DISCUSIÓN GENERAL

DEVELOPMENT OF A PARENTING INTERVENTION FOR SEPARATED FAMILIES WITH ADOLESCENTS

The literature reviewed in Chapter 2, and the findings presented in Chapter 3, highlight the importance of intervention programs for separated families with adolescent children. The review of the empirical literature provided in Chapter 2 outlines the proposed mediators and moderators in the relationship between parental separation and child and adolescent

outcomes, and it is these factors which should be targeted by intervention programs for separating families with adolescents. This chapter begins by presenting a review of

empirically supported interventions for affecting the proposed mediators and moderators in the relationship between parental separation and adolescent outcomes. Discussion of the most efficacious methods for delivering intervention programs to families is also included in this chapter as it could be argued that the method of delivery is as important as the content for the program to be successful in including and retaining families, and ultimately achieving

program outcomes.

This chapter will then provide an overview of intervention research with separated families, followed by a more detailed description of the aims and outcomes of the most commonly cited and well-researched programs. This description will be followed by a

critical analysis of the empirical development and evaluative methodology of these programs.

This critical analysis will focus on whether programs have targeted the proposed mediators and moderators identified in Chapter 2, whether they have used empirically supported intervention components and delivery methods to do so, and whether they have evaluated outcomes according to program aims.

Separated families with younger children have more commonly been the focus of interventions, largely because the majority of families who separate do so in the earlier years of marriage and therefore have younger children at the time of separation (Australian Bureau of Statistics, 2003a), but also due to earlier beliefs that separation has less pronounced effects on older children compared to younger ones (Kalter & Rembar, 1981). For this reason only a limited number of studies which include adolescent children can be included in this review.

Empirically Supported Interventions for Targeting Identified Mediators and Moderators in the Relationship Between Parental Separation and Adolescent Adjustment

As reviewed in Chapter 2, research indicates that economic, family, and child factors influence the relationship between parental separation and child and adolescent outcomes.

The variables with the most consistent empirical support are socioeconomic status and socioeconomic decline, resident parent adjustment, interparental conflict and cooperative coparenting, parenting effectiveness, positive parent-child relationships, and children’s appraisal of, and coping with, negative separation-related events.

Developing a program for separated families that utilises empirically supported

strategies for changing these proposed mediators and moderators of the relationship between parental separation and child outcomes is likely to improve adolescent adjustment in

separated families. This method of program development has been recommended by Dumka, Roosa, Michaels, and Suh (1995), and has been used to develop prevention programs for separated families (Wolchik, West et al., 2000; Wolchik et al., 1993).

Improving the socioeconomic status of separated families is beyond the scope of most interventions programs. However, as noted in Chapter 2, some of the effects of economic factors on child and adolescent outcomes are mediated by parent adjustment and parenting practices. A review of empirically supported strategies for targeting resident parent

adjustment, interparental conflict and cooperative coparenting, parenting effectiveness, positive parent-child relationships, and children’s appraisal of, and coping with, negative separation-related events is presented next.

An effort is made to include empirically supported interventions as defined by Chambless and Hollon (1998), that is “clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population” (p. 7). However,

interventions for some of the mediators and moderators presented here are in a less-advanced stage of development. In these cases, interventions with the most consistent theoretical and empirical support will be presented. It is important to note that while interventions for some of these factors may be empirically supported for intact families, this does not assure their efficacy with separated families. For example, therapies to improve couple communication and reduce martial conflict in married families may not translate directly to separated

families. However, if there is strong support for their efficacy with married families and there

is additional, albeit limited, theoretical and empirical support for their use in separated families, including them in programs for separated families is the best practice available.

Resident Parent Adjustment

Resident-parent adjustment refers more specifically to parent well-being and the absence of anxiety, stress and depression symptomatology. Therefore, interventions to improve parent adjustment in separated families should be empirically supported therapies for reducing anxiety, depression, and stress, and improving the psychological well-being of adults. Two such empirically supported treatments are stress inoculation training (SIT;

Meichenbaum, 1993) for reducing stress and anxiety and increasing well-being, and cognitive-behaviour therapy (CBT; Beck et al., 1979) for reducing depression symptomatology.

As the name suggests, the aim of SIT is to train participants to develop skills to

“inoculate” themselves against the effects of environmental stressors on psychological and physical health (Saunders, Driskell, Hall Johnston, & Salas, 1996). While SIT was developed as a clinical intervention to assist clients to manage phobias, pain, and anger (Meichenbaum, 1993), it has since been applied to a wide range of stressors (Saunders et al., 1996). SIT prepares individuals for stressful experiences before they occur by providing education about the effects of stress, providing skills practise in strategies to deal with stress, and encouraging the use of the acquired skills in stressful situations. The skills practise varies according to the type of stressor that is the focus of the intervention and may include cognitive control

techniques which aim to reduce ruminations about current and future stressors, cognitive restructuring techniques which aim to reduce negative cognitive appraisals of stressors, and physical relaxation techniques which aim to reduce physiological arousal (Meichenbaum, 1993; Saunders et al., 1996). A recent meta-analytic study concluded that SIT is efficacious for reducing state anxiety and enhancing performance in stressful situations (Saunders et al., 1996). Further, SIT for reducing stress and anxiety is considered a well-established treatment (Chambless et al., 1998).

CBT is based on the cognitive model of depression which attributes the development of depression symptomatology to an individual’s negative evaluations of themselves, their experiences, and their future (Beck, 1967). CBT is similar to SIT in that it aims to change an individual’s cognitive style by encouraging a more realistic way of evaluating situations, and

uses education and cognitive restructuring to achieve this goal. Clients are educated about negative cognitive errors, and assisted to identify and challenge their own negative thoughts.

These thought challenging skills are acquired and practised in CBT sessions and clients are strongly encouraged to practise these skills outside CBT sessions (Beck et al., 1979).

CBT also incorporates behavioural techniques to encourage individuals to respond to situations in more adaptive ways. For example, clients can be given homework tasks to collect evidence regarding the realistic nature of their thoughts, to engage in activities which distract attention from negative thoughts (e.g. work, exercise, cognitive control strategies), and to monitor and increase their engagement in pleasant and rewarding activities which has been shown to improve mood (Beck et al., 1979). Some CBT interventions focus more heavily on the behavioural aspects of intervention, based on the theoretical hypothesis that depression is associated with reduced positive reinforcement for adaptive behaviours (Lewinsohn & Gotlib, 1995). These programs focus on increasing pleasant activities and reducing aversive social events by providing clients with training in problem-solving and social communication skills (Craighead, Craighead, & Ilardi, 1998; Jacobson et al., 1996;

Lewinsohn, Hoberman, & Clarke, 1989).

Research indicates that CBT is an efficacious treatment for reducing depression symptomatology (Dobson, 1989), and like SIT, CBT for depression is considered a well-established treatment (Chambless et al., 1998). While these meta-analytic results are based on evaluations of interventions with clinical samples, there is also evidence to suggest that these techniques are efficacious in preventing depression symptomatology in adolescents and adults at risk of developing depression (Clarke et al., 1995; Lewinsohn et al., 1989).

It is likely that parenting programs that include training in SIT techniques to reduce anxiety and stress associated with parental separation will increase parent adjustment. It is also likely that training in cognitive and behavioural techniques for reducing depression symptomatology will increase parent adjustment.

Interparental Conflict and Cooperative Coparenting

There is consistent support for the use of cognitive-behavioural marital therapy (CBMT) to reduce marital conflict and improve marital communication (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Hahlweg & Markman, 1988; Halford, Sanders, & Behrens, 1993; Jacobson & Follette, 1985; Markman, Renick, Floyd, Stanley, & Clements, 1993).

CBMT is based on research indicating that compared to non-distressed couples, maritally distressed couples have deficiencies in communication skills (Christensen & Sheck, 1991);

cognitive deficits (Eidelson & Epstein, 1982); and reduced frequency of positive interactions and increased frequency of negative interactions (Halford, Hahlweg, & Dunne, 1990; Halford

& Sanders, 1988). Following from this, CBMT aims to affect these identified problems by focusing on skills training and practise in communication skills, problem-solving skills, and conflict management, and activities to challenge unrealistic beliefs and increase positive interactions (Halford & Behrens, 1996).

It could be argued that marital conflict occurs in the context of a continuing

relationship, whereas post-separation interparental conflict occurs after a relationship has dissolved, suggesting that the types of strategies used to reduce marital conflict would not be appropriate for separated parents. However, post-separation interparental conflict occurs in the context of a continuing coparenting relationships where communication and conflict are often problematic. For this reason, it is likely that many of the strategies used in cognitive-behavioural marital therapy to address these communication and cognitive deficits may be effective in reducing interparental conflict and improving coparental communication in separated couples.

Parenting Effectiveness and Positive Parent Child Relationships

Behavioural family intervention (BFI) has consistently been shown to be an efficacious intervention for teaching positive parenting practices (Serketich & Dumas, 1996; Taylor &

Biglan, 1998), and while investigated less frequently, there is support for positive effects of BFI on parent-child relationships (Ralph & Sanders, 2003; Wolchik et al., 1993). BFI is based on behavioural principles (Skinner, 1953) and coercion theory (Dishion et al., 1992;

Patterson, 1992; Patterson et al., 1992; Patterson & Yoerger, 1997) and aims to change the family interaction patterns that influence child behaviour problems. It does this by providing parents with information and skills training in positive parenting and child management strategies, including increasing positive interactions with children, setting limits, providing praise and rewards for desirable behaviours, discouraging inappropriate behaviour with non-violent punishments (e.g. time out, removal of privileges, logical consequences), and using problem solving to resolve family conflict (Forgatch & Patterson, 1987; Patterson &

Forgatch, 1987; Sanders & Dadds, 1993).

Because parenting practices are dependent on other factors besides knowledge and acquisition of parenting skills (for example, parenting depression and marital distress) BFI provides additional components for dealing with these problems. These components are cognitive-behavioural in their approach and include thought monitoring and thought challenging for alleviating parental depression, and partner support and problem-solving discussions for reducing marital distress (Dadds, 1992; Sanders & Dadds, 1993).

The majority of studies investigating the efficacy of BFI have included families with children displaying oppositional behaviours (Forehand & Long, 1988; Sanders, 1999;

Sanders, Markie-Dadds, Tully, & Bor, 2000; Webster-Stratton & Hammond, 1997).

However, there is evidence to suggest that BFI is an effective adjunct therapy to improve parenting skills, parent-child relationships, and child adjustment across a wider range of child problems, including child obesity, anxiety disorders, sleeping problems (Taylor & Biglan, 1998). For example, research in Australia has found that a parent-focused intervention component based on BFI added significantly to the efficacy of a child-focused CBT

intervention for children and adolescents (aged 7 to 14 years) with anxiety disorders (Barrett, Dadds, & Rapee, 1996; Dadds, Heard, & Rapee, 1992). Further, BFI has also been included as an adjunct to CBT for depressed adolescents, where parents are trained in communication, negotiation, and problem-solving in parallel sessions, and then taught to practise these skills in combined sessions with their adolescent children (Coping with Depression Course for Adolescents; Hops, 1992).

While the majority of studies evaluating the efficacy of BFI have focused on the reduction of clinical-level problems in young children, there is also evidence that BFI is an efficacious method for preventing child adjustment problems in families with sub-clinical levels of distress and disorder (Dadds, Spence, Holland, Barrett, & Laurens, 1997; Sanders, 1999), and for increasing effective parenting, positive parent-child relationships, and reducing behavioural and emotional problems in adolescents (Bank, Marlowe, Reid, Patterson, & Weinrott, 1991; Barrett et al., 1996; Dadds et al., 1992; Dadds et al., 1997;

Ralph & Sanders, 2003). While there is some evidence that BFI is less effective with single-mothers than with married parents (Taylor & Biglan, 1998), it is effective for reducing child behaviour problems in single-mother families, especially if mothers are provided with additional training in problem-solving for non-parental problems (Pfiffner, Jouriles, Brown, Etscheidt, & Kelly, 1990).

Child Appraisal and Coping

Cognitive restructuring is a component of cognitive-behaviour therapy (Beck et al., 1979) and stress innoculation training (Meichenbaum, 1993), and as described above, aims to replace negative appraisal with realistic ones. There is consistent support for the efficacy of cognitive restructuring in the prevention and early intervention of child and adolescent internalising and externalising problems (Kazdin, 2003; Kazdin & Weisz, 1998). Empirically supported CBT programs for the prevention and early intervention of child and adolescent anxiety (Barrett et al., 1996; Dadds et al., 1997; Kendall, 1994; Kendall et al., 1997) and successful CBT programs for the prevention and treatment of child and adolescent depression (Clarke et al., 1995; Gillham, 1995; Jaycox, 1994; Rhode, Lewinsohn, Clarke, Hops, &

Seeley, 2005; Stark et al., 2005) include cognitive restructuring components. This suggests that programs for separated families which aim to improve children’s appraisal of negative separation-related events may benefit from the inclusion of training in cognitive

restructuring.

There is evidence that children and adolescents who receive training in adaptive coping strategies show greater adaptation to normative and non-normative stressors, including invasive medical procedures (Powers, 1999), and the transition to secondary school (Elias et al., 1986). Further, there is a large body of evidence indicating that training in coping skills (including problem-solving skills training, relaxation training, engagement in distracting and enjoyable activities) is efficacious in preventing and treating child and adolescent depression, anxiety, and behaviour problems (Kazdin, 2003; Kazdin & Weisz, 1998). Training in

relaxation skills is an important component of empirically supported CBT programs for child and adolescent anxiety (Barrett et al., 1996; Dadds et al., 1997; Kendall, 1994; Kendall et al., 1997); while problem solving skills training is a major component of successful intervention and early intervention programs for child and adolescent depression (Gillham, 1995; Jaycox, 1994) behavioural problems (Durlak, Fuhrman, & Lampman, 1991). In addition, Hains and colleagues have found that SIT programs that include cognitive restructuring and relaxation skills training prevent and reduce externalising and internalising symptomatology in

adolescents (Hains, 1992; Hains & Szyjakowski, 1990). These findings suggest that

providing coping skills training to adolescents in separated families is likely to increase their adjustment.

Summary

The findings from prevention and intervention research with families suggest that cognitive-behavioural approaches are effective methods for improving parent adjustment, parenting effectiveness, and positive parent-adolescent relationships. Behavioural family intervention (BFI), incorporating information and skills training in positive parenting and child management strategies, is an empirically supported intervention for increasing positive parenting practices and reducing adolescent behavioural problems. In addition, there is support for behavioural family intervention as an adjunct to cognitive behavioural techniques for reducing adolescent anxiety and depression. The efficacy of cognitive-behavioural

marital therapy for reducing conflict and improving communication in married couples provides a rationale for the utilisation of cognitive behavioural treatment methods for reducing conflict and improving communication in separated dyads. These treatment

methods include skills training and practise in communication skills, problem-solving skills, and conflict management, and activities to challenge unrealistic beliefs. There is also support for the use of cognitive-behavioural approaches to improve parent adjustment and adolescent appraisal and coping. These intervention techniques include skills training in cognitive restructuring, problem-solving, cognitive control, assistance seeking, physical relaxation training, and engaging in enjoyable and distracting activities.

Effective Methods for Delivering Intervention Programs to Families

A number of factors need to be considered when designing an intervention program for families. These include (a) the level of therapist contact, that is, the amount of professional assistance participants will receive while completing the program, (b) whether programs should be delivered to individuals or groups, and (c) the most effective teaching strategies to promote learning, behaviour change, and generalisation and maintenance of learning and behaviour change. These factors are discussed below.

Levels of Therapist Contact

Behavioural parenting programs can be organised into three categories based on the level of therapist contact: (a) self-administered (b) minimal contact, or (c)

therapist-administered (Glasgow & Rosen, 1978). Self-therapist-administered programs are those where clients receive written and/or audio-visual materials and complete the program without therapist contact. In this category, clients may have contact with clinicians or researchers for

data-collection purposes provided that practical advice or clinical support is not given during these contacts. Self-administered programs vary widely in the type of material provided, with some providing brief written information (e.g. Bogenschneider & Stone, 1997) and others requiring parents to read written material and work through written and practical tasks (e.g. Endo, Sloane, Hawkes, & Jenson, 1991; Giebenhain & O'Dell, 1984).

Minimal contact programs are those where participants complete the program using written and/or audio-visual materials with limited involvement from clinicians. This involvement often consists of weekly phone-calls, however it can also include contact by mail, email, or brief meetings. The aim of these contacts is to assist clients to understand and apply the information and skills to their own family (Glasgow & Rosen, 1978). Minimal contact programs have been offered in rural areas to address barriers to program participation often found in small remote communities. These barriers include difficulties maintaining confidentiality in small towns where everyone knows each other, low therapist availability, and limited accessibility for families due to increased demands on time and finances when required to travel long distances to program venues (Connell, Sanders, & Markie-Dadds, 1997). In therapist-administered programs, clients are provided with written and/or

audiovisual materials, and meet regularly with a clinician to clarify information presented in provided materials, to apply information to their own specific situation, and to practise skills presented in the program materials (Glasgow & Rosen, 1978).

There is support for the acceptability and efficacy of self-administered behavioural parenting programs for specific child problems, including disruptive behaviour during mealtimes at home (Ergon-Rowe, Ichinose, & Clark, 1991; McMahon & Forehand, 1978) and during shopping trips (Clark et al., 1977; Ergon-Rowe et al., 1991; Sanders, 1999), child whining (Endo et al., 1991), bedtime problems including fear of the dark (Giebenhain &

O'Dell, 1984) and night waking (Seymour, Brock, During, & Poole, 1989), and for oppositional behaviour and conduct problems (Webster-Stratton, 1992; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988). There is also support for the use of minimal contact parenting programs for reducing discrete child problems including night waking (Seymour et al., 1989) and disruptive behaviour during shopping trips (Clark et al., 1977), and for

reducing oppositional behaviour and conduct problems (Connell et al., 1997); Webster-Stratton, 1990).

Therapist-administered delivery is the standard for behavioural parenting interventions and there is consistent support for the acceptability and efficacy of programs with this level of therapist contact (Sanders et al., 2000; Serketich & Dumas, 1996; Taylor & Biglan, 1998).

Further, comparisons of the efficacy of parenting programs according to the level of therapist contact indicate that program efficacy varies with the level of therapist contact (Sanders et al., 2000; Seymour et al., 1989). In a comparative study evaluating the relative efficacy of

Further, comparisons of the efficacy of parenting programs according to the level of therapist contact indicate that program efficacy varies with the level of therapist contact (Sanders et al., 2000; Seymour et al., 1989). In a comparative study evaluating the relative efficacy of