Behavioral parenting interventions for child disruptive behaviors and anxiety: What's different and what's the same

Abstract

This paper reviews the role of parents in behavioral interventions with children's disruptive and anxiety problems. The evolution of interventions for these two types of problems differs, as has the role of parents in these interventions. In contrast to the central role of parents in the conceptualization and treatment of disruptive behaviors, parents have played a more varied and less prominent role in the conceptualization and treatment of children's anxiety. Furthermore, the literature involving parents in the treatment of children's anxiety indicates these interventions are more efficacious than control groups but not more efficacious than intervening with the child alone. Some limited evidence emerges for parenting as a mediator in the treatment of disruptive behaviors, but not of anxiety, where the role of parenting has rarely been measured. Implications for conceptualizing the role of parents in intervention programs for youth are discussed and directions for future research are delineated (e.g., collecting long term follow-up data, examine moderators of treatment response, develop programs for comorbid diagnoses).

Introduction

Fifty years ago, Boardman (1962) described an alternative to the standard psychotherapeutic approach with children: “A ‘short cut’ involving the application of simple learning principles…” (p. 293) where the parents of 5-year old “Rusty” were taught procedures to change his rebellious behavior. Subsequently, in the mid to late 1960s, a group of clinical psychologists began programs of clinical research utilizing parents as the focus of intervention for the disruptive behaviors of their young children (Bernal et al., 1968, Hanf, 1969, Patterson and Brodsky, 1966, Wahler et al., 1965). Although the exact interventions utilized across these programs of research varied to some extent, the common factor was a focus on behavior, specifically changing parent behavior in order to change child behavior. This approach stood in contrast to the prevailing approach at the time: play therapy and psychodrama with the child to resolve underlying anxiety that was causing the child's disruptive behavior (Patterson, 1982).

The early efforts by Bernal, Hanf, Patterson, Wahler and their colleagues were initially constituted by case studies and uncontrolled group designs; however, these collective lines of research led to a major intervention approach evolving over the next 45 years. Behavioral parent training has now been carefully studied with rigorous research designs and is recognized as the leading intervention strategy for disruptive behaviors [i.e., Oppositional Defiant Disorder and Conduct Disorder (Eyberg, Nelson, & Boggs, 2008)] (for reviews, see Chorpita et al., 2011, Dretzke et al., 2009, Eyberg et al., 2008, Lundahl et al., 2006, Maughan et al., 2005, McMahon et al., 2006, Serketich and Dumas, 1996, Weisz and Gray, 2008).

In contrast to working through parents to address disruptive behaviors, a different set of intervention strategies evolved in the early 1990s in the United States to address childhood anxiety: cognitive behavioral strategies implemented directly with the child (e.g., Kendall, 1994). The role of parents was noted early on in the treatment of anxiety in the United States (for an early conceptualization, see Kendall, Howard, & Epps, 1988) and shown to be efficacious through single subject research methodology (Howard & Kendall, 1996); however, interventions focused directly on the child, rather than indirectly effecting change through the parent (e.g., Flannery-Schroeder and Kendall, 2000, Kendall, 1994, Kendall and Southam-Gerow, 1996). In contrast, a more definitive role for parents in the treatment of child anxiety was recognized in the early 1990s among Australian researchers (Dadds, Heard, & Rapee, 1992) and began to be incorporated into randomized trials as one arm of intervention by the mid-1990s (Barrett, Dadds, & Rapee, 1996). Then, building upon their paper delineating a framework for family involvement (Ginsburg, Silverman, & Kurtines, 1995), in the late 1990s, Silverman and her colleagues began to examine the role of parents in the treatment of children's anxiety in the United States (Silverman et al., 1999a, Silverman et al., 1999b). As this literature has expanded, the role parents have played in the treatment of anxiety has varied substantially across studies (Barnish & Kendall, 2005) and, as we will delineate later, is substantially different from and more varied than the consistent and central role parents have played in the treatment of disruptive behaviors.

The purpose of this paper is to review and contrast the literature examining the role of parents in behavioral treatment (not prevention) of children's disruptive behaviors and anxiety. We use the convincing literature for the role of parents in the treatment of disruptive behaviors as a backdrop for updating, expanding, and re-evaluating conclusions reached recently by others (Barnish and Kendall, 2005, Breinholst et al., 2012, Kendall et al., 2012, Reynolds et al., 2012, Silverman et al., 2008) about the less frequently studied role of parents in the treatment of child anxiety. The goal is to identify similarities and differences in the role of parenting generally and relevant parenting behaviors specifically in the development and treatment of disruptive behavior and anxiety. By considering the state of the literature on parenting with both of these domains of child problems, we hopefully will facilitate communication across the two fields of study. If researchers and clinicians working with anxious children can learn from those working with disruptive children and vice versa, then the role of parenting in our conceptualization and treatment of child psychopathology will be enhanced.

To the best of our knowledge, this is the first effort to compare and contrast the role of parents in the etiology and treatment of these two types of child problems. We believe that such a comparison is critical for several reasons. First, both disruptive behaviors and anxiety are among the most common psychiatric disorders of children and primary reasons for the referral of children to mental health services (Hindshaw and Lee, 2003, Silverman et al., 2008). Second, the two types of child problem behaviors exemplify the different roles of parents in the treatment of the broadband categories of child externalizing and internalizing problems.

We chose to focus on anxiety, rather than depression, and disruptive behaviors, rather than Attention Deficit Hyperactivity Disorder (ADHD), as representative of interventions with internalizing and externalizing problems, respectively, for two reasons. First, we located approximately six times the number of treatment studies for childhood anxiety than for childhood depression that met our criteria for inclusion. More definitive conclusions, in turn, can be reached when there are more studies to evaluate. Second, ADHD is an externalizing problem that also can be impacted by parent training (see Pelham & Fabiano, 2008); however, unlike ODD and CD, ADHD is considered a “chronic disorder” (Pelham & Fabiano, 2008, p. 2009) that, from our perspective and that of others (Pelham & Fabiano, 2008), is most often treated primarily with medication (stimulants) (e.g., Gureasko-Moore et al., 2005, Pelham, 2012). Furthermore, by separating disruptive behaviors and ADHD, we are being consistent with DSM-IV-TR (American Psychiatric Association, 2000) nosology (i.e., Attention-Deficit and Disruptive Behavior Disorders) and the 2008 special issue of the Journal of Clinical Child and Adolescent Psychology on Evidence-Based Psychosocial Treatments for Children and Adolescents edited by Silverman and Hinshaw.

It is important to point out that there are a range of parenting interventions available for the treatment of disruptive behaviors. As examples, some, but not most, are mastery based (i.e., a parent demonstrates a certain level of acquisition of one skill before moving to the next skill) (e.g., McMahon & Forehand, 2003); some programs are conducted in groups (e.g., Webster-Stratton & Herman, 2008), whereas others are conducted with individual families (e.g., McMahon & Forehand, 2003); and some, but not all, programs rely extensively on modeling, roleplaying, and parent practice with the child while receiving feedback (e.g., McMahon & Forehand, 2003). Similarly, there are a range of available parenting interventions for anxiety disorders which share similarities, but also are not identical. Some involve a focus on parental anxiety (e.g., Cobham, Dadds, & Spence, 1998) whereas others do not (e.g., Silverman et al., 1999a, Silverman et al., 1999b); some are conducted primarily with the parent and child together (e.g., Silverman et al., 1999a), whereas others have separate sessions for the parent and the child (e.g., Spence, Donovan, & Brechman-Toussaint, 2000); some are conducted primarily in groups (e.g., Silverman et al., 1999a) and others are conducted with individual families (e.g., Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008). Our point is that there is heterogeneity within parenting interventions for each of these two types of child problems. Nevertheless, each intervention does engage the parent, at least to some extent, in the treatment of childhood problems and, in turn, will be reviewed here.

In the subsequent sections, we will consider the following topics pertaining to parents and how they have differed for the conceptualization and treatment of disruptive behaviors versus anxiety: (a) the role of parenting in their development; (b) the evolution of parenting interventions; (c) the specific roles of parents in the interventions; and (d) the specific parenting behaviors that have been targeted. Based on this review, we “accept” the conclusion of the numerous reviews already cited: A parent behavioral intervention is an efficacious approach for addressing child disruptive behaviors. When considered against this backdrop, we then consider the current state of the literature for parenting interventions with anxiety. We then review studies which have examined parenting as the mediator of child behavior change when a parenting intervention is implemented and conclude by delineating some areas of future research.