The Relationship between Adolescents’ Treatment Readiness and Externalizing Behavior
Master Thesis Forensic Orthopedagogy Graduate School of Child Development and Education, University of Amsterdam M. Helder 10673490 Guidance: Drs. E. Kornelis, & Dr. J. Van Horn Second evaluator: Prof. G. J. J. M. Stams Amsterdam (March, 2016)
Abstract
Background: A large percentage (33 up to 60%) of the treatments in outpatient forensic treatment programs result in dropout. The aim of this study was to evaluate the impact of a parent training program (Parenting with Love and Limits) in the Netherlands on adolescents’
problem behavior and treatment readiness. Change in treatment readiness of parents and adolescents and adolescents’ externalizing problem behavior was examined.
Method: 45 families with adolescents aged 13 to 19 years old and their siblings participated in the study. A one-group pretest-posttest design was adopted. Participants completed the Child
Behavior Check List (CBCL), Youth Self Report (YSR) and University of Rhode Island Change Assessment (URICA) at the beginning and end of the parenting program. Results: Analyses showed that there was a significant reduction in CBCL/YSR externalizing
behavior. There were no noteworthy differences in treatment readiness. Some associations were found between readiness and treatment outcomes in terms of externalizing behavior. Conclusions: The current study was not able to demonstrate that readiness for change among
parents and adolescents increases during treatment. Nonetheless significant reductions in externalizing problem behavior were found. Thus, remaining in the precontemplation and contemplation stages of change during treatment does not imply positive treatment outcomes
do not occur. Further studies of the program could further investigate the role of treatment readiness and motivation in Parenting with Love and Limits.
Keywords: parent-training, externalizing problem behavior, treatment readiness, adolescents, outcome
The Relationship Between Adolescents’ Treatment Readiness and Externalizing Behavior
Lack of treatment motivation among adolescents with behavior problems is considered a major problem in youth forensic services (McMurran & Ward, 2010; Van Binsbergen, 2003; Verdonck & Jaspaert, 2009). Unmotivated or unwilling clients may be more likely to drop out of therapy. Previous research shows that the dropout rate among juveniles is relatively high in outpatient forensic treatment programs, with one-third to sixty percent of the youngsters dropping out of treatment (Baruch, Vrouva, & Fearon; 2009; McMurran & Theodosi, 2007; Sheldon, Howells, & Patel, 2010), whereas non-completion rates within correctional
institutions are relatively low, ranging from 9 to 17.6% (McMurran, & McCulloch, 2007; Sheldon et al., 2010). This is worrisome, given that offenders who drop out of treatment have the most criminogenic needs (i.e., dynamic risk factors) and, therefore, are at higher risk of reoffending compared to completers (McMurran & Theodosi, 2007; Sheldon et al., 2010). Drop-out decreases the likelihood of successful alleviation of behavioral problems (Johnson, Mellor, & Brann, 2008; McMurran & Ward, 2010; Sells, Early, & Smith, 2011), or even worsens the symptoms. Besides undermining the effectiveness of therapy, dropping out also entails substantial costs to the client, the caregivers and society. Unmotivated clients who drop out of treatment are costly because of the investment of time and resources during the intake, risk assessment and early stages of treatment, which they may not have benefitted from (Johnson et al., 2008; McMurran & Ward, 2010). They also replace others who are on the waiting list, and because they do not show up, clinicians are left with unoccupied
appointment hours, which decreases staff productivity (Johnson et al., 2008). In the long term untreated externalizing behavior leads to economic difficulties in society in terms of
recidivism, damage, victims, and poorer social and economic prospects in adulthood (Baruch, Vrauva, & Wells, 2011; Scott, Knapp, Henderson, & Maughan, 2001).
Previous research shows that certain subgroups are more likely to drop out of treatment than others (Baruch et al., 2009). Especially among adolescents diagnosed with a conduct disorder (CD) or oppositional defiant disorder (ODD) the probability of dropping out is significantly increased (Baruch et al., 2011; Harder, Knorth, & Kalverboer, 2012). CD and ODD often present with other disorders such as ADHD, depression, anxiety and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) (Baruch et al., 2011; Sells et al., 2011). Comorbidity, the simultaneous occurrence of various disorders, often predicts poorer response to treatment because of high drop-out rates and low levels of participation
and engagement (Van Binsbergen, 2003; Verdonck & Jaspaert, 2009). Other factors that increase the likelihood of dropping out include the following: Johnson et al. (2008) found that clients experiencing family problems were more likely to drop out of treatment, because parents may be preoccupied with other issues in their lives, which may interfere with the child’s chance to complete treatment. Another study suggested that school problems, being younger, having higher self-reported delinquency scores and being homeless increased the likelihood of dropping out (Baruch et al., 2009). In the Dutch context a Surinamese/Antillean ethnicity, being female, being older and lower parental SES were found to increase drop out in adolescents (De Haan et al., 2015).
In order to prevent drop out it may be important to involve parents or caregivers in the therapeutic process. The reason for this is that changes in parenting behavior cause changes in adolescents’ behavior (Dékoviç, Asscher, Manders, Prins, & Van der Laan, 2012; Feldblyum, Williams, Walker, & Jackson-Walker, 2014). It can be a formidable challenge to effectively engage parents or caregivers in their child’s treatment, because they can have the conviction that their child is solely responsible for his/her externalizing behavior. Therefore, parents may be less inclined to engage in treatment (Sells et al., 2011). However, previous research in the juvenile justice field showed that family-based therapy (i.e., treatment programs that focus on family factors such as communication style and parent-child relationship quality) results in a higher level of adolescents’ and parents’ engagement in treatment, and lower dropout rates compared to individual psychotherapy (e.g., Feldblyum et al., 2014).
There is considerable agreement on the fact that treatment readiness can be influenced through intervention and in interaction with the environment (DeLeon, Melnick, & Tims, 2001; Drieschner, 2005; Miller & Rollnick, 1991; Prochaska & DiClemente, 1984; Van Binsbergen, Knorth, Klomp, & Meulman, 2001; Verdonck & Jaspaert, 2009). Parenting with Love and Limits (PLL) is such an intervention, which is aimed at unmotivated and/or
conduct-disordered adolescents and their parents (Hoogsteder, 2012; Sells et al., 2011). PLL is a family based intervention that is recently applied in forensic outpatient treatment. PLL uses the Transtheoretical Model (TTM) and motivational interviewing (MI) to increase the readiness of juveniles and their parents to actively invest in reaching treatment goals (Roedelof, Bongers, & Van Nieuwenhuizen, 2013; Verdonck & Jaspaert, 2009).
The TTM, developed by Prochaska and DiClemente (1984), distinguishes six stages of motivation during treatment: Precontemplation, Contemplation, Preparation, Action,
Consolidation and Relapse (Prochaska, DiClemente, & Norcross, 1992). In early stages people are hardly motivated to change their behavior and might not even consider their
behavior as problematic. In the more advanced stages, they have more insight into possible reasons for changing problematic behavior. Therefore, they make a greater personal
investment, eventually followed by a successful change, a focus to maintain improvements and prevention of relapse (Feldblyum et al., 2014). Most people tend to pass through the motivation stages in a spiral pattern, that is, they move back and forth between various stages in terms of performing the desired behavior as well as readiness to change it (Feldblyum et al., 2014; Norcross, Krebs, & Prochaska, 2011; Van Binsbergen et al., 2001). Treatment readiness implies that a person can engage in treatment and is able to start with treatment (McMurran & Ward, 2010). It is hypothesized that readiness precedes engagement, which in turn influences completion of treatment and, eventually, treatment outcomes (Casey, Day, Howells, & Ward, 2007; Day et al., 2009; Sheldon et al., 2010). The PLL therapist applies motivation techniques matching the motivational stage of the client, and tries to enhance the client’s motivation to change. This way the therapist tries to redirect the external motivation of the client to an internal motivation. Offenders who are intrinsically motivated accept responsibility for their actions and commit to making a change (Chambers, Eccleston, Day, Ward, & Howells, 2008). In contrast, extrinsic motivation refers to external pressure applied on the individual in order to attain a certain outcome (Brooks & Kahn, 2015).
MI is a therapeutic approach that integrates the principles of client-centered therapy (Rogers, 1951) with cognitive behavioral strategies focused on the stages of change within the TTM (Miller & Rollnick, 1991; Prochaska et al., 1992). MI is a directive, client-centered counselling style of enhancing treatment motivation by helping clients to explore and resolve ambivalence (Lewis & Osborn, 2004; McMurran & Ward, 2010; Miller & Rollnick, 2012). The clinician has to keep four general principles in mind: 1) expressing empathy through reflective listening, 2) developing a discrepancy between the client’s current behavior and future goals, 3) rolling with resistance, and 4) supporting self-efficacy (Miller & Rollnick, 1991).
Attrition is associated with lower treatment motivation levels, failure to comply in the treatment process and to practice skills, finally resulting in recidivism, and other negative treatment outcomes (Day et al., 2009; Sheldon et al., 2010). Hence, active participation of clients is an important prerequisite for achieving the desired behavioral change. Treatment engagement is a predictor of treatment outcome, since a positive relationship was found between motivation to change and treatment success, and between non-completion (drop-out) and (general and specific) recidivism (i.e. re-offending of any type versus the same crime as in the index case (e.g. property crime, violence, sexual transgression)) (Drieschner, 2005;
Harder et al., 2012; McMurran & Theodosi, 2007; Van Binsbergen, 2003; Verdonck & Jaspaert, 2009).
There is an impressive body of literature about measures of treatment motivation and readiness (e.g., The Stages of Change Readiness and Treatment Eagerness Scale
(SOCRATES); Miller & Tonigan, 1996, Circumstances, Motivation, Readiness and
Suitability (CMRS Scales); DeLeon, Melnick, Kressel, & Jainchill, 1994). The bulk of this literature is either concerned with addicted patients or with psychotherapy patients with various problems (Drieschner, 2005). As yet, little is known about using measures of treatment readiness with adolescent offenders (Cohen, Glaser, Calhoun, Bradshaw, & Petrocelli, 2005). In addition, little information is provided concerning the reliability and validity of these instruments The current study expands on existing literature by examining the association between outcomes in terms of change in adolescents’ problem behavior and treatment readiness in adolescents who receive the family intervention Parenting with Love and Limits (PLL) at the Waag, a center for outpatient forensic psychiatric treatment in the Netherlands. The University of Rhode Island Change Assesment (URICA) is a measure for intrinsic readiness to change used in youth forensic treatment at the Waag. The URICA has a general character and it is not focused on specific behavioral problems (Callaghan et al., 2008; Cohen et al., 2005). Due to the lack of alternatives the URICA will nevertheless be used in the current study. Gaining insight into the role of readiness of adolescents and their
caretakers could enhance therapeutic practice by understanding how to enhance motivation, so interventions for youths with serious behavioral problems will be more effective. The first objective of the study was to assess the outcomes of PLL in terms of change in adolescents’ problem behavior and treatment readiness during the intervention. A second objective was to explore the association between treatment readiness and problem behavior. A third objective was to identify to what extent readiness of parents or caretakers was associated with
adolescents’ behavior change and treatment readiness.
It is hypothesized that statistically significant improvements will be observed on each of the scales assessing externalizing behavior of adolescents and treatment readiness of parents as well as adolescents. Moreover, treatment readiness is hypothesized to be associated with change in treatment outcome; adolescents and parents who report a higher stage of readiness to change after completing PLL will supposedly report better treatment outcomes.
Method
Participants
Data for the present study were drawn from an existing archive of families who completed the PLL treatment between June 2012 and September 2015. Families were only included in this study if they met the inclusion criteria and at least part of the pre- and posttreatment measures were completed by parents and adolescents. This resulted in a total sample size of 45 families, including data from 30 mothers, 19 fathers and 48 adolescents (the sample contained 4 siblings). Of the adolescents in this sample, 34 (71%) were boys and 14 (29%) were girls. The adolescents ranged in age from 13 to 19 years old (M = 15.23; SD = 1.57). Participating families attended treatment at various locations of the Waag; in The Hague (n = 15; 31.3%), Amsterdam (n = 25; 52.1%), Haarlem (n = 4; 8.3%), and Almere (n = 4; 8.3%). Treatment duration ranged from 1 month to 14 months (M = 6.43; SD = 3.15).
Setting and Intervention
The Waag is a center for outpatient forensic mental health in the Netherlands that provides treatment for clients aged 12 years and older who exhibit transgressive and/or criminal behavior, with the aim of reducing recidivism. Clients often have (severe)
psychological problems and substance abuse problems may also be an issue. The policlinic contributes to a safer society by working to achieve lasting behavior changes in clients. Clients may be referred by the police or the judiciary. Voluntary admission is also a
possibility for individuals who are considered at risk of (re)offending by mental health care providers or general practitioners.
Parenting with Love and Limits (PLL) is an intensive and relatively short-term treatment program which combines group and family therapy to reduce adolescents’ externalizing behaviors (e.g., conduct disorder, oppositional defiant disorder, and attention deficit/hyperactivity disorder) and frequently co-occurring problems, such as depression, alcohol or drug use, chronic truancy, domestic violence, or suicidal ideation (Sells, 1998; Sells; 2000; Sells et al., 2011). PLL has been developed by Dr. Scott Sells at the Savannah Family Institute in the United States. The Waag is the only Dutch institution licensed to implement and practice the PLL-model (Hoogsteder, 2012). PLL is used to treat moderate- to high-risk adolescents between 12 and 18 years of age, and is also used for adolescents with less extreme behavior (e.g., school failure, persistent lying and disrespect). PLL teaches
families how to reestablish adult authority through consistent limits while reclaiming a loving relationship. There are six 2-hour multifamily sessions which include whole-family group meetings and separate parent and teen group meetings (Baruch et al., 2011; Feldblyum et al., 2014; Sells et al., 2011). The group training, guided by two group facilitators, covers parent-teen interaction, behavioral contracts, appropriate consequences for high-risk challenging behavior, praising the teenager, nurturance strategies, and how to enlist and use outside support (Baruch et al., 2011). PLL differs from other mental health interventions in criminal justice settings by alternating motivational group sessions with directive family therapy. Parallel to the group training individual coaching sessions are offered to practice the skills learned in the group setting focusing on the specific situation of the family.
Measures
Externalizing behavior. The Child Behavior Checklist (CBCL) is a standardized assessment instrument that measures emotional and behavioral problems of children and adolescents aged 4-18, as reported by parents (Achenbach, 1991). It consists of 118 items, which contribute to eight specific dimensions of dysfunction: anxious/depressed, somatic complaints, withdrawn, social problems, thought problems, attention problems, delinquent and aggressive behavior. In the current study, four of the subscales of the CBCL are used as an indication of externalizing behavior: 1) Rule-Breaking behavior, 2) Aggressive behavior, 3) Oppositional/Defiant, and 4) Conduct problems. Specific statements regarding the child’s behavior are rated on a 3-point scale (1 = “not true” and 3 = “very true or often true”. Scores between 60 and 70 (84th to 98th percentile compared with age-based norms) are considered to be “borderline” or “at-risk”, and scores above 70 (>98th percentile) are considered to be clinically significant (Feldblyum et al., 2014). A large body of research has demonstrated the reliability and validity of the CBCL in clinical and non-clinical populations (Lengua,
Sadowski, Friedrich, & Fisher, 2001; Karam, Sterreth, & Kiaer; 2015). For the Dutch population, however, the validity has been shown to be sufficient and the reliability insufficient (Verhulst & Van der Ende, 2013). Internal consistency α scores for individual subscales in the current sample range between .63 and .92 (see Table 7), and may be considered satisfactory.
Treatment readiness. The University of Rhode Island Change Assessment Questionnaire (URICA; McConnaughy, Prochaska, & Velice, 1983) measures intrinsic readiness to change, in terms of the Transtheoretical Model (TTM) (DiClemente & Hughes, 1990). This questionnaire is made up of 32 items answered on a 5-point scale ranging from (1
= “strongly disagree” and 5 = “strongly agree”). The items are divided among four subscales, representing four of the six stages of change previously described:
Precontemplation, Contemplation, Action, and Maintenance. Parents are asked about their level of motivation to change their parenting behavior toward their teenage children, while adolescents are asked about their level of motivation to change their behavior towards their parents and their personal problems. Sample items include “As far as I’m concerned, I don’t have any problems that I personally need to change” and “I have a problem with my teenager and I really think I should work at it.” The scoring method used in this sample, modified from a method described by DiClemente, Schlundt, and Gemmell (2004), generates readiness scores calculated from URICA subscale scores to assign stage of readiness. The scoring is based on cut-off scores derived from prior research, with scores below 8 considered
precontemplation, scores of 8 to 11 in contemplation, and scores above 12 in preparation. In the current sample internal consistency α scores for the subscales range from.48 to.89 (see Table A1 in the appendix).
Procedure
After intake clients of the Waag are asked to sign an informed consent form regarding whether or not they give permission to use their data for research purposes. Before the first PLL group meeting, parents or carers and adolescents are asked to complete forms about treatment readiness, behavior, and psychological functioning. Both the parents and
adolescents participating in PLL received the pre-test measures at home before they began the first class. If necessary the forms were administered at the Waag with assistance of the PLL therapist or an intern. After completion of the program, which is after completing the first coaching cycle and when the family members are 80 percent satisfied with the achieved results, parents and adolescents are asked to complete the forms a second time.
Statistical Analysis
The current study was conducted with a one-group pretest-posttest design to compare participant behavior before and after treatment. Acquired data were analyzed using SPSS Statistics 23.0. Results of a power analysis indicated that a sample size of 34 was required to test the hypotheses with 80 % power and a medium effect size (d = .5). Based on Cohen’s (1988) rules of thumb, d values (i.e., standardized mean differences) of d = .2 are considered small, d = .5 are medium, and d = .8 are considered to be large, when making comparisons between means. That is, 34 subjects will be sufficient in order to avoid that no difference is
found when there actually is a difference. This sample size was attained for adolescents’ YSR reports as well as parents’ CBCL reports. Because of the relatively small number of fathers whose data could be used, according to the initial power analysis it was necessary to combine data of both parents to be able to detect a real effect. Therefore father reports were used when mother reports were missing or insufficient. To detect a large effect size (d = .8) a sample size of 15 would be sufficient, which is attained for mothers’ and fathers’ reports. Paired-sample t-tests were conducted to assess for change following program participation. The pre-treatment and post-treatment scores were compared for each of these subscales, with parents’ and adolescents’ reports examined separately. Because of the small sample size a non-parametric test (Wilcoxon) was used to determine change in treatment readiness (Agresti & Franklin, 2009). To investigate the effect of treatment readiness on problem behavior a non-parametric test of correlation (Spearman’s r) was used, because of the non-linear relationship between the two variables, which was checked in advance using scatter grams.
Results
The current study aims to investigate change in adolescents’ problem behavior and treatment readiness of parents as well as adolescents. Additionally, the association between treatment readiness and therapeutic outcomes in terms of adolescents’ externalizing behavior in the family intervention PLL will be explored.
Externalizing Behavior
Comparison of pre- and post-treatment CBCL scores indicated a statistically significant decrease in Rule-breaking, Aggression, and Conduct Disorder as reported by mothers (small effect sizes). The means and standard deviations of these scores are presented in Table 1. Comparison of pre- and post-treatment CBCL scores indicated a statistically significant decrease in Rule-breaking, Aggression, Oppositional-Defiant and Conduct
Disorder as reported by fathers (medium effect sizes). Mean pre-treatment scores were in the at-risk range except for the Aggression subscale, which was in the clinically significant range, as reported by both mothers and fathers. Post-treatment CBCL scores were in the at-risk range as reported by both mothers and fathers, except for Oppositional and Conduct disorder
problems, which were in the normal range. Out of the 48 adolescents in the sample, self-report scores were only available for 37 of them. Adolescents’ mean pre-treatment YSR scores were all in the normal range, and comparison of these scores with their post-treatment
scores showed a change in the subscales Aggression, Oppositional-Defiant and Conduct Disorder (small effect sizes).
Table 1
Means and Standard Deviations of Youth Self Report (YSR) and Child Behavior Checklist (CBCL) Subscale Scores Before and After Treatment for Adolescents and Parents.
Pre-treatment M(SD) Post-treatment M(SD) t(df) Effect size Cohen’s d Youth Self Report (YSR) Rule-breaking 7.00 (3.80) 6.38 (3.77) 1.23 (36) .16 Aggression 9.43 (4.64) 7.49 (4.94) 2.60 (36)* .41 Oppositional 4.11 (1.90) 3.24 (1.82) 2.49 (36)* .46 Conduct 6.43 (3.52) 5.41 (3.95) 1.80 (36)* .28 Mothers’ report Rule-breaking 10.67 (4.85) 9.11 (4.96) 2.10 (26)* .32 Aggression 15.26 (7.38) 13.22 (8.02) 1.73 (26)* .26 Oppositional 6.12 (2.44) 5.54 (3.08) 1.36 (25) .21 Conduct 10.42 (4.97) 8.77 (5.41) 1.84 (25)* .32 Fathers’ report Rule-breaking 10.94 (4.40) 8.56 (4.86) 2.57 (15)* .51 Aggression 16.31 (6.32) 11.81 (7.31) 2.44 (15)* .66 Oppositional 6.63 (2.00) 5.38 (2.70) 1.91 (15)* .53 Conduct 11.38 (5.48) 8.69 (5.38) 2.73 (15)* .50 Parents’ reports Rule-breaking 10.11 (4.87) 8.69 (4.67) 2.22(34)* .30 Aggression 14.80 (7.18) 12.77 (7.75) 1.84(34)* .27 Oppositional 5.89 (2.46) 5.49 (2.96) .97(34) .15 Conduct 9.63 (4.91) 8.11 (5.15) 2.02(34)* .30 Note: scores are presented at the format mean (standard deviation). p <.05, one-tailed.
Treatment Readiness
scores on the URICA are presented in Table 2. Statistically significant decreases were detected on the mean Maintenance stage (z = -1.792, N – Ties = 14, p = .036, one-sided) as reported by adolescents and on the mean Contemplation stage (z = -1.891, N – Ties = 10, p = .030, one-sided), and Maintenance subscale (z = -1.741, N – Ties = 10, p = .041, one-sided) scores of the URICA as reported by parents (see Table 3). No significant differences were found on the other subscales of the URICA.
Table 2
Means and Standard Deviations University of Rhode Island Change Assessment
Questionnaire (URICA) Subscale Scores Before and After Treatment for Adolescents and Parents. Pre-treatment M(SD) Post-treatment M(SD) Difference
Teen self-report Precontemplation 2.70 (.60) 2.84 (.55) .14 Contemplation 3.31 (.67) 2.96 (.90) -.35
Action 3.38 (.49) 3.63 (.67) .25
Maintenance 3.17 (.84) 2.69 (.78) -.48
Parents’ report Precontemplation 2.47 (.58) 2.55 (.73) .08 Contemplation 4.06 (.46) 3.51 (.69) -.55
Action 4.13 (.43) 4.25 (.53) .12
Maintenance 3.61 (.66) 3.02 (.78) -.14
Table 3
Change in University of Rhode Island Change Assessment Questionnaire (URICA) Scores Before and After Treatment, Wilxocon Matched-pairs Signed-ranks Test, One-tailed.
z-value p value
Teen self-report Precontemplation -.774 .220
Contemplation -.877 .191 Action Maintenance -.982 -1.792 .163 .036*
Parents’ report Precontemplation .118 .453
Action Maintenance -.102 -1.741 .460 .041*
As can be derived from Table 4 most individuals remain in the Precontemplation or Contemplation stages over time. Few parents (respectively 2 mothers and 1 father) made the transition from the pre-action stages at baseline to preparation and action at the end of treatment (see Table 4). One of the mothers was already in the Action stage at the beginning of treatment. At pre-treatment assessment, 1 (2.9%) client was in the Action stage, 22 (64.7%) were in the Contemplation stage, and 11 (32.4%) in Precontemplation. At the post-treatment assessment, 4 (11.8%) were allocated to Action, 15 (44.1%) to Contemplation and 15 (44.1%) to Precontemplation.
Table 4
Stage Transition Matrix Describing Stage-of-change Movement.
Stage of change at the end of treatment Stage of change at baseline Precontemplation Contemplation Action Adolescents Precontemplation 8 (80%) 2 (20 %) 0 Contemplation 3 (75%) 1 (25%) 0 Action 0 0 0 Mothers Precontemplation 1 (100%) 0 0 Contemplation 3 (23%) 8 (62%) 2 (15%) Action 0 0 1 (100%) Fathers Precontemplation 0 0 0 Contemplation 0 4 (80%) 1 (20%)
Action 0 0 0
Treatment Readiness and Adolescent Behavior
The third hypothesis was tested using Spearman rank correlation analysis to examine whether there is a correlation between change in readiness and change in externalizing behavior problems as reported by adolescents and parents. Table 5 displays the results for adolescents, table 6 for parents. Concerning URICA self-report subscale change scores of adolescents there was a significant positive correlation between change in Action scores and Aggression as reported by adolescents (rs = .490, N = 14, p = .038, one-tailed), and between Maintenance scores and change in Oppositional behavior (rs = .530, N = 14, p = .026). There were significant negative correlations between change in Action scores on the URICA
subscale change score and Aggression (rs = -.526, N = 11, p = .048) and Conduct problems (rs = -.539, N = 11, p = .044) as reported by parents. Higher Action scores were related to lower aggression and conduct problems as reported by parents, while higher Action and Maintenance scores were related to higher aggression and oppositional behavior problems as reported by adolescents.
Table 5
Spearman’s rs Nonparametric Correlations Between Change in University of Rhode Island Change Assessment Questionnaire (URICA of Adolescents and Change in Externalizing Problem Behavior as Reported by Adolescents (YSR) and Parents (CBCL).
Precontemplation rs Contemplation rs Action rs Maintenance rs YSR Rule-breaking .200 .085 .068 .367 Aggression -.121 .179 .490* .262 Oppositional .226 .292 .267 .530* Conduct -.163 .200 .000 .336 CBCL Rule-breaking .211 -.303 -.486 -.176 Aggression -.231 -.362 -.526* -.183 Oppositional -.305 -.360 -.367 -.247 Conduct .119 -.270 -.539* .056
*
p<.05, one-tailed.
As for the URICA parent reports there was a significant positive correlation between change in Precontemplation scores on the URICA subscale change score and Oppositional behavior as reported by adolescents (rs = .564, N = 12, p = .028, one-tailed). There were significant negative correlations between change in Contemplation scores on the URICA subscale change score and Conduct problems (rs = -.558, N = 11, p = .037), and between Action scores and Rule-breaking behavior (rs = -.640, N = 11, p = .017) as reported by parents. Higher Contemplation and Action scores were related to lower rule-breaking behavior and conduct problems as reported by parents. Less Precontemplation scores were related to less oppositional behavior problems as reported by adolescents. Spearman’s rank correlations (rs) are shown in Table 6.
Table 6
Spearman’s rs Nonparametric correlations Between Change in University of Rhode Island Change Assessment Questionnaire (URICA) of Parents and Change in Externalizing Problem Behavior as Reported by Adolescents (YSR) and Parents (CBCL).
Precontemplation rs Contemplation rs Action rs Maintenance rs YSR Rule-breaking .208 -.173 -.380 .072 Aggression .351 -.175 -.146 .044 Oppositional .564* -.447 -.567 -.115 Conduct .251 -.225 -.413 .037 CBCL Rule-breaking .231 -.473 -.640* .019 Aggression .039 -.449 -.403 .106 Oppositional -.218 .127 -.270 .181 Conduct .214 -.558* -.515 -.002 * p<.05, one-tailed Discussion
The present study examined the association between outcomes in terms of change in adolescents’ problem behavior and treatment readiness of families who received PLL at the
Waag. It was found that adolescents showed significant reductions in externalizing problem behavior according to parental as well as adolescent self-reports. Participants’ readiness does not appreciably change from baseline to end of treatment. Results do suggest that readiness is associated with youth’s externalizing problem behavior.
Adolescents in this study showed clinical improvement in conduct problems,
aggressive, oppositional and rule-breaking behavior. These findings are consistent with five previous studies of PLL which found that youth completing PLL had significantly lower externalizing problems (Baruch et al., 2011; Feldblyum et al., 2014; Karam et al., 2015; Sells et al., 2011; Early, Chapman, & Hand, 2013). In comparison with results of Baruch et al. (2011) (d = .73), smaller effect sizes were found, which could be explained by lower pretreatment problem scores, especially for adolescents who reported to be in the normal range. The difference in effect sizes might, however, also be due to the smaller sample size used in this study. Despite small effect sizes the results are clinically significant, since there were significant improvements in the proportion of parents reporting problems in the non-clinical range. Noteworthy is that effect sizes for fathers were medium. The findings need to be treated with caution because follow-up data were not obtained from 52% of parents who completed a CBCL at intake and from 51% of adolescents who completed a YSR at intake. Surprisingly, no significant improvements were found in parents’ and adolescents’ self-reported readiness scores. In fact most respondents (68%) remained in the same stage of change. This finding contrasted with previous studies that did provide evidence for transition to advanced stages of readiness for change during treatment (Day et al., 2009; Sells et al., 2011; Van Binsbergen et al., 2001). This may be due to the fact that previous studies used other instruments to assess treatment readiness, namely the Parent and Adolescent Readiness Scale (PRS) and the Corrections Victoria Treatment Readiness Questionnaire (CVTRQ). Another explanation for this finding may be that the study of PLL was conducted by model developer Dr. Scott Sells, and others who were involved in the development of the program (Feldblyum et al., 2013; Karam et al., 2015). Furthermore, the sample size was rather small consisting of 19 adolescents and their parents, which may have resulted in insufficient power and limited external validity and generalizability of the results.
There are several other possible explanations for the lack of significant findings with respect to treatment readiness. The lack of support for the hypothesized increase in treatment readiness may have been due to the small sample size, self-report bias and psychometric properties of the URICA. A possible explanation is that the minimal change is caused by the fluctuating way in which the stages of change are transversed (Callaghan et al., 2008;
Norcross et al., 2011). Another explanation may be that most participants are extrinsically motivated and may not feel as if they themselves need to change (Cohen et al., 2005; McConnaughy et al., 1983). Since the URICA is a measure for intrinsic readiness to change this could explain the lack of forward transition to action-oriented stages of change. Some researchers question the clinical and scientific utility of the URICA (e.g., Callaghan et al., 2008).
The final hypothesis in this study stated that there would be a relation between treatment readiness and change in adolescents’ externalizing problem behavior. Although it would be expected that clients remaining in the precontemplation or contemplation stages across treatment would manifest little change in their externalizing behavior, the opposite was true. This could be explained by the complexity of criminal behavior which involves internal as well as external factors. Especially adolescents often have an external locus of control, which means they externalize blame for their problems and have difficulty acknowledging responsibility for their behavior (Cohen et al., 2005). They may have a desire to change certain aspects of their behavior, but not be willing to work on other behavioral changes (Callaghan et al., 2008). A second explanation for these findings may be that the PLL-therapists are skillful in dealing with denial and reluctance to change, and make sure clients remain in treatment and do not dropout. Attendance, participation, number of treatment sessions and completion of the full treatment intervention may be related to improved outcomes (Early et al., 2013). Lastly, there may be alternative explanations for the positive impact of the PLL intervention on externalizing problems, such as improved family
functioning or communication, restored nurturance, cognitive-behavioral change or the working alliance (Feldblyum et al., 2014; Norcross et al., 2011; Early et al., 2013).
Limitations
This study has several limitations. First, this study relied exclusively on self-report measures of behavior. There may have been social desirability issues, whereby parents may have been more likely to exaggerate their reports of adolescents’ externalizing behavior. Adolescents, however, may have minimized the severity of their behavior prior to treatment (Brooks & Khan, 2015). Adolescents who exhibit problematic behavior more often have an external locus of control, i.e., they tend to avoid taking responsibility and blame others or the circumstances (Barriga, Hawkins, & Camelia, 2008). In this light, moreover, it is not
surprising youths in this sample did not progress in readiness to change their behavior, which they may not have wanted to change to begin with. Secondly, the conclusions that can be
drawn are limited because only a subset of parents and adolescents that attended the PLL-program completed CBCL, YSR and URICA measures pre- and post-intervention (Baruch et al., 2011). Because of the small sample size the power to detect significant changes and associations was limited. Finally, the study design was longitudinal, which may have caused bias due to selective attrition (i.e., non-random loss of participants over time). Therefore the extent to which findings can be generalized beyond the sample used in this study is limited (Brooks, & Khan, 2015; Snyder, Glaser, & Calhoun, 2014). Moreover, because there was no control group it is not possible to say whether the improvement in adolescents’ problem behavior occurred because of the intervention.
Future Directions
Future studies are needed with larger sample sizes to generalize findings to a broader population. Additionally, follow-up measurements done several months after completing PLL could demonstrate whether the program achieves longer lasting change (Baruch et al., 2011). Moreover, these may produce different findings, “such as the appearance of a stronger relationship between parent readiness and adolescent behavior over time” (Feldblyum et al., 2014, p. 254). Preferably, a randomized controlled trial (RCT) design should be used to ensure greater control of confounding variables, alternative explanations which account for some of the results (e.g., parental attitude is a case in point). One of the recommendations is to obtain more clarification on the various possible causes for the lack of improvement in treatment readiness and weak correlation between externalizing behavior and readiness. Future studies are also needed to explore which concepts or techniques within the PLL program could reduce resistance and increase treatment readiness (Smits, Sells, & Reynolds, 2006). This would be useful because treatment readiness is not only dependent on client characteristics, but also on the therapeutic situation (McMurran & Ward, 2010). A variety of factors may impact on readiness of change within the field of forensic child and youth care, such as delinquency history, different types of crimes and offenders (including differences in gender, age and cultural background) and parent-child relationship quality (Day et al., 2009; Snyder et al., 2014; Early et al., 2013). Further research may shed more light on these factors, which could hold implication for treatment practice.
Conclusion
The current study was not able to demonstrate that treatment readiness among parents and adolescents increases during treatment. Nonetheless, significant reductions in
externalizing problem behavior were found. There also seems to be a relation between the stage of change and treatment outcomes in terms of externalizing problem behavior. Thus, remaining in the precontemplation and contemplation stages of change during treatment does not imply that positive treatment outcomes do not occur (Callaghan et al., 2008; Norcross et al., 2008).
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Appendix
Table A1
Internal Consistency – Child Behavior Checklist (CBCL) and University of Rhode Island Change Assessment Questionnaire (URICA) Scales.
Internal consistency (α) T0 Internal consistency (α) T1
CBCL/YSR Adolescents Parents Adolescents Parents
Rule-breaking .70 .72 .74 .79 Aggression .83 .89 .84 .92 Oppositional .63 .71 .67 .86 Conduct .76 .79 .79 .83 URICA Precontemplation .67 .50 .48 .72 Contemplation .82 .69 .86 .77 Action .61 .65 .77 .69 Maintenance .79 .79 .78 .72
