Capítulo 8: Aproximaciones Metodológicas y Trabajo de Campo
8.1 El enlace permanente a los datos del estudio
8.2.3 Entrevistas grupales
The preceding review of the literature discussed the nature and prevalence of child conduct problems. The outcomes of these behaviour problems, the risk factors associated with the development and maintenance of child conduct problems, and the parenting experiences of parents with young children displaying behaviour problems were described. The review then outlined interventions for parents with young children displaying conduct problems and presented the rationale for low-intensity parenting programmes. The evidence for low- intensity parenting programmes was then described with a particular focus on the Triple P Discussion Groups, an example of a topic-specific, low-intensity group parenting programme, which were used in the current thesis. Limitations of the previous research evaluating the Triple P Discussion Groups were discussed focusing on the strategies to promote generalisation of parenting skills when delivering low-intensity parenting programmes, the lack of research with parents of primary school aged children, and the lack of father inclusion in research evaluating such programmes.
The literature review then discussed two additional risk factors associated with child conduct problems; poor parental mental health and parenting stress. First, interventions for common mental health problems were discussed and the rationale and effectiveness of cognitive behavioural therapy based low-intensity interventions addressing mental health problems was presented. The impact of addressing parental mental health on child behaviour problems was then considered and the review argued for combined support that targets both parenting practices and common mental health problems as a way of enhancing outcomes of low-intensity parenting programmes.
As outlined in the literature review, there is a high prevalence of child conduct problems among young children in developed Western countries (e.g., Australian Institute of Family Studies, 2011; Bradshaw & Tipping, 2010; Sanders et al., 2007). Early conduct
problems are associated with negative outcomes during late childhood, adolescence, and adulthood (e.g., Campbell et al., 2006; Fergusson & Horwood, 1998; Fergusson et al., 2005; Knoester, 2003; McLeod & Kaiser, 2004) and less positive parenting experiences (e.g., Baker & Heller, 1996). This indicates the importance of addressing conduct problems displayed by young children and suggests there is a high level of need for intervention. As parenting is inextricably linked with children’s development and behaviour, parenting programmes based on social learning and behavioural theories have been recommended for the prevention and intervention of child conduct problems (e.g., Advisory Group on Conduct Problems, 2009; Dretzke et al., 2009; Eyberg et al., 2008; Furlong et al., 2012; National Institute for Health and Clinical Excellence, 2013). One major challenge is that the benefits of parenting programmes are limited as few parents access such programmes (Sanders et al., 2007; Taylor & Biglan, 1998). It has been argued that a population health approach to parenting support is required to ensure that available programmes are meeting the needs and preferences of all parents (e.g., Sanders & Kirby, 2014; Sanders et al., 2014). A population health approach to parenting support involves the delivery of low-intensity programmes.
Low-intensity interventions are programmes that require a low usage of practitioner time or usage of time in a cost-effective way (Bennett-Levy et al., 2010). They can range from single to several sessions that are topic-focused (Dishion & Stormshak, 2007a) and are designed for parents with children with mild to moderate problems (Sanders & Murphy- Brennan, 2010). Low-intensity parenting programmes appear to produce beneficial outcomes for parents and children (e.g., Boyle et al., 2010; Kjøbli & Ogden, 2012; Turner & Sanders, 2006). Group based low-intensity topic-specific parenting programmes, such as the Triple P Discussion Groups, have promising intervention outcomes for parents and preschool aged children (Dittman et al., 2015; Joachim et al., 2010; Morawska et al., 2010; Morawska et al., 2014) and parents with 3-12 year old children in a low-resource context (Mejia et al., 2015). Furthermore, high levels of satisfaction with the Triple P Discussion Groups have been reported. These RCTs have found that attending a single exemplar of a Triple P Discussion Group led to improvements in child behaviour problems and parenting practices (Dittman et al., 2015; Joachim et al., 2010; Mejia et al., 2015; Morawska et al., 2010; Morawska et al., 2014), in comparison to a waitlist control. Effects of participating in a Triple P Discussion Group have also been found for target child behaviours (Joachim et al., 2010; Morawska et al., 2014), parenting self-efficacy (Dittman et al., 2015; Joachim et al., 2010; Morawska et al., 2014), and partner relationships (Morawska et al., 2010).
Several studies found no effects for the Triple P Discussion Groups on measures of parental mental health, inter-parental conflict, and parenting experiences at post-intervention
(Dittman et al., 2015; Joachim et al., 2010; Morawska et al., 2010) which may have been due to floor/ceiling effects. An exception was that Mejia et al. (2015) found a reduction in parental mental health problems over time with small effects reported at post-intervention and medium effects at 6-month follow-up. Furthermore, Dittman et al. (2015) found that by 6-month follow-up, significant reductions in parental mental health problems and inter-parental conflict had occurred following attending a Triple P Discussion Group. It is possible that such programmes would lead to improvements in these domains, as previous research has found that parents with a child displaying difficult behaviour are more likely to report having a stressful or depressing parenting experience (Sanders et al., 2007). Therefore, reducing child conduct problems may lead to improvements in parental mental health and parenting experiences. It may be that effects on these areas are delayed or that exposure to multiple parenting exemplars through participation in a series of Triple P Discussion Groups is required. Training in multiple exemplars may be likely to lead to more robust changes at multiple levels of the family system, such as parental mental health and inter-parental conflict, than narrowly focused single exemplar training. Furthermore, given that most of the previous research evaluating the Triple P Discussion Groups did not screen parents into studies on the basis of the level of their child’s conduct problems, it is unlikely that parents would have reported high levels of other familial risk factors (e.g., high levels of psychological distress and inter-parental conflict) which may have accounted for the lack of effects. When parents are recruited on the basis of elevated child behaviour problems in a low-resource context, reductions in parental mental health problems were found (Mejia et al., 2015). More research is needed to test the minimally sufficient level of intervention required when families are screened into studies on the basis of an elevated level of child conduct problems using a cut- off score on a standardised measure.
The effects of the Triple P Discussion Groups are mixed for several other measures (e.g., child behaviour in general, parenting practices in general, parenting self-efficacy across settings) and these findings suggest that the generalisation of parenting skills after attending a Triple P Discussion Groups may be limited and need to be examined in more detail (Morawska et al., 2010; Morawska et al., 2014). Further investigation needs to examine whether strategies that aim to enhance generalisation, such as multiple exemplar training, results in superior intervention outcomes when compared to single exemplar training. Based on generalisation theory, teaching multiple exemplars in comparison to teaching a single exemplar is likely to enhance generalisation by fostering parents’ ability to apply parenting skills flexibly to a range of behaviours and settings, resulting in greater improvement in child behaviour. Furthermore, the findings from Boyle et al. (2010) indicate that the effects of an
individually-administered low-intensity Triple P programme addressing behaviours of concern to parents, can be seen in both target and generalisation settings. The findings from Glogower and Sloop’s (1976) study suggested that in addition to teaching multiple exemplars, teaching more general concepts may facilitate generalisation.
There are also gaps in the literature about the effects of the Triple P Discussion Groups for parents with primary school aged children. In addition, there is paucity of research on the effects of such programmes for fathers. The current thesis addressed these gaps by examining the effects of the Triple P Discussion Groups with parents of primary school aged children screened in on the basis of their conduct problems using a cut-off score. Among two-parent families, both mothers and fathers were encouraged to take part in the evaluation and intervention process and the effects of the intervention were examined separately for mothers and fathers.
Other key risk factors associated with child conduct problems are poor parental mental health and parenting stress (e.g., Duncombe et al., 2012; Solem et al., 2011). Poor parental mental health and parenting stress are also associated with less optimal parenting and discipline practices (e.g., Australian Institute of Family Studies, 2012; Lovejoy et al., 2000). Of great concern is the high prevalence of common mental health problems among parents with young children (e.g., Australian Institute of Family Studies, 2012; Marryat & Martin, 2010; Sanders et al., 2007). There is evidence to suggest that parenting programmes have differential effects for children of parents with poor mental health (e.g., Kjøbli et al., 2013; Reyno & McGrath, 2006) highlighting the need to address parental mental health when delivering parenting support. Previous research evaluating combined interventions that target parenting practices and parental mental health simultaneously among parents of children with behaviour problems have generally reported positive effects for both parenting and mental health outcomes (e.g., Gavita & Joyce, 2008; Sanders et al., 2000; Sanders & McFarland, 2000). However, these evaluations have typically used high-intensity interventions. There is little known about the effects on parenting, parental mental health, and child outcomes for combined interventions that are low in intensity.
2.5.1 Aims and Hypotheses of the Thesis
This thesis aimed to add to the current literature on low-intensity topic-specific group parenting programmes by conducting two separate but interlinked studies. Study one based in Auckland, New Zealand examined the effects of single exemplar training of a two-hour topic- specific parenting group in comparison to multiple exemplar training consisting of four two- hour topic-specific parenting groups. The study used a RCT design and examined the effects
of the two conditions for parents with a 5-8 year old child screened in on the basis of their child’s conduct problems. It was hypothesised that mothers in both conditions would report significant reductions in child conduct problems and ineffective parenting practices as well as greater parenting self-efficacy. Mothers allocated to the multiple exemplar condition were expected to report significantly greater change in child behaviour, parenting practices, and parenting self-efficacy than those in the single exemplar condition as a result of the generalisation promotion strategies, which aimed to enable parents to apply parenting skills more flexibly, incorporated in multiple exemplar training. For mothers, intervention effects for child behaviour, parenting practices, and parenting self-efficacy expected at post-intervention were hypothesised to be maintained at 6-month follow-up and it was expected that a high level of satisfaction with the interventions would be reported.
As there is paucity of research on the effects of low-intensity group parenting programmes for fathers, study one also aimed to explore the effects of the two conditions on father-reported child conduct problems, fathers’ parenting practices, and fathers’ parenting self-efficacy. In addition, the study investigated the effects of single exemplar training in comparison to multiple exemplar training on measures of parenting experiences, parental mental health, inter-parental conflict, and partner relationship satisfaction for mothers and fathers. It may be that parents allocated to the multiple exemplar condition are more likely to report significant changes in parenting experiences, parental mental health, inter-parental conflict, and partner relationship satisfaction. This was expected as greater exposure to exemplars is likely to lead to greater improvements in parenting and child behaviour, which in turn could lead to improved mental health, more positive parenting experiences, greater partner relationship satisfaction, and greater consistency between parents. Furthermore, training in multiple exemplars may be more likely to lead to robust changes at multiple levels of the family system than narrowly focused single exemplar training.
The second study in this thesis was based in Glasgow, UK and aimed to explore the effects of a combined low-intensity group based parenting programme with a low-intensity group based cognitive behaviour intervention for common mental health problems among parents with 3-8 year old children. The effects of the combined programme were evaluated by examining change in parenting practices, parental mental health, child behaviour, parenting self-efficacy, family relationships, and positive mental health at pre-, mid- and post- intervention. The maintenance of intervention effects were examined at 3-month follow-up. The effects of the combined programmes were explored using both quantitative and qualitative methods and aimed to answer the following research questions:
1. Does the combined low-intensity parenting programme and a low-intensity cognitive behaviour intervention for common mental health problems change parenting practices and parental mental health?
2. Does the combined programme change disruptive child behaviour, parenting experiences, family relationships, parenting self-efficacy, positive mental health, and among two-parent families, partner support?
3. What are parents’ perceptions of the combined programme? 4. What are parents’ perceived impacts of the combined programme? 5. What factors affect parents’ implementation of strategies?