intervention
6-month follow-up
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
F
p
d (95% CI)
F
p
d (95% CI)
Child outcomes
ECBI intensity
150.10 (30.51)
133.49 (27.01)
131.46 (33.23)
145.53 (22.24)
114.50 (19.25)
115.75 (24.22)
13.45
0.001
0.54 (0.08, 1.00)
4.95
0.031
0.42 (− 0.04, 0.87)
ECBI problem
19.37 (6.23)
15.96 (7.32)
15.48 (8.17)
19.40 (5.55)
12.14 (5.66)
11.88 (6.67)
9.17
0.004
0.65 (0.19, 1.11)
4.73
0.034
0.61 (0.15, 1.07)
SDQ total difficulties
15.16 (5.89)
13.60 (5.92)
12.72 (7.10)
15.11 (5.94)
12.26 (4.91)
11.80 (5.87)
1.83
0.185
0.22 (− 0.24, 0.67)
0.64
0.460
0.15 (− 0.31, 0.60)
PDR weekdaya
11.46 (5.39)
9.68 (4.66)
10.18 (5.07)
10.40 (6.44)
7.87 (3.77)
7.56 (3.99)
2.55
0.116
0.12 (− 0.33, 0.58)
4.67
0.039
0.26 (− 0.20, 0.71)
PDR weekend dayb
12.71 (5.41)
8.90 (4.55)
9.48 (5.26)
10.92 (5.81)
6.76 (4.28)
6.72 (3.97)
2.53
0.117
0.06 (− 0.40, 0.52)
4.38
0.046
0.17 (− 0.29, 0.63)
Parenting outcomes
PS
3.45 (0.58)
3.11 (0.56)
3.07 (0.49)
3.49 (0.61)
2.80 (0.61)
2.79 (0.60)
7.57
0.008
0.58 (0.12, 1.04)
5.50
0.023
0.53 (0.07, 0.99)
PTC behavioral
69.33 (22.97)
76.49 (15.96)
78.90 (15.31)
64.06 (20.07)
80.35 (14.42)
85.67 (10.75)
4.84
0.031
0.42 (− 0.03, 0.88)
8.62
0.004
0.56 (0.10, 1.01)
PTC setting
81.27 (14.93)
88.30 (8.49)
87.34 (10.30)
80.80 (12.97)
88.78 (9.02)
92.55 (6.17)
0.20
0.662
0.07 (− 0.38, 0.52)
9.54
0.003
0.40 (− 0.05, 0.86)
PES parenting experience
14.35 (3.64)
16.34 (3.15)
16.09 (4.14)
15.07 (2.79)
17.40 (2.62)
17.49 (2.67)
1.65
0.216
0.11 (− 0.35, 0.56)
2.25
0.163
0.21 (− 0.24, 0.66)
PPC extentc
33.22 (15.11)
29.03 (14.22)
33.24 (16.03)
38.57 (17.67)
34.02 (17.66)
32.09 (16.33)
0.30
0.598
0.02 (− 0.46, 0.50)
1.34
0.256
0.39 (− 0.10, 0.88)
PPC problemc
5.73 (3.93)
3.97 (3.58)
4.86 (3.48)
6.32 (4.06)
5.28 (3.93)
4.25 (3.57)
1.68
0.223
− 0.18 (− 0.66, 0.31)
2.51
0.125
0.30 (− 0.19, 0.78)
Mental health
DASS− 21
10.85 (8.21)
7.69 (5.95)
9.47 (8.25)
10.23 (8.07)
7.28 (5.77)
6.28 (4.54)
0.03
0.877
− 0.03 (− 0.48, 0.42)
4.90
0.031
0.31 (− 0.14, 0.77)
Partner relationship
PES partner supportd
10.36 (2.51)
10.97 (1.60)
10.43 (2.38)
9.60 (3.10)
10.74 (2.69)
11.05 (2.96)
0.42
0.531
0.18 (− 0.31, 0.68)
5.24
0.036
0.48 (− 0.01, 0.97)
RQIe
32.32 (9.29)
34.50 (6.25)
31.44 (9.89)
32.09 (10.20)
33.55 (9.40)
34.80 (9.11)
0.48
0.521
− 0.07 (− 0.56, 0.41)
4.66
0.059
0.36 (− 0.13, 0.85)
F = univariate effect for condition, significant p values are bolded; d = effect size for condition; d 0.20 ≤ 0.49 = small, d 0.50 ≤ 0.79 = medium, d ≥ 0.80 = large
an = 33 for the DDDG condition, n = 41 for the SET condition
bn = 33 for the DDDG condition, n = 39–40 for the SET condition
cn = 29 for the DDDG condition, n = 36 for the SET condition
dn = 28–29 for the DDDG condition, n = 35 for the SET condition
en = 29 for the DDDG condition, n = 35 for the SET condition

#### Parenting Outcomes

The ANCOVAs for ineffective parenting behavior and behavioral parenting self-efficacy showed significant condition effects. At post-intervention, mothers in the SET condition reported fewer ineffective parenting behaviors and greater parenting self-efficacy in handling difficult child behaviors when compared to mothers in the DDDG condition. The condition effect was medium in size for parenting behaviors (d = 0.58) and small in size for behavioral parenting self-efficacy (d = 0.42). There were no short-term condition effects on parenting self-efficacy across settings, parenting experiences, or inter-parental conflict.

#### Mental Health and Partner Relationship

There were no significant condition effects on mothers’ mental health or their perceptions of partner support and partner relationship satisfaction at post-intervention.

### Father Short-Term Effects

#### Child Outcomes

Table 3 displays the descriptive statistics, univariate F values, d values, and 95% confidence intervals for fathers’ short-term outcomes. The MANCOVA for disruptive child behavior did not reveal any significant multivariate condition effects at post-intervention for fathers, however medium effects in favour of the SET condition over the DDDG condition were found on the ECBI Problem subscale (d = 0.73). There was, however, a significant multivariate effect on target and non-target negative child behaviors for fathers, F(2, 51) = 3.55, p = 0.038. The univariate condition effect indicated that fathers in the SET condition reported less target and non-target negative child behaviors on weekdays (d = 0.79), but not weekend days, than fathers in the DDDG condition. No condition effect was found for father-rated child psychosocial problems on the SDQ at post-intervention.
Table 3
Descriptive statistics and univariate condition effects for fathers at post-intervention and 6-month follow-up
Measure
DDDG (N = 27)
SET (N = 31)
Condition effects
Pre-intervention
Post-intervention
6-month follow-up
Pre-intervention
Post-intervention
6-month follow-up
Post-intervention
6-month follow-up
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
F
p
d (95% CI)
F
p
d (95% CI)
Child outcomes
ECBI intensity
134.89 (26.89)
118.59 (23.62)
113.51 (17.22)
142.81 (29.87)
114.48 (27.16)
113.51 (25.83)
1.03
0.320
0.42 (− 0.10, 0.93)
0.12
0.742
0.27 (− 0.24, 0.79)
ECBI problem
16.37 (6.64)
14.93 (7.17)
12.70 (5.39)
18.14 (7.80)
11.28 (6.51)
10.29 (7.82)
5.89
0.019
0.73 (0.21, 1.26)
2.81
0.107
0.57 (0.05, 1.09)
SDQ total difficulties
12.52 (5.24)
11.15 (4.65)
10.68 (3.49)
14.79 (6.21)
12.49 (4.84)
12.31 (5.50)
0.62
0.461
0.16 (− 0.35, 0.67)
0.51
0.501
0.11 (− 0.40, 0.62)
PDR weekdaya
8.73 (4.81)
9.38 (4.29)
8.24 (4.05)
10.90 (6.83)
6.70 (3.92)
6.16 (3.83)
7.23
0.010
0.79 (0.26, 1.33)
5.62
0.025
0.70 (0.16, 1.23)
PDR weekend dayb
8.78 (4.72)
8.98 (5.15)
8.33 (4.12)
10.17 (6.58)
7.55 (4.16)
6.81 (3.62)
1.88
0.178
0.48 (− 0.04, 1.00)
3.35
0.076
0.49 (− 0.03, 1.02)
Parenting outcomes
PS total
3.33 (0.54)
2.96 (0.55)
2.99 (0.64)
3.32 (0.73)
2.83 (0.72)
2.78 (0.63)
0.85
0.373
0.18 (− 0.33, 0.69)
2.10
0.159
0.30 (− 0.21, 0.82)
PTC behavioral
74.28 (21.08)
80.38 (12.94)
83.72 (11.20)
68.38 (22.30)
82.90 (12.91)
85.04 (12.44)
1.76
0.190
0.38 (− 0.13, 0.90)
1.32
0.258
0.33 (− 0.18, 0.84)
PTC setting
86.84 (9.45)
90.03 (6.84)
89.81 (6.82)
82.50 (11.65)
86.99 (9.05)
90.17 (9.01)
0.69
0.413
0.12 (− 0.39, 0.63)
2.36
0.131
0.43 (− 0.08, 0.95)
PES parenting experience
17.07 (3.85)
18.36 (2.34)
18.15 (2.77)
15.81 (3.39)
18.03 (2.81)
18.00 (2.19)
0.06
0.847
0.25 (− 0.26, 0.77)
0.71
0.483
0.30 (− 0.21, 0.82)
PPC extentb
32.19 (16.19)
28.21 (12.06)
26.23 (8.28)
38.19 (18.92)
30.33 (14.05)
34.14 (15.43)
0.02
0.885
0.22 (− 0.30, 0.73)
3.85
0.055
− 0.11 (− 0.62, 0.41)
PPC problemb
5.35 (3.90)
4.43 (3.37)
3.52 (2.81)
5.97 (4.13)
4.63 (3.51)
4.80 (3.67)
0.04
0.866
0.10 (− 0.41, 0.62)
1.79
0.204
− 0.16 (− 0.68, 0.35)
Mental health
DASS− 21
7.59 (6.79)
7.44 (5.90)
7.37 (4.97)
11.73 (10.10)
8.72 (7.95)
9.73 (9.19)
0.12
0.796
0.32 (− 0.19, 0.84)
0.19
0.679
0.20 (− 0.31, 0.71)
Partner relationship
PES partner supportc
10.74 (2.70)
11.78 (1.69)
11.90 (1.68)
10.53 (2.49)
11.04 (2.61)
11.24 (2.59)
1.60
0.222
− 0.20 (− 0.72, 0.32)
1.38
0.285
− 0.17 (− 0.69, 0.34)
RQIb
33.62 (8.47)
36.25 (5.39)
35.01 (6.23)
33.41 (8.69)
34.46 (8.28)
33.19 (9.84)
1.22
0.303
− 0.18 (− 0.70, 0.33)
0.75
0.412
− 0.18 (− 0.70, 0.33)
F = univariate effect for condition, significant p values are bolded; d = effect size for condition; d 0.20 ≤ 0.49 = small, d 0.50 ≤ 0.79 = medium, d ≥ 0.80 = large
an = 25 for the DDDG condition, n = 31 for the SET condition
bn = 26 for the DDDG condition, n = 31 for the SET condition
cn = 26 for the DDDG condition, n = 30–31 for the SET condition

#### Parenting, Mental Health and Partner Relationship Outcomes

There were no short-term condition effects on the parenting measures for fathers, nor were there any condition effects for fathers’ mental health, fathers’ perceptions of support from their partner, or relationship satisfaction at post-intervention.

### Mother Maintenance Effects

#### Child Outcomes

Significant univariate condition effects for disruptive child behavior were maintained at 6-month follow-up (see Table 2). Mothers in the SET condition continued to report a lower frequency (d = 0.42) and number (d = 0.61) of disruptive child behaviors when compared to mothers in the DDDG condition. No significant differences in mother-rated child psychosocial problems and target and non-target negative child behavior were found at 6-month follow-up.

#### Parenting Outcomes

Significant condition effects for parenting behavior and behavioral parenting self-efficacy found at post-intervention were maintained at 6-month follow-up (d’s were 0.53 and 0.56 respectively). In addition, a small univariate condition effect was found for mothers’ setting parenting self-efficacy at 6-month follow-up (d = 0.40), with mothers in the SET condition reporting higher parenting self-efficacy across a range of settings than mothers in the DDDG condition. As at post-intervention, no condition effects for mother-rated parenting experiences and inter-parental conflict were found at 6-month follow-up.

#### Mental Health and Partner Relationship

Significant univariate condition effects were found for mental health (d = 0.31) and perceptions of support from their partner (d = 0.48) at 6-month follow-up. Mothers in the SET condition reported better mental health and more positive perceptions of partner support than mothers in the DDDG condition. No condition effect was found for partner relationship satisfaction at 6-month follow-up for mothers.

### Father Maintenance Effects

The MANCOVAs and ANCOVAs examining maintenance condition effects for fathers did not reveal any significant condition effects on any child or parent outcome measure (see Table 3) indicating that effects found at post-intervention were not maintained at 6-month follow-up.

### Completer Analyses

The MANCOVAs and ANCOVAs examining the short-term and maintenance condition effects were repeated using only the sample of mothers and fathers who completed outcome measures at post-intervention and 6-month follow-up (see Fig. 1). Among the completer sample, the short-term condition effects for mothers were still significant and effect sizes were similar for disruptive child behaviour (ECBI Intensity: d = 0.38, 95% CI − 0.12, 0.88; ECBI Problem: d = 0.62, 95% CI 0.10, 1.13) and parenting behavior (PS: d = 0.60, 95% CI 0.09, 1.11), but the condition effect for behavioral parenting self-efficacy (PTC) was no longer significant, (d = 0.30, 95% CI − 0.21, 0.81). The effect sizes for mother-rated disruptive child behavior, parenting behavior, parenting self-efficacy, mental health, and perceptions of partner support found among the completer sample at 6-month follow-up were similar in size to the ITT sample, even though the condition effects were not significant (completer sample: ECBI Intensity: d = 0.19, 95% CI − 0.33, 0.71; ECBI Problem: d = 0.68, 95% CI 0.14, 1.21; PS: d = 0.54, 95% CI 0.02, 1.07; PTC Behavior: d = 0.35, 95% CI − 0.17, 0.88; PTC Setting: d = 0.21, 95% CI − 0.31, 0.73; DASS-21: d = 0.11, 95% CI − 0.43, 0.65; PES Partner Support: d = 0.44, 95% CI − 0.10, 0.97). For fathers, all significant condition effects found in the ITT sample were also found in the completer sample, with a large effect found for PDR Weekday at post-intervention (d = 0.99, 95% CI 0.37, 1.60). In addition, a significant multivariate condition effect for disruptive child behavior was found at post-intervention, F(2, 42) = 4.16, p = 0.023. Univariate analyses showed that the effect between conditions was found on the ECBI Problem Total subscale only, with fathers in the SET condition reporting less child disruptive behaviors at post-intervention than fathers in the DDDG condition. The size of the condition effect was large (d = 1.05, 95% CI 0.45, 1.66).

### Statistically Reliable and Clinically Significant Change

Significantly more mothers in the SET condition reported pre- to post-intervention improvements in the frequency of their child’s disruptive behavior that were statistically reliable and clinically significant than those in the DDDG condition (see Table 4). Among fathers, a significantly greater proportion of those in the SET condition reported statistically reliable improvement and clinically significant improvement in the number of disruptive behaviors displayed by their child when compared with fathers in the DDDG condition. A small proportion of parents in each condition (n = 1–3) reported deterioration in their child’s disruptive behavior between pre- and post-intervention.
Table 4
Statistically reliable and clinically significant change from pre- to post-intervention on the ECBI by condition
Measure
Mothers
Fathers

DDDG (N = 34)
SET (N = 41)
Fisher’s χ2
p
DDDG (n = 27)
SET (n = 31)
Fisher’s χ2
p
n
%
n
%
n
%
N
%
Statistically reliable change
ECBI intensity

6.96
0.021

1.79
0.461
Reliably improved
11
32.4
26
63.4

10
37.0
16
51.6

Reliably deteriorated
3
8.8
1
2.4

2
7.4
2
6.5

No reliable change
20
58.8
14
34.1

15
55.6
13
41.9

ECBI problem

5.41
0.051

7.87
0.015
Reliably improved
10
29.4
21
51.2

4
14.8
15
48.4

Reliably deteriorated
2
5.9
0
0.0

2
7.4
2
6.5

No reliable change
22
64.7
20
48.8

21
77.8
14
45.2

Clinically significant change
ECBI intensity

11.05
0.009

3.32
0.339
Clinically significant change
8
23.5
23
56.1

8
29.6
15
48.4

Did not achieve clinical change
14
41.2
7
17.1

6
22.2
6
19.4

Worsened
2
5.9
0
0.0

1
3.7
0
0.0

Not in clinical range
10
29.4
11
26.8

12
44.4
10
32.3

ECBI problem

7.50
0.055

8.35
0.041
Clinically significant change
9
26.5
23
56.1

5
18.5
15
48.4

Did not achieve clinical change
18
52.9
12
29.3

12
44.4
6
19.4

Worsened
2
5.9
1
2.4

2
7.4
2
6.5

Not in clinical range
5
14.7
5
12.2

8
29.6
8
25.8

Significant p values are bolded

### Participant Satisfaction

Overall satisfaction with each of the Triple P Discussion Groups was relatively high (M’s ranged from 49.98 to 55.52). A high proportion of parents rated the quality of the groups as at least ‘good’ (range 77.0–96.0%). Many reported that they had gained sufficient knowledge to be able to implement the parenting strategies introduced in session (range 84.5–100.0%). A high level of intent to use the strategies was also indicated. Satisfaction with the format and content of the groups was also high, but satisfaction with the amount and type of help provided during each discussion group varied by topic with lower satisfaction reported for the Dealing with Disobedience group. The extent to which the groups met parents’ needs was also lowest for Dealing with Disobedience.

## Discussion

This study compared the effects of narrowly focused training and sufficient exemplar training of low-intensity topic-specific parenting groups on a range of child and parent outcomes using an RCT design. The effects for both mothers and fathers of children displaying at least mild conduct problems were examined. The results partially supported our hypothesis that SET would lead to better intervention outcomes for children. At post-intervention, mothers in the SET condition reported a lower frequency and number of disruptive child behaviors, the primary outcome measure for the study, and fathers reported that their child displayed less target and non-target negative behaviors on weekdays. The relative effect sizes showed there were medium effects for sufficient exemplars over and above the narrowly focused training condition. Lower levels of mother-rated disruptive child behavior was maintained at 6-month follow-up. In addition, when compared to parents in the DDDG condition, a greater proportion of mothers and fathers in the SET condition reported statistically reliable and clinically significant reductions in their child’s disruptive behavior from pre- to post-intervention. Greater change in child behavior among the SET condition was assumed to be a result of the generalization promotion strategy that aimed to enhance parents’ ability to apply parenting skills flexibly and feel more confident in their parenting, resulting in a broader, more robust change in child behavior.
Even though the results overall indicated that mothers and fathers in the SET condition reported greater improvement on their child’s disruptive behavior, the primary outcome measure for the study, significant condition effects did not emerge across all secondary child outcome measures at all time points. A possible explanation for this is that because families were screened into the study based on reporting elevated disruptive child behavior problems using an abbreviated version of the ECBI, there was sufficient scope for change on this measure. Whereas the SDQ scores for mothers and fathers were in the borderline range at pre-intervention, and even though on average they moved into the normal range at post-intervention, there was less scope for improvement. Furthermore, the PDR may be less sensitive to change given that it provides a measure of the occurrence and non-occurrence of negative child behaviors on a specific day, although a medium effect was found for fathers at 6-month follow-up on the PDR Weekday subscale.
There was support for the hypothesis that SET would lead to better intervention outcomes for parents. Mothers in the SET condition reported fewer ineffective parenting behaviors and greater parenting self-efficacy across a range of behaviors at post-intervention. These condition effects were maintained at 6-month follow-up. Furthermore, at 6-month follow-up, mothers in SET condition also reported greater parenting self-efficacy for dealing with difficult child behaviors in a range of settings, less mental health difficulties, and more positive perceptions of support from their partners in comparison to mothers in the DDDG condition. The effect sizes for these measures were small to medium in size. Additional benefits for mothers demonstrated in the study further supports that the generalization of parenting skills promoted by SET led to superior intervention outcomes. However, it should be acknowledged that the study results might be partly explained by participants in the SET condition finding the topics more relevant to them than the topic of the narrowly focused training condition. Support for this possibility is provided by the lower satisfaction ratings for the disobedience topic relative to the other groups.
In contrast to mothers, SET did not result in greater intervention effects for fathers on measures of parenting, mental health, or partner relationship at post-intervention or 6-month follow-up. It is unclear if these results represent a real lack of effect. There are several alternative explanations of the outcomes for fathers in the SET condition. Less positive results for fathers may be a result of lower attendance of fathers in the interventions. Among families in the SET condition, a greater number of fathers than mothers did not attend any of the sessions. Furthermore, a substantial proportion of mothers from two-parent families attended alone. Taken together, these findings indicate that fathers had less direct contact with the intervention material and thus had fewer opportunities than mothers to learn and practice parenting strategies.
Previous research has reported that attending a DDDG leads to positive outcomes for parents and their young children [16, 18]. The findings from the current study add to this literature by indicating that multiple training exemplars of four TPDGs produces greater change for mothers and young school-aged children. The previous evaluations of the DDDG have also reported high satisfaction among parents of primarily preschool aged children. In the current study, the TPDGs were generally acceptable to parents of young school-aged children. Parents indicated that overall the sessions were relevant and useful.
There are several implications for practice that arose from the current study. Results demonstrated that SET of low-intensity topic-specific parenting groups appears to have additional benefits for improving mother- and father-rated child behavior and mothers’ parenting behavior, parenting self-efficacy, mental health, and perceptions of partner support. For families with young children displaying mild to moderate conduct problems, practitioners could consider teaching parenting skills through training in a sufficient number of exemplars. Narrowly focused training could be a first line of approach to intervention with training in additional exemplars reserved for those who fail to generalize parenting skills effectively. More intensive parenting programs could then be reserved for families who do not benefit from training in several exemplars, those with children displaying high levels of conduct problems, and those with multiple family risk factors.
A key aim of low-intensity programs is to improve the cost-effectiveness of interventions [11] and consideration needs to be given to the cost of additional sessions, the potential added benefits for children and parents, the increased risk of attrition with a greater number of sessions, and the feasibility within a population health approach to parenting support. Delivering multiple exemplars adds to the cost of the intervention and requires more time from parents but increases effect sizes of low-intensity parenting groups. Parents’ needs and preferences for parenting support would also likely influence the uptake of sufficient exemplar training. It may be that parents are more likely to take part in several topic-specific parenting groups that are tailored to their particular parenting challenges than a more general parenting program. In addition, multiple groups enable greater opportunity for more than one parent to participate, either separately or together.
Low-intensity parenting groups may also be a way to engage and enhance father participation in parenting programs. Among two-parent families, both parents should be encouraged to attend and engage with the program to promote co-parenting [19]. Child care services could be offered to enable mothers and fathers to participate in parenting programs. Flexible delivery options timed to suit both parents could include offering evening sessions or full-day weekend workshops in easy to access settings. Ways to enhance father participation in low-intensity topic-specific parenting groups should be investigated as such programs appear to be an attractive option for intervention among fathers.
While the self-referral method for recruitment used is a clinically viable method which could be undertaken in settings that do not have substantial budgets or resources [36], it may result in samples that are not representative of the general population of families with similar problems. In relation to this point, although attrition from the study was relatively low, there were more single parent families, more mothers with lower levels of education, and more low SES families among those who did not complete post-intervention measures. If additional resources had been available, further efforts could have been made to retain these participants and sample across a more diverse range of socioeconomic backgrounds and promote participation among ethnic minorities.
Furthermore, the study relied on self-report measures to evaluate the intervention outcomes. It is unknown whether changes reported on the outcome measures were actually observed or whether improvements relate to changes in parents’ perceptions of their child and parenting. However, parental reports are particularly valuable given their unique knowledge about their child’s behavior and their status as participants [37], and in the current study information on child behavior was sought from both parents. As observational measures can be subject to reactivity effects and may inadequately measure low prevalence behaviors, ideally, intervention outcomes and the generalization of parenting skills should be measured using both self-report measures and observational methods. The current study was unable to obtain observational measures due to budget constraints.
Further trials with larger samples, more diverse families, and longer-term follow-up would extend the findings from the current study. It remains an empirical question as to how many additional exemplars are required before superior intervention outcomes are attained, and whether this number is the same for mothers and fathers and those parenting as a couple or by themselves. It is possible that additional benefits may have been found after two or three exemplars; thus, future research could investigate this possibility. Future research should also aim to directly compare the effects of receiving SET of topic-specific low-intensity parenting groups with a high-intensity group parenting program as well as examine moderators or predictors of intervention outcomes.
Overall, low-intensity parenting groups that are topic-specific appear to be an acceptable option for intervention for parents with young school-aged children displaying conduct problems. The current study highlighted the potential of teaching using generalization promotion strategies to enhance child and maternal intervention outcomes of low-intensity topic-specific parenting groups.

## Summary

A large proportion of young children display mild to moderate levels of conduct problems. Survey data also indicates a high prevalence of ineffective parenting practices are used by parents of young children, suggesting a need for efficacious, cost-effective interventions. Low-intensity parenting groups, such as the Triple P-Positive Parenting Program Discussion Groups, appear to be a cost-effective intervention for child conduct problems. Several studies evaluating a Triple P Discussion Group on disobedience found promising results for improving child and parent outcomes. However, a sufficient exemplar training approach that incorporates generalization promotion strategies may assist parents to more flexibly apply positive parenting principles to a broader range of child target behaviors and settings, leading to greater change. We compared the effects of sufficient exemplar training to an existing narrowly focused low-intensity intervention. We predicted that this kind of training would help consolidate the learning of these skills and result in more robust intervention effects across a broader range of child and parent outcomes. We also predicted that sufficient exemplar training would lead to more robust changes at multiple levels of the family system, such as parental mental health and their partner relationship, than narrowly focused training. In addition, this study also targeted a research gap on the effects of low-intensity parenting programs for fathers, by attempting to engage fathers as well as mothers. Another focus of the study was to examine the effects of the Triple P Discussion Groups among parents with young school-aged children by addressing key topics relevant to this developmental phase.
Participants were 75 mothers and 58 fathers from 78 families with a 5–8 year old child residing in Auckland, New Zealand. A 2 (condition: narrowly focused training vs. sufficient exemplar training) by 3 (time: pre-intervention, post-intervention, 6-month follow-up) RCT design was used to compare the effects of the conditions on a range of child and parent outcomes.
We found that sufficient exemplar training resulted in more robust changes in child behavior and superior outcomes for mothers on measures of parenting behavior, parenting self-efficacy, mental health, and perceptions of partner support at post-intervention and 6-month follow-up. There was some support in favour of sufficient exemplar training for father-reported child behavior. However, in contrast to mothers, sufficient exemplar training did not result in greater intervention effects for fathers on measures of parenting, mental health, or partner relationship at post-intervention or 6-month follow-up. Attendance and overall satisfaction were generally high.
Topic-specific low-intensity parenting groups appear to be an acceptable option for intervention for parents with young school-aged children displaying conduct problems and may be a way to engage and enhance father participation in parenting programs. These results indicate that teaching sufficient exemplars may promote generalization leading to enhanced intervention outcomes.

## Acknowledgements

We would like to thank all the participating families for their time and effort. This study was completed as part of a Universitas 21 Joint PhD from the University of Auckland and the University of Glasgow. We are grateful to the University of Auckland for a doctoral scholarship that enabled the first author to the complete this research as well as support for research costs. Marion Henderson was supported by MRC/CSO Quinquennial funding of the Social Relationships and Health Improvement Programme, which is part of the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, MC 12017/11, SPHSU11. Prior to 2015, Marion Henderson was supported by UK Medical Research Council Grant U130031238.

## Compliance with Ethical Standards

### Conflict of interest

The Triple P—Positive Parenting Program is owned by the University of Queensland (UQ). The University through its main technology transfer company UniQuest Pty Limited, has licensed Triple P International Pty Ltd to disseminate the program worldwide. Royalties stemming from this dissemination activity are distributed to the Parenting and Family Support Centre, School of Psychology, UQ; Faculty of Health and Behavioural Sciences at UQ; and contributory authors. No author has any share or ownership in Triple P International Pty Ltd. Matthew R Sanders is the founder and an author on various Triple P programs and a consultant to Triple P International. Melanie L Palmer, Louise J Keown, and Marion Henderson declare no conflicts of interest.

### Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Written informed consent was obtained from all individual participants included in the study.

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Metagegevens
Titel
Enhancing Outcomes of Low-Intensity Parenting Groups Through Sufficient Exemplar Training: A Randomized Control Trial
Auteurs
Melanie L. Palmer
Louise J. Keown
Matthew R. Sanders
Marion Henderson
Publicatiedatum
09-10-2018
Uitgeverij
Springer US
Gepubliceerd in
Child Psychiatry & Human Development / Uitgave 3/2019
Print ISSN: 0009-398X
Elektronisch ISSN: 1573-3327
DOI
https://doi.org/10.1007/s10578-018-0847-z

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