PARENTING INTERVENTION TO HELP CHILDREN WITH BEHAVIOUR PROBLEMS IN CHILD PROTECTION AND OTHER FAMILY SUPPORT SERVICES

PARENTING INTERVENTION TO HELP CHILDREN WITH BEHAVIOUR PROBLEMS IN CHILD PROTECTION AND OTHER FAMILY SUPPORT SERVICESChild Psychiatry, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki
Faculty of Medicine, Doctoral Program in Population Health, University of Helsinki
and
Department of Public Health Finnish Institute for Health and Welfare
Helsinki
CHILD PROTECTION AND OTHER FAMILY SUPPORT SERVICES
Piia Karjalainen
ACADEMIC DISSERTATION
To be presented for public examination with the permission of the Faculty of Medicine of the University of Helsinki, in Haartman Institute Lecture Hall 2, on the
19th of March, 2021 at 12 o’clock.
Helsinki 2021
Supervisors Professor Eeva Aronen, PhD Department of Child Psychiatry, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland Docent Päivi Santalahti, PhD Department of Child Psychiatry, University of Turku, Finland Senior Researcher, Olli Kiviruusu, PhD Mental Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland Reviewers Professor Hanna Ebeling, PhD Department of Child Psychiatry, University of Oulu, Finland Docent Kirsi Peltonen, PhD Department of Social Sciences, University of Tampere, Finland Opponent Assistant Professor Patty Leijten, PhD Research Institute for Child Development and Education, University of Amsterdam, Netherlands The Faculty of Medicine uses the Urkund system (plagiarism recognition) to examine all doctoral dissertations. Dissertationes Scholae Doctoralis Ad Sanitatem Investigandam Universitatis Helsinkiensis ISBN 978-951-51-7143-6 (print) ISBN 978-951-51-7144-3 (PDF) ISSN 2342-3161 (print) ISSN 2342-317X (online) Unigrafia, Helsinki 2021 Cover image by Valentina Sheboltaeva, lincesed by Getty Images, image number 1188326790. All rights reserved. Used by permission.
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ABSTRACT
This thesis uses a randomized controlled trial (RCT) study setting to investigate the effectiveness of a parenting intervention (the Incredible Years®, IY) in modifying children’s behaviour problems, parenting practices and parents’ psychological well-being among families in child protection and other special support services. The study also explored parent’s perceptions of the program.
A systematic review of the literature confirmed that there is solid research evidence on the effectiveness of parenting programs on child behaviour and parenting practices. However, the review also revealed a lack of evidence of the effectiveness of these programs with families in touch with child protection services (CPS).
The study examined the effects of the intervention on child problem behaviour, parenting practices and parent’s well-being. Participants in the study were 3–7-year-old children with behaviour problems (N = 102, intervention group N = 50, control group N = 52) and their parents (N = 122). Parents in the intervention group received 19 sessions of the long IY Preschool Basic parenting program and the controls received treatment as usual (TAU), while on the waiting list (WL) for the next available parent group organized after the study.
Results of the study show that child problem behaviour decreased more in the intervention group in comparison to control group before and after the intervention, when measured by using scale scores of ECBI Problem and cut- offs for clinically relevant cases (ECBI Problem and CBCL External). The intervention also increased positive parenting practices, although changes in parental stress or parents’ psychological well-being in the intervention group did not differ from parents in the control group. Child behaviour problems decreased at one year follow-up in both the intervention (N = 44) and the control groups (N = 45), although no differences between the groups were evident at the follow-up. The positive changes in child behaviour at home were not evident at day care or school at baseline, post-intervention or one- year follow-up, and there were no significant differences between the groups.
The study also compared parents with (N = 43) and without (N = 19) CPS contact in terms of their satisfaction with the IY® Parenting Program. Satisfaction scores ranged between 5.8 and 6.2 (max 7) for all studied intervention domains. Mean attendance rate in the group sessions was 11.5 (SD 5.9), and 74% of participants attended at least nine out of 19 sessions. No group differences were found in satisfaction or attendance between CPS and non-CPS parents. Parents in CPS committed well to the program and found it as useful as parents without CPS contact.
The results of the present study indicate promising evidence that parenting interventions such as the IY® parenting program may be effective
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in terms of child conduct problems in the short term in families within the CPS context. Sustaining the positive effects and generalizing them to day care and school contexts remains challenging in the context of child protection and other family support services in real-life conditions. IY® parenting program appears to be acceptable to parents involved in CPS, and their engagement to the program can be considered as reasonably good. Key words: child behaviour problems, parenting, parenting program, intervention, evidence-based, child protection services
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TIIVISTELMÄ
Väitöskirjaa varten tehty systemaattinen kirjallisuuskatsaus vahvisti, että vanhemmuuden tuen ohjelmien tehokkuudesta lasten käyttäytymiseen ja vanhemmuuden käytäntöihin on vankkaa tutkimusnäyttöä. Tarkastelu kui- tenkin paljasti, että näyttöä näiden ohjelmien tehokkuudesta lastensuojelun piirissä olevien perheiden parissa ei juurikaan ole.
Tutkimukseen osallistui 3-7-vuotiaita lapsia, joilla oli käyttäytymison- gelmia (N = 102, interventioryhmä N = 50, kontrolliryhmä N = 52), sekä hei- dän vanhempansa (N = 122). Interventioryhmän vanhemmat osallistuivat 19 kerran alle kouluikäisten lasten vanhemmille tarkoitettuun vanhemmuusryh- mäohjelmaan (IY® Preschool Basic). Verrokit saivat hoitoa tavalliseen tapaan, samalla kun he olivat jonossa seuraavaan mahdolliseen paikkakun- nalla tutkimuksen jälkeen järjestettävään vanhemmuusryhmään.
Tutkimuksen tulokset osoittavat, että lasten ongelmakäyttäytyminen väheni enemmän interventioryhmässä kuin kontrolliryhmässä ennen ja jäl- keen intervention tarkasteltuna, erityisesti kun käyttäytymistä mitattiin ECBI Problem -asteikon pistemäärällä. Myös kliinisesti merkitsevän raja-arvon (ECBI Problem ja CBCL External) ylittävien lasten määrä väheni enemmän interventio- kuin kontrolliryhmässä. Interventio myös lisäsi positiivisia van- hemmuuskäytäntöjä. Muutokset vanhempien stressissä tai vanhempien psykologisessa hyvinvoinnissa eivät eronneet interventio- ja kontrolliryhmän vanhempien välillä. Lasten käyttäytymisongelmat vähenivät yhden vuoden seurannassa sekä interventio- (N = 44) että kontrolliryhmässä (N = 45), mutta ryhmien välillä ei enää havaittu eroja interventioryhmän eduksi. Lapsen käyttäytymisen positiivisia muutoksia ei havaittu päivähoidossa tai koulussa, kun tarkasteltiin muutoksia lähtötilanteesta intervention jälkeiseen tai yhden vuoden seurantaan, eikä ryhmien välillä ollut merkitseviä eroja.
Tutkimuksessa verrattiin myös lastensuojelun (N = 43) ja muiden palve- luiden piirissä olevien vanhempien (N = 19) tyytyväisyyttä IY® vanhemmuus- ohjelmaan. Pistemäärät vaihtelivat välillä 5,8 - 6,2 (maksimi 7) kaikilla tutkituilla intervention osa-alueilla. Vanhemmat osallistuivat ryhmiin keskimäärin 11,5 kertaa (SD 5,9), ja 74 % osallistui vähintään yhdeksään 19 ryhmäkerrasta. Lastensuojelun ja muiden palveluiden piirissä olevien vanhempien välillä ei havaittu eroja tyytyväisyydessä tai osallistumisessa. Lastensuojelun piirissä olevat vanhemmat sitoutuivat hyvin ohjelmaan ja
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pitivät sitä yhtä hyödyllisenä kuin vanhemmat, joilla ei ollut yhteyttä lastensuojeluun.
Tämän tutkimuksen tulokset antavat positiivisia viitteitä siitä, että van- hemmuuden tuen interventiot, kuten IY®-vanhemmuusryhmäohjelma, voi- vat vähentää tehokkaasti lasten käyttäytymisongelmia lyhyellä aikavälillä las- tensuojelun kontekstissa olevissa perheissä. Positiivisten vaikutusten ylläpi- täminen ja niiden siirtyminen päivähoito- ja kouluympäristöihin näyttää kui- tenkin haasteelliselta. IY®-vanhemmuusryhmäohjelma näyttää soveltuvan hyvin lastensuojelun piirissä oleville perheille. Avainsanat: lasten käyttäytymisongelmat, vanhemmuus, vanhemmuus- ohjelma, interventio, näyttöön perustuva, lastensuojelupalvelut
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ACKNOWLEDGEMENTS
My greatest appreciation goes to all the participants who made the evaluation of the IY® program possible: parents and children, group leaders and contact persons in the research cities. This dissertation would not have been possible without you.
I wish to express my most sincere gratitude to my supervisors: Päivi Santalahti, Olli Kiviruusu and Eeva Aronen. I am priviledged to have been surrounded by such wonderful people. Päivi was the one with whom we decided to start this research project, and she has supported me in doing it in so many ways every step of the way – also helping in actual gathering of the data, sometimes by sitting on a driveway waiting for a parent to fill in a questionnaire in one city or another. She once said that dissertation is the biggest learning experience there is, and she was absolutely right. I also want to thank Olli for not only being forever so patient and thorough, but also for his dedication to this work as well as great companionship. His expertise in statistical methods is also highly appreciated. I also want to express my appreciation to Eeva for expertise, many valuable and always encouraging and gentle advice and support during this process. I couldn’t have done this without you all.
I am also greatful for several people who helped me with gathering the data: Taru Haula, Henna Jurvanen, Emilia Kaasalainen, Minna Kaasinen, Ulla Lång, Tiina-Katriina Mustonen and Lauri Sääksvuori; and also Kaisla Kasteenpohja for analyses. My gratitude also goes to Marjut Grainger for managing the data and Johanna Cresswell-Smith for helping out with the language. Raija Juntunen from HUS Children’s Hospital also deserves great thanks for helping out in various ways.
Professor Hanna Ebeling and Docent Kirsi Peltonen were the official reviewers of my study, appointed by the Faculty of Medicine. I thank them both for their thorough and highly professional examination of my thesis, as well as for their kind and encouraging comments.
This study was carried out at the Mental Health Unit of the Finnish institute for health and welfare (THL). I am grateful for the excellent research facilities provided by THL, as well as the current Head of Mental Health Unit Jaana Suvisaari and former head of the unit Mauri Marttunen for being so supportive of my work, as well as the former assistant of our unit Mirja Ihanus.
I want to thank the current and former workers of our unit Kari Aaltonen, Terhi Aalto-Setälä, Kaija Appelqvist-Schmidlechner, Petri Arvilommi, Noora Berg, Katja Björklund, Marjut Grainger, Jenna Grundström, Henna Haravuori, Minna Holm, Hanna Huhdanpää, Eeva Huikko, Taina Huurre, Teija Kasteenpohja, Jaakko Keinänen, Kristiina Lindfors, Maija Lindgren, Maili Malin, Marko Manninen, Janette Niiranen, Juulia Paavonen, Timo
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Partonen, Johanna Pitkänen, Pia Solin, Agnes Stenius-Ayoade, Anna Sofia Sarvasmaa, Sebastian Therman, Satu Viertiö and especially my dear friends Riikka Lämsä and Nina Tamminen for collegial support and many joyful moments. It has been a pleasure to be a part of such a special work community.
I wish to thank Doctoral Programme in Population Health (DocPop) for organizing interesting courses, having dedicated teachers and offering opportunities to have inspiring discussions with other students.
I gratefully acknowledge all the funding I have received for this study from the Alli Paasikivi Foundation, the Jalmari and Rauha Ahokas Foundation, the Yrjö Jahnsson Foundation, the MLL Research Fund, the Emil Aaltonen Foundation, the Marjaniemi Lions Club Ladies, the Helsinki University Hospital Research Funds and the Pediatric Research Center.
My warmest thanks go to all my friends outside of the research field. I am so lucky to have long-standing friendships with such a great bunch of people. You take an interest and encourage me in in my work, and take my mind off it when necessary. Special thank you goes to my dear friend Kati Granlund, with whom we have tackled the IY field together.
I wish to express my deep gratitude to my parents Marjatta and Seppo for all the support and help I have received during my life. You have always believed in me and supported me in realizing even my strangest and wildest ideas, and you have never doubted my abilities – or at least never showing if in doubt.
Mikko, the light of my life and my soul-mate, thank you for being you and for being there for me.
My dearly beloved Emilia and Luukas, my heart belongs to you. Thank you for being so understanding and supportive. Sorry for being quite often absent-minded and sorry that the food was not always on the table on time. However, the future is yours, and this is my humble attempt to make the world a bit better place. This work is dedicated to you.
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CONTENTS
Abbreviations ....................................................................................................... 14
2.2 Childhood behaviour problems, oppositional defiant disorder and conduct disorder ............................................................................. 20
2.2.1 Behaviour problems ........................................................................ 20
2.2.3 Conduct Disorder (CD) ..................................................................... 22
2.2.4 Prevalence ......................................................................................... 23
2.2.6.1 Risk factors ............................................................................ 25
2.2.6.2 Protective factors ................................................................... 28
2.2.8 Consequences and Prognosis .......................................................... 30
2.2.9 Treatment ......................................................................................... 32
2.3 Evidence-based parenting programs to reduce child behaviour problems .................................................................................................. 34
2.3.1 Background ....................................................................................... 35
2.3.3 Theoretical framework ..................................................................... 37
2.3.7 Parent’s perceptions on parenting programs .................................. 46
2.4 Incredible Years® Parenting Program .................................................... 47
2.4.1 Aims and content ............................................................................. 48
2.4.2 Methods ........................................................................................... 49
2.4.3 Fidelity .............................................................................................. 51
2.4.4 Effectiveness and cost-effectiveness................................................. 52
4 Methodology ............................................................................................... 60
4.2 Design of the randomized controlled trial .............................................. 61
4.3 Randomization procedure and power .................................................... 61
4.4 Procedure ................................................................................................62
4.4.3 Ethical considerations ...................................................................... 65
4.6 The intervention ..................................................................................... 66
4.8 Measures ................................................................................................. 68
4.8.2 Child behaviour measures (Studies II and III) ............................... 68
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4.8.5 Program attendance measures (Study IV) ....................................... 70
4.8.6 Program evaluation measures (Study IV) ........................................ 70
4.8.7 Other measures outlined in study protocol...................................... 71
4.9 Statistical analysis ................................................................................... 71
4.9.1 Study II ............................................................................................. 71
4.9.2 Study III ............................................................................................ 72
4.9.3 Study IV ............................................................................................ 72
5.1 Results of the systematic review (Study I) .............................................. 74
5.2 Results of the RCT (Studies II, III and IV) ............................................. 75
5.3 Intervention effectiveness on child outcomes (Study II and Study III) ................................................................................................. 77
5.3.1 Child behaviour outcomes reported by parents ............................... 77
5.3.2 Child behaviour outcomes reported by teachers ............................. 81
5.4 Intervention effectiveness on parent outcomes (Study II) ..................... 83
5.4.1 Parenting outcomes from pre- to post-intervention (Study II) ...................................................................................................... 83
5.4.2 Parent’s psychosocial wellbeing outcomes (Study II) ......................84
5.5 Attendance and parent’s perceptions on the program (Study IV) ........84
5.5.1 Parents attendance and retention ....................................................84
5.5.2 Parent’s evaluation of the intervention ............................................ 85
5.5.3 Comparing differences between parents in CPS and non-CPS (Study IV) ..........................................................................................86
6 Discussion .................................................................................................... 87
6.2 Child behaviour (Studies II and III) ...................................................... 88
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6.4 Parent’s psychosocial well-being (Study II) ........................................... 94
6.5 Parent’s attendance and retention (Study IV) ........................................ 95
6.6 Parent’s evaluation of the intervention (Study IV) ................................ 96
6.7 Strengths and limitations ....................................................................... 98
6.8 Conclusions ...........................................................................................100
References .......................................................................................................... 102
I Karjalainen, P., Santalahti, P. & Sihvo, S. (2016) Ovatko vanhemmuustaitoja tukevat ohjelmat vaikuttavia lapsen käytöshäiriöiden ja ongelmien ennaltaehkäisyssä ja vähentämisessä? - Järjestelmällinen katsaus. [Are programs supporting parenthood skills effective in the prevention and reduction of conduct disorders and problems of childhood? Systematic review]. Duodecim, 132:967–74.
II Karjalainen, P., Kiviruusu, O., Aronen, E.T. & Santalahti, P.
(2019) Group-based parenting program to improve parenting and children's behavioral problems in families using special services: A randomized controlled trial in a real-life setting. Children and Youth Services Review, 96, 420–429.
III Karjalainen, P., Santalahti, P., Aronen, E.T. & Kiviruusu, O.
(2021) Parent- and teacher-reported long-term effects of parent training on child conduct problems in families with child protection and other support services: a randomized controlled trial. Child and Adolescent Psychiatry and Mental Health, 15:7.
IV Karjalainen, P., Kiviruusu, O., Santalahti, P. & Aronen, E.T.
(2020) Parents’ perceptions of a group-based parenting programme in families with child protection and other family support services in a real-life setting. Child & Family Social Work, 1–12.
The publications are referred to in the text by their roman numerals.
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ABBREVIATIONS
ADHD Attention Deficit Hyperactivity Disorder BT Behaviour Therapy CBCL Child Behavior Checklist CBT Cognitive Behaviour Therapy CD Conduct Disorder CPS Child Protection Services DSM-5 Diagnostic and Statistical Manual of Mental Disorders EB Evidence-Based EBP Evidence-Based Practice EBPP Evidence-Based Parenting Programs ECBI Eyberg Child Behavior Inventory GHQ General Health Questionnaire ICD-10 Classification of Diseases IY Incredible Years NICE National Institute for Health and Care Excellence ODD Oppositional Defiant Disorder PMT Parent Management Training PMTO Parent Management Training - Oregon Model PPI Parenting Practices Interview PPSQ Program Satisfaction Questionnaire PSI-SF Parenting Stress Index – Short Form RCT Randomized Controlled Trial SES Socio Economical Status SESBI-R Sutter-Eyberg Student Behavior Inventory SWEMWBS Warwick-Edinburgh Mental Wellbeing Scale, short form TRF Teacher Report Form UN United Nations UNICEF United Nations Children’s Fund WHO World Health Organization
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1 INTRODUCTION
According to a Finnish epidemiological study based on parent interviews of children’s mental health diagnosis, 4.8% of 8-year-old children had conduct disorders (Almqvist et al., 1999). A further Finnish study (Maasalo et al., 2016) reported 11.4% of 4-12-year-old children to have clinically significant behaviour problems and 10.7% had borderline conduct problems as reported by parents.
Epidemiological studies have shown that the world-wide prevalence of conduct disorder is more than four times higher among children within Child Protection Services (CPS) (Bronsard et al., 2016) in comparison to the genereal population (Polanczyk et al., 2015). At school or in day care, children in touch with CPS are more likely to have (Bronsard et al., 2016) poor academic performance, such as reading and math skills, and impaired cognitive functioning (Colton, Heath, & Aldgate, 1995; Fallon et al., 2017; Crozier & Barth, 2005). Poor academic performance increases the risks for later antisocial behaviours, school dropout (Courtney et al., 2001), grade retention and suspension (Trout et al., 2008), as well as poor health and incarceration (Yoshikawa, 1995).
Studies also show taht children involved in CPS do not receive adequate psychiatric help for their mental health or other difficulties (Lahti et al., 2018; Sawyer et al., 2007; McCue et al., 2012). Quite often any help which is provided is not sufficient to treat their psychiatric difficulties and have not been tailored to meet their complex and specific needs (McCrae et al., 2010). Furthermore, children in CPS are five to eight times more likely to have been hospitalized for serious psychiatric disorders in their teens compared to their peers, and four to six times in young adulthood (Vinnerljung et al., 2006).
As behaviour problems and disorders are common, they incure high costs to society (e.g. higher use of special education, unemployment benefits, social benefits, health care services and justice system) in addition to causing suffering to children and their families. Behaviour problems and conduct disorders also predict deprivation in adulthood (e.g. substance abuse, mental health problems, unemployment, and raised mortality). (Biederman et al., 2006; Erskine et al., 2016; Fergusson et al, 2005; Kim-Cohen et al. 2003; Rutter et al., 2010, Mason et al., 2004; Raaijmakers et al., 2011; Scott et al., 2001). For these reasons it is important to treat these disorders effectively in all families.
Studies have shown that parents who have poor child management techniques (Hickox & Furnell, 1989), high levels of hostile feelings (Lesnik- Oberstein, Koers & Cohen, 1995), reduced emotional responsiveness and escalated verbal aggression (Hawley et al., 1995; Moser & Jacob, 1997) are at increased risk in maltreating their children (Hickox & Furnell, 1989). Several systematic reviews, meta-analysis and a meta-meta-analysis show that
Introduction
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structured, social learning, cognitive-behaviour or attachment based parent training programs are the most effective ways to reduce children’s behaviour problems, symptoms of conduct disorder, as well as increasing positive parenting practices (Barlow et al., 2014; Dretzke et al., 2005; Furlong et al., 2012; Menting et al., 2013; Mingebach et al., 2018; Piquero et. al, 2016).
Even though there is extensive knowledge of their effectiveness, these evidence-based programs are rarely offered to parents within CPS (Barth et al., 2005; Chaffin & Friedrich, 2004; Hurlburt et al., 2007). This is also reflected in the number of studies conducted in relation to child protection. Previous parenting intervention studies have mainly focused on normative samples or different clinical populations, while studies among clients of CPS are scarce and present somewhat contradictory results (Barlow et al., 2006; Montgomery et al., 2009). Findings of a meta-analysis performed by Barlow and colleagues (2006) showed insufficient evidence to support the use of parenting programs to reduce physical abuse or neglect, but implied that these programs may be effective in improving outcomes associated with physically abusive parenting. Montgomery and colleagues came to a similar conclusion in their meta-analysis (2009), and were not able to draw definitive conclusions about the potential of parenting programs in reducing recurrence of abuse. Furthermore, the results of a meta-analysis by Vlahovicova and colleagues (2017) in physically abusive families suggest that behavioral parenting programs are modestly but significantly effective strategies…