Investigating existing interventions
for clinic-referred young children:
Behavioural and parenting stress outcomes
after day treatment and ambulant treatment
University of Amsterdam
Faculty of Social and Behavioural Sciences Graduate School of Child Development and Education
Name: M. A. Moens Student number: 5934869
Supervisor UvA: Prof. Dr. R. G. Fukkink Supervisor Kabouterhuis: Drs. F. Y. Scheper Second reader: Dr. E. I. de Bruin
Date: September 2013 Words: 7480
Investigating Existing Interventions for Clinic-referred Young Children:
Behavioural and Parenting Stress Outcomes after Day Treatment and Ambulant Treatment Martina A. Moens
University of Amsterdam
Author Note
Martina A. Moens, Department of Child Development and Education, University of Amsterdam.
This research was in cooperation with a medical child centre (MOC ‘t Kabouterhuis) and the medical centre of Free University (VUmc).
Correspondence concerning this paper should be addressed to Martina A. Moens, Department of Child Development and Education, University of Amsterdam, Room G1.01, Nieuwe Prinsengracht 130, 1018 VZ, Amsterdam, The Netherlands.
Abstract
This study investigated treatment outcomes of 117 young children (Mage = 3.7, SDage = 1.28) with behaviour problems, who either attended day treatment or ambulant treatment in a Dutch specialized treatment center. Using repeated measures MANOVA, treatment outcomes were evaluated by children’s behavioural outcomes and outcomes of parenting stress, that were both assessed at admission and discharge. Furthermore, child problem behaviour and parenting stress were investigated as treatment moderators with multiple hierarchical regression. Results showed significant decreases in child problem behaviour and parenting stress, with the ambulant treatment group showing a slightly stronger decrease in parenting stress. Moreover, externalizing problem behaviour was found to be a treatment moderator on the change in parenting stress. High levels of externalizing behaviour problems at pre-test were related to larger decreases in parenting stress. It was concluded that existing day treatment and ambulant treatment in clinical practice seem effective approaches in treatment for young children with behaviour problems. Suggestions for alternative approaches to evaluate treatment outcomes, more aimed at the individual child, were discussed.
Keywords: day treatment, ambulant treatment, child problem behaviour, externalizing
Investigating Existing Interventions for Clinic-referred Young Children: Behavioural
and Parenting Stress Outcomes after Day Treatment and Ambulant Treatment
Significant numbers of toddlers and preschoolers (3-5 years) exhibit behaviours severe enough to cause concern to parents, teachers, and other caregivers (Campbell, Shaw, & Gilliom, 2000; Powell, Dunlap, & Fox, 2006). Estimates of the overall prevalence rates of problematic preschool behaviour vary greatly, somewhere between 7% and 25% (Egger & Angold, 2006). The challenging behaviours of these children have their impact on preschool placements and care, disrupt family functioning, and affect growth in several developmental domains (e.g., Campbell et al., 2000; Qi & Kaiser, 2003). For this reason, research on the negative trajectories of early problem behaviour has gained the importance of providing prevention and intervention services to young children with challenging behaviour and their families (Powell et al., 2006). Therefore, this study aimed to evaluate such intervention services for young children with challenging behaviour.
Challenging behaviour in young children is defined as “any repeated pattern of behaviour, or perception of behaviour, that interferes with or is at risk of interfering with optimal learning or engagement in prosocial interactions with peers and adults” (Powell et al., 2006, p. 26). Most often such behaviours are disrupted sleeping and eating routines, physical and verbal aggression, property destruction, severe tantrums, noncompliance, and withdrawal. Typically developing children also pass through stages during which they exhibit these types of behaviours. However, it is the persistence, intensity, and pervasiveness of problem
behaviours that determine their seriousness, and the need for intervention (Powell et al., 2006). Such child problem behaviour can be divided into internalizing and externalizing
problems. Internalizing problems appear, for example, in the form of withdrawal or anxiety, whereas externalizing problems take the form of rule breaking behaviour and aggressive
behaviour (Achenbach & Rescorla, 2000, 2001). These problems can co-occur in children and can lead to social problems and deviant behaviours (Fanti & Henrich, 2010).
Aforementioned child behaviours are highly demanding for parents. Parenting is challenging within any family, and parenting stress is considered to be normal and adaptive for all parents (Deater-Deckard & Scarr, 1996). However, the challenges of raising children may differ among parents, and some parents may be more or less reactive to these challenges. When parents experience stress in their role as a parent, this has important implications for parent, child, and family functioning. Stressors and hardships within families place demands on the family system that need to be managed (McCubbin & Patterson, 1983). Stressors are defined as life events or transitions, together with the hardships (i.e., the demands on the family specifically associated with the stressor event), that impact the family unit. The family’s resources for meeting the demands of a stressor, and the family’s subjective
definition of the seriousness of the stressor, play an important role in preventing the stressors from creating a disruption in the family system. When the demands are not to overcome, stress emerges (McCubbin & Patterson, 1983). Parenting stress is more specifically defined in terms of demands associated with parenting. It is defined as a specific form of stress
perceived by parents that results from the demands of being a parent (Abidin, Jenkins, & McGaughey, 1992). That is, parenting stress refers to a condition or feeling experienced when a parent perceives that the demands associated with parenting exceed the personal and social resources available to meet those demands.
Parenting stress and child problem behaviour
Research has shown that parenting stress is strongly linked to child internalizing and externalizing symptoms (Anthony et al., 2005; Grant et al., 2003; Morgan, Robinson, & Aldridge, 2002). This is in line with theory that describes the interaction patterns among child characteristics (e.g., social skills, attachment status, cognitive ability), parent characteristics
(harsh discipline, parenting stress), and environmental influences (education, income), which have their influence on a child’s development (Sameroff & Chandler, 1975, inSameroff & Seifer, 1983). These relationships between child behaviour symptoms and parenting stress are mostly investigated in clinical samples. For example, in children with disabilities, high child problem behaviours and limited pro-social behaviours were found to be associated with higher parenting stress (Beck, Hastings, & Daley, 2004). Moreover, parenting stress has been demonstrated to have a higher association with a child’s behaviour problems than with the child’s developmental delay (Baker et al., 2003).
In samples of typical developing children, similar patterns of parenting stress and child behaviours are found. In a sample of typically developing preschool-aged children, both stressful life events and daily parenting hassles predicted negative affect and problem
behaviours (Crnic, Gaze, & Hoffman, 2005). However, the amount of parenting stress differs among parents. Self reports of parenting stress show statistically and clinically higher levels of stress among parents of children with clinical behaviour disorders, compared to nonclinical samples (Dumas, Wolf, Fisman, & Culligan, 1991). Moreover, parenting stress has been demonstrated to have a higher association with a child’s behaviour problems than with the child’s developmental delay (Baker, Blacher, Crnic, & Edelbrock, 2002; Baker et al., 2003). To conclude, it has been notified that maladaptive child behaviour in preschool children and parenting stress have a mutually escalating effect (Baker et al., 2002, 2003). High parenting stress contributed to a worsening in child behaviour problems over time, and high child behaviour problems contributed to a worsening in parenting stress. Again, a reason to intervene in early childhood.
Considering the mutually escalating effect of maladaptive child behaviour and parenting stress, the literature mentions the possibility of a moderated relationship between child behaviour problems and parenting stress. Parenting stress might moderate the impact of
children’s behaviour problems on parenting behaviour (Hastings, 2002). That is, when parents are experiencing high levels of stress they might respond to children’s behaviour problems coercively, whereas parents with low stress levels might be more proactive and positive (Hastings, 2002). Moreover, the literature mentions the possibility of child behaviour problems as moderator of parenting stress. A meta-analytic review about parent training programs included the child’s symptom level at pre-treatment as moderator of the effect of the programs (Lundahl, Risser, & Lovejoy, 2006), which indicates the possibility of child
problem behaviour as moderating mechanism.
Treatment
To overcome problematic patterns in families, with regard to child behaviour problems and parenting stress, interventions among children and their families could be highly
beneficial, especially in early childhood. Early childhood interventions for young children with developmental and behaviour problems, could overcome problems later in life
(Tremblay et al., 2004), and these interventions may result in long-term gains on the health of individuals and communities. Studies on intervention programs have made clear that support in families with young disruptive children may have measurable effects on outcomes (Tse, 2006). Even in adulthood, intervening to change a child’s course early on, may have long-lasting effect on the development of the child. Therefore, the quality of care for disruptive preschoolers in early childhood settings should be optimized (Tse, 2006). In optimizing these settings, it is important to investigate centres that provide treatment for disruptive
preschoolers.
In child psychiatry clinics, there are different forms of treatment for disruptive preschoolers. Day treatment programs have been a mainstay of psychiatric intervention among preschoolers for several decades. Such treatment programs are also referred to as partial hospitalization, and provide intensive treatment in a group setting for several hours
weekly, usually with educational and recreational components (Tse, 2006). Despite the common practice of these programs as a treatment modality for disruptive preschoolers, little research is available on the effectiveness of day treatment programs.
Only a small amount of studies have investigated the effectiveness of day treatment programs (Tse, 2006). A study of two cases provides preliminary evidence for day treatment as a beneficial option for young children with disruptive behaviours. Besides day treatment for the child, home-based intervention strategies were implemented to develop parents’ competence. Results of the day treatment indicated positive behaviour changes in both cases (Burke, Kuhn, Peterson, Peterson, & Brack, 2010). In accordance, a year-long rather intensive multi-method behavioural intervention program for high-risk preschool and kindergarten children having aggressive, hyperactive, and impulsive behaviour, contributed to
improvements of teacher ratings of disruptive behaviour, self-control, and social skills, as well as direct observations of child disruptive behaviour (Barkley et al., 2000). More recently, Martin, McConville, Williamson, Feldman, and Boekamp (2013) found that children’s
symptom severity decreased from admission to discharge after family focused psychiatric partial hospitalization program, particularly with respect to externalizing problems. These studies together already provided promising preliminary evidence for the effectiveness of day treatment. Nevertheless, Tse (2006) concluded that the limiting availability of day treatment studies asks for more evidence in this area, which indicates the need for more research of day treatment programs.
Another way of treatment for families with children having behaviour problems, is ambulant treatment. In contrast to day treatment programs, more aimed at the child, the content of ambulant treatment is more aimed at providing parenting skills to intervene in the behaviour disruptions of the child, rather than hospitalization, as is the case in day treatment. A common collective name for ambulant treatments that were previously named as intensive
outpatient family therapy or home training, is ‘intensive pedagogical help at home’. These are forms of “intensive home visits to families, in which the parent(s) and child(ren) have to work on the improvement of education in corporation with a social worker, whether or not
combined with working on the improvement in one or more other family responsibilities” (Vogelvang, 1993, p. 4, in Veerman, Janssens, & Delicat, 2005).
Ambulant treatment as such has rarely been investigated. However, there is a
tremendous amount of studies regarding parent training programs, and it has generally been accepted that parent training can be effective (Kaminski, Valle, Filene, & Boyle, 2008). In accordance, studies on intervention programs have made clear that parenting support in families with young disruptive children may have measurable effects on outcomes (Tse, 2006). Therefore, the ambulant treatment, in which the environment of the family is part of the treatment, is expected to improve parenting skills and family functioning.
Despite the scarcity in effectiveness studies regarding ambulant treatment specifically, a Dutch meta-analysis of the Family Preservation Services (FPS) has shown that problems of both children and parents clearly decreased after FPS (Veerman et al., 2005). Parenting stress and children’s externalizing behaviour problems were evaluated for their effect size, and were both medium. However, the authors mention that it is unclear whether the programs caused these effects. Therefore, more research regarding ambulant treatment, as well as day treatment, is needed.
In sum, child behaviour problems and parenting stress are often indicators of
problematic patterns within families, and these patterns already occur in families with young children. These problems ask for intervention in early childhood. Existing interventions in clinical practice such as day treatment and ambulant treatment could be highly beneficial regarding these problems, but are not often investigated. The moderated patterns that might occur between child behaviour problems and parenting stress are hardly investigated either. It
is mentioned earlier that there is a need for investigating treatment moderators, because the literature is scarce in examining treatment moderators (Beauchaine, Webster-Stratton, & Reid, 2005).
Research Questions
The aim of this study was to evaluate the outcomes of day treatment and ambulant treatment by changes in children’s behavioural outcomes and outcomes of parenting stress. Research questions are: (1a) What is the influence of day treatment and ambulant treatment on internalizing and externalizing behaviour problems, and do these outcomes differ between the day treatment group and the ambulant treatment group? (1b) What is the influence of day treatment and ambulant treatment on the outcomes of parenting stress, and do these outcomes differ between children of the day treatment and the ambulant treatment? It was expected that children, as a group, would demonstrate a significant decrease in internalizing and
externalizing problems and that parents would experience a decrease in both the child domain and parent domain of parenting stress. For exploratory reasons it was investigated whether age of the children influenced treatment outcomes.
In addition, it was investigated (2a) whether changes in child behaviour outcomes are moderated by parenting stress (See Figure 1), and vice versa, (2b) whether changes in
parenting stress are moderated by child behaviour outcomes (See Figure 2). Following Lundahl et al. (2006), who used pre-treatment levels as moderators, pre-test levels of child problem behaviour as well as parenting stress were treated as moderators in this study.
Parenting stress Pretest Child Problem Behaviour Pretest Child Problem Behaviour Pretest Treatment
Figure 1. Parenting stress as moderator of the change in Child Behaviour Problems from Pretest to Posttest
Child Problem Behaviour Pretest Parenting Stress Pretest Parenting Stress Posttest Treatment
Figure 2. Child Behaviour Problems as moderator of the change in Parenting Stress from Pretest to Posttest
Method
Participants
Study participants were young children from one and a half to seven years, who received day or ambulant treatment at a Dutch medical child treatment centre, called Medisch
Orthopedagogisch Centrum (MOC) ‘t Kabouterhuis. This treatment centre focuses on
families with young children who struggle with complex developmental or severe behaviour problems. Participating children presented a range of clinical concerns regarding their problem behaviour.
The final study sample included 117 young children (Mage = 3.7, SDage = 1.28). The
day treatment group consisted of 61 children. The ambulant treatment group included 56 children. Table 1 shows the characteristics of both treatment groups separately, as well as the characteristics of the total sample. Results of the Mann-Whitney U test showed no significant differences between the day and ambulant treatment group in age (U = 1480, z = -.999,
p = .318), sex (U = 1596.50, z = -.952, p = .341), and cultural background (U = 1482.50, z = -.540, p = .589).
Table 1
Children’s characteristics by group
Treatment group
Characteristic Day treatment Ambulant treatment Total
Sample size 61 56 117
Mean age (SD) 3.5 (0.89) 3.9 (1.57) 3.7 (1.28)
No. (%) of boys 53 (86.9%) 45 (80.4%) 98 (83.8%)
No. (%) of children with a
Dutch cultural background 33 (54.1%) 31 (55.4%) 64 (57.7%)
Procedure
The children were incorporated in a larger study towards evaluation of treatments in the centre, for which routine outcome monitoring (ROM) procedures were used. ROM involves documenting the outcome of treatments through repeated assessments (De Beurs et al., 2011). Children were selected from the larger study when (a) at least one of the parents had completed all relevant questionnaires, and (b) when the child had not been previously admitted to day treatment or ambulant treatment. Whether the parents received ambulant treatment or day treatment for their child, was established by mutual agreement between the parents and the treatment centre.
Parents completed online or paper questionnaires about their child’s problem behaviour and parenting stress, both at the start and at the end of the treatment. Asking the parents to fill out these questionnaires was standard procedure in the treatment centre. Social workers, who visited the parents, monitored that parents received and filled out the
questionnaires, either on paper, or online via email. The parents provided informed consent for study participation. The Medical Ethical Committee of the Free University (VUmc) provided permission for the larger study, of which this study used data.
The questionnaires were collected over a period of approximately 3.5 years, from August 2009 to December 2012. They were available in a dossier system (Care4), and were retrieved from this system. Children’s length of stay in day or ambulant treatment varied according to their clinical needs, progress, and insurance funding, from three to thirty-five months.
Day treatment
Day treatment at MOC ‘t Kabouterhuis is an intensive form of diagnosis and treatment in a group of children. On average, a child visits the day centre two days a week and the treatment takes place for a period of around six to nine months. Day treatment focuses on (1)
getting insight into the complex development issues or behavioural problems of the child, (2) making steps in development, (3) and making the behavioural problems manageable.
Methodologies in the day treatment, see Appendix, are based on Geeraets (1998).
Day treatment is mainly child focused. Activities in day treatment focussing on the child are, (1) providing structure, safety, upbringing, and care in a medical pedagogy
treatment climate. The daily routine of the group is arranged in a certain manner to make sure that continuously new skills are practiced. The centre works with a (2) comprehensive
development program, which focuses on communication, language, motor and social skills, and improving self-confidence. Furthermore, special attention is paid to (3) specific
development for children with autism spectrum disorder, and (4) specific development for very young children who are physically and socio-emotional particularly vulnerable. (5) Observations are done for getting insight into what skills are mastered, and (6) research or treatment modules such as, speech therapy, psychotherapy, play therapy, psychiatry, and medication, are deployed. Moreover, attention is paid to (7) additional activities focused on the specific problems of the child, and (8) enhancing the independence of the child.
In general, all children receive the same approach in the group, such as in terms of providing structure and in terms of methodologies. However, for each child there is a specific tailored approach (e.g., expectations toward the child, extra instruction, extra visual cues, working in smaller groups).
Although day treatment is mainly child focused, it is combined with family
counselling, focussing on (1) practical and theoretical support of the parents in raising their child, and (2) integration between the approach in the day treatment group and at home. Activities that are focussing on the family are mostly aimed at the alignment between the approach in the day treatment group and the approach at home. It takes place once in two weeks, on average.
Ambulant treatment
Ambulant treatment is a rather different approach compared to day treatment. In ambulant treatment at MOC ‘t Kabouterhuis, conversations are held at home by a family counsellor. The conversations are meant to build a working relationship, and to further clarify the problems of the child and the request for help of the parent(s). Parents receive help in stimulating the child’s development in the family situation, and learn to handle the behaviour problems. In contrast to day treatment, children in ambulant treatment stay in their own family or go to school or childcare. On average, the treatment takes place once a week for one and a half hour to three hours, for a period of six to eighteen months. The treatment is focused on competence enlargement, by learning new (parenting) skills, and the goal is that parents gain insight into the problems of their child. It is a no protocol or not fully described treatment (NJI; Vermeij & Addink, 2011, p. 39). Methodologies are based on Burgt and Van Vugt (2000), see Appendix.
Ambulant treatment is mainly family focused. Activities in ambulant treatment
focussing on the family are, (1) parenting supporting conversations, (2) providing information on the developmental tasks of the child, (3) parenting skills training, and (4) assessment whether other specialized treatment is needed. The content of these activities depend on the parents’ needs. For each family a specific tailored approach is present, depending on these needs (e.g., optional use of video home training or modelling, support in conversations with teachers or other third parties involved). The activities are mostly tailored based on the skills of the parents, but in case of more problems such as debts, it is also possible that the family counsellor acts as a social worker.
Although ambulant treatment is mainly family focused, some activities are specifically child focused, such as, (1) observation of the child during play and interaction with parent(s)
and family counsellor, and (2) psychological assessment, speech therapy, physical therapy, psychiatric or medical research at the treatment centre.
Measures
Problem behaviour. The Child Behaviour Checklist (CBCL) is the most widely used
measure of children’s behaviour problems. It is a reliable questionnaire of behavioural, emotional, and social problems of a child. Depending on the age of the children, the version for children from 1.5 to 5 years consisting of 99 items or the version for 6 to 18 years
consisting of 118 items have been used (Achenbach & Rescorla, 2000, 2001). Items are rated on a 3-point scale, 0 meaning ‘not true’, 1 ‘somewhat or sometimes true’, and 2 ‘very true or often true’.
T-scores were calculated for internalizing, externalizing, and total problems. The internalizing problems scale consists of six subscales: anxious/depressed,
withdrawn/depressed, somatic complaints, social problems, problematic thoughts, and
attention problems. The externalizing problems scale consists of two subscales: rule breaking behaviour, and aggressive behaviour. When t-scores are between 60 to 63 for internalizing, externalizing, and total problem scales, these indicate that the problems are in the subclinical range. T-scores greater than 63 are problems in the clinical range.
The CBCL has strong psychometric properties that have been well-established in published studies with high test-retest reliabilities on most scales of both CBCL 1.5-5 and CBCL 6-18 (Achenbach & Rescorla, 2000, 2001). For the Dutch translation these
psychometric properties were confirmed (De Groot, Koot, & Verhulst, 1994).
Parenting stress. The Nijmeegse Ouderlijke Stress Index (NOSI), is a translation of
the Parenting Stress Index (PSI) by Abidin (De Brock, Vermulst, Gerris, Veerman, & Abidin, 2004). It is a clinical and research self-report instrument which consists of 123 items that are scored on a six-point scale, ranging from (1) ‘I completely disagree’ to (6) ‘I completely
agree’. The NOSI is designed as a screening and diagnostic assessment technique to identify parent and child systems which are under stress, and in which deviant development of the child is likely to take place, or where dysfunctional parenting is likely to occur. A higher score on the NOSI indicates higher feelings of stress experienced by the parent concerning the parents’ perceived capabilities in parenting the child. The NOSI has 13 subscales, it includes both parent domain and child domain scores. These domains are summed to yield a total stress score that assesses the overall magnitude of life stress a parent is experiencing.
Deviation scores were calculated for the child domain, the parent domain, and total parenting stress. Scores between 1.28 and 1.68 indicate problems in the subclinical range, while scores of 1.68 and higher are problems in the clinical range. Psychometric properties were confirmed with good test-retest reliability coefficients (De Brock et al., 2004).
Statistical analyses
To answer the research question of children’s behavioural and parenting stress outcomes, two way mixed (treatment group by time) multivariate analysis of variance (MANOVA) with repeated measures were used, with additional ANOVAs. Changes from pre-test to post-test were examined on children’s internalizing and externalizing problem symptom scores, as well as on parenting stress child domain and parent domain.
Multiple hierarchical regressions were used to investigate possible moderator effects. For these analyses both treatment groups were taken together, because the numbers of participants were too small to analyze separately. Acknowledging the presence of two different treatment groups while taken together as one group, a control variable for treatment was taken into account in the analyses. The moderator analyses were conducted using the procedure described by Baron and Kenny (1986). Explanatory variables were pre-tests of one of the subscales child problem behaviour, internalizing, externalizing, and total problems, and one of the subscales parenting stress, child and parent domain, and total stress. The dependent
variables were the post-tests of the aforementioned subscales of child problem behaviour or parenting stress.
Separate regressions were conducted for each of the child problem behaviour variables and for each of the parenting stress variables. First, scores for all included variables were standardized into z scores, for interpretation purposes. To investigate whether changes in parenting stress were moderated by child behaviour problems, the interactions between pre-tests of parenting stress and pre-pre-tests of child behaviour problems were entered, after controlling for treatment and pre-tests of parenting stress. Likewise, parenting stress was investigated as moderator by entering interactions between pre-tests of child behaviour problems and pre-tests of parenting stress. After adding the moderator, R² change values were inspected.
Before conducting the abovementioned MANOVAs and regression analyses, a priori power analyses were performed with G*Power 3.1 to determine whether the sample size was sufficient to detect significant differences. Results revealed that the sample size was sufficient to detect small to medium effect sizes. To adjust for Type 1 errors, a Bonferroni correction was used for additional univariate ANOVAs, and the alpha was set at p < .025.
Preliminary analyses
The assumptions for repeated measures MANOVA and hierarchical regression were met. Missing values were treated using pairwise deletion, in order to include cases in any of the analyses for which they had the necessary information. Normality and linearity of the variables were satisfactory for all of the variables, and there were no univariate outliers (no z scores > 3.29). With the use of a p < .001 criterion for Mahalanobis distance, one multivariate outlier was deleted (Tabachnick & Fidell, 2012).
To check for differences in characteristics between the subsample of pre- and post-tests and the larger sample containing only pre-post-tests, χ²-post-tests and t-post-tests were performed. The
subsample did not significantly differ from the larger sample on gender, χ² = 2.694, df = 1, n = 714, p = .101, age, t (712) = -.458, p = .647, and cultural background, χ² = 35.570, df = 47, n = 590, p = .889. To check for differences in pre-test scores between the subsample and the larger sample, t-tests showed no significant differences in pre-test internalizing problems,
Welch’ t (194.152) = .238, p = .812, pre-test externalizing problems, t (427) = -.765, p = .445,
and pre-test total problems, t (427) = -.500, p = .617. The subsample did significantly differ from the larger sample in pre-test total parenting stress, t (343) = -3.193, p = .002, pre-test parenting stress child domain, t (344) = -2.769, p = .005, and pre-test parenting stress parent domain, t (344) = -3.138, p = .002. Parents in the subsample had a higher score on parenting stress.
Results
Evaluation of the treatments
For child behaviour problems, repeated measures MANOVA showed a significant main effect across time, Wilks’Λ = 0.73, F (2, 114) = 21.36, p < .001. Additional ANOVAs revealed that there were significant decreases in problem behaviour across time, for
internalizing problems, F (1, 115) = 24.41, p < .001, as well as for externalizing problems, F (1, 115) = 42.71, p < .001 (Table 2 and 3). For the two groups together, effect sizes were small to medium for internalizing problems, Cohen’s d = 0.39, and externalizing problems, Cohen’s d = 0.49. Looking at the effect sizes of the two treatment groups separately, effect sizes were small to medium for internalizing problems, Cohen’s d = 0.43, and medium for externalizing problems, Cohen’s d = 0.56, in the day treatment group. The ambulant treatment group showed small to medium effect sizes, Cohen’s d = 0.39 and Cohen’s d = 0.48 for internalizing and externalizing problems respectively. In other words, highest effect sizes on child behaviour problems were found in the day treatment group, with medium effect sizes for externalizing problems.
Table 2
Means, standard deviations, and effect sizesa
Variable
Total Day treatment Ambulant treatment
Pre-test Post-test d Pre-test Post-test d Pre-test Post-test d
N M SD M SD N M SD M SD N M SD M SD
CBCL Internalizing 117 58.49 10.76 53.94 12.33 0.39 61 55.21 10.17 50.67 11.01 0.43 56 62.05 10.32 57.50 12.80 0.39
CBCL Externalizing 117 61.27 12.48 55.12 12.75 0.49 61 57.26 11.55 51.08 10.54 0.56 56 65.64 12.07 59.52 13.56 0.48
NOSI Parent domain 93 1.20 1.71 0.50 1.56 0.43 48 0.52 1.50 0.12 1.47 0.27 45 1.92 1.63 0.91 1.56 0.63
NOSI Child domain 93 1.77 1.60 1.08 1.52 0.44 48 1.14 1.40 0.56 1.42 0.41 45 2.44 1.54 1.64 1.44 0.54
a
No significant Time x Treatment interaction was found for child behaviour problems, Wilks’Λ = 1.00, F (2, 114) = 0.01, p = .999. That is, there was no significant difference between the groups in the decrease of child problem behaviour. However, there were
significant differences between the day treatment group and the ambulant treatment group in pre- and post-test scores, Wilks’Λ = 0.85, F (2, 114) = 9.80, p < .001. The ambulant
treatment group displayed overall higher levels on internalizing problems, F (1, 115) = 13.84,
p < .001, and externalizing problems, F (1, 115) = 17.69, p < .001, than the day treatment
group (Table 2 and 3).
For parenting stress, MANOVA showed a significant main effect across time, Wilks’Λ = 0.66, F (2, 90) = 22.85, p < .001. Additional ANOVAs revealed that there were significant decreases in parenting stress across time, for parenting stress child domain
F (1, 91) = 36.80, p < .001, and parenting stress parent domain F (1, 91) = 35.34, p < .001
(Table 2 and 4). For two groups together, effect sizes were small to medium for parenting stress, Cohen’s d = 0.43, for the parent domain, and Cohen’s d = 0.44 for the child domain. Looking at the effect sizes of the two treatment groups separately, effect sizes were small to medium, Cohen’s d = 0.27 for the parent domain, and Cohen’s d = 0.41 for the child domain, in the day treatment group. The ambulant treatment group showed effect sizes of
Cohen’s d = 0.63 and Cohen’s d = 0.54 for parent domain and child domain respectively. In other words, highest effect sizes on parenting stress were found in the ambulant treatment group, with medium effect sizes for parent domain of parenting stress and child domain of parenting stress.
Furthermore, a significant Time x Treatment interaction was found for parenting stress, Wilks’Λ = 0.93, F (2, 90) = 3.50, p < .05. Additional ANOVAs revealed that this was evident on the parent domain of parenting stress, F (1, 91) = 6.69, p < .05. Figure 3 shows the means on parenting stress parent domain as a function of treatment. The figure reveals that the
decrease in parenting stress parent domain for the ambulant treatment group was slightly larger than it was for the day treatment group, Cohen’s d = 0.39 (Morris, 2008).
It is also evident from Figure 3 that, overall, the ambulant group displayed higher levels of parenting stress parent domain than the day treatment group at pre- and post-tests, Wilks’Λ = 0.83, F (2, 90) = 9.40, p < .001. The ambulant treatment group displayed overall higher levels of parenting stress parent domain, F (1, 91) = 13.76, p < .001, and child domain,
F (1, 91) = 18.40, p < .001, than the day treatment group. For exploratory reasons, it was
investigated whether the age of the children had an impact, but this was not the case.
Figure 3. Interaction effect of Time x Treatment for Parenting Stress Parent Domain
0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 Pretest Posttest day ambulant
With respect to clinical range scores in the ambulant treatment group, children’s scores for externalizing problems decreased from the clinical range at pre-test to the normal range at post-test. Also, internalizing problems decreased from the subclinical range to the normal range. More specifically, clinical range scores for internalizing and externalizing pre-tests were 53.6 and 64.3 percent. These numbers decreased to 33.9 and 37.5 percent at post-tests respectively. However, it should be noted that the standard deviations are relatively large. That is, a proportion of children in the subclinical and clinical range does still exist, although the average scores of the ambulant treatment group have decreased to the normal range.
With respect to the day treatment group, although on average children’s scores remained in the normal range, percentages of children in the clinical range decreased. For internalizing problems, percentages of children in the clinical range decreased from 29.5 at pre-test to 19.7 at post-test. For externalizing problems, percentages of children in the clinical range decreased from 37.7 at pre-test to 13.1 at post-test.
Table 4
Results of Repeated Measures ANOVA on Parenting Stress
Parenting Stress Parent domain Parenting Stress Child domain Effect MS df F p MS df F p Time 23.049 1 35.34 <.001** 22.027 1 36.80 <.001** Treatment 56.310 1 13.76 <.001** 66.234 1 18.40 <.001** Time x Treatment 4.363 1 6.69 .011* 0.531 1 0.88 .349 Error(Time) 0.652 91 0.598 91 Error(Treatment) 4.092 91 3.600 91 ** p < .001, *p < .05 Greenhouse-Geisser Table 3
Results of Repeated Measures ANOVA on Child Behaviour Problems
Internalizing problems Externalizing problems
Effect MS df F p MS df F p Time 1207.43 1 24.41 <.001** 2210.49 1 42.71 <.001** Treatment 2727.30 1 13.84 <.001** 4128.30 1 17.69 <.001** Time x Treatment 0.002 1 0.00 .995 .045 1 0.00 .977 Error(Time) 49.47 115 51.76 115 Error(Treatment) 197.044 115 233.414 115 ** p < .001, *p < .05 Greenhouse-Geisser
Treatment moderators
Regarding child behaviour problems as moderator on parenting stress, two significant moderators are found with hierarchical multiple regressions. Results of the moderator
analyses with the child problem behaviour variables as treatment moderators on parenting stress are presented in Table 5.
First, change in parenting stress child domain was moderated by externalizing problems. After step 1, when control variables treatment and pre-tests were entered, R2 = .574, Finc (2, 90) = 60.69, p < .001. After step 2, with the interaction term between the pre-test parenting stress child domain and the pre-pre-test externalizing problems entered, ΔR2 = .030,
Finc (1, 89) = 6.76, p < .05. Second, change in total parenting stress was moderated by externalizing problems. After step 1, when control variables treatment and pre-tests were entered, R2 = .616, Finc (2, 88) = 70.69, p < .001. After step 2, with the interaction term between the pre-test total parenting stress and the pre-test externalizing problems entered, ΔR2 = .032, Finc (1, 87) = 8.05, p < .01. Thus, externalizing problems moderated the change in parenting stress child domain, and the change in total parenting stress, as displayed in Figure 4 and 5 respectively. It seems that higher externalizing problems or total problems are related to slightly higher levels of parenting stress at pre-test, and the decrease of stress across time is somewhat larger for high externalizing problems compared to low externalizing problems.
Regarding parenting stress as moderator on child behaviour problems, no significant moderators are found. Results of the moderator analyses with the parenting stress variables as treatment moderators on child problem behaviour are presented in Table 6. Neither total parenting stress, parenting stress child domain, nor parenting stress parent domain illustrated significant effects as moderator for internalizing, externalizing, or total problems. In other words, parenting stress does not seem to moderate the change in child problem behaviour.
Figure 4. Parenting Stress Child Domain with Externalizing
Problems as a Treatment Moderator
Figure 5. Total Parenting Stress with Externalizing Problems
as a Treatment Moderator -2 -1,5 -1 -0,5 0 0,5 1 1,5 2 2,5 Pretest Posttest
Low ext. problems High ext. problems
-2 -1,5 -1 -0,5 0 0,5 1 1,5 2 2,5 Pretest Posttest
Table 5
Hierarchical Multiple Regression Analyses Predicting Parenting Stress with Child Problem Behaviour as Treatment Moderator
Predictor
Post-tests Parenting Stress Parenting Stress
Child Domain
Parenting Stress Parent Domain
Total Parenting Stress
∆R2 β ∆R2 β ∆R2 β
Test of moderatora
Pre-test Parenting Stressb x
Pre-test Internalizing Behaviour Problems
.004 .060 .001 -.025 .001 .024
Pre-test Parenting Stressb x
Pre-test Externalizing Behaviour Problems
.027* .167 .012 .110 .031** .179
Pre-test Parenting Stressb x
Pre-test Total Behaviour Problems
.011 .105 <.001 .010 .008 .090
n 90 90 90
Note. aBefore testing the moderators, first was controlled for treatment (day or ambulant) and for appurtenant pre-tests. bThe pre-test always refers to the post-test associated with it (e.g. looking at the post-test results for Parenting Stress Child Domain, the pre-test referred to is the pre-test Parenting Stress Child Domain).
Table 6
Hierarchical Multiple Regression Analyses Predicting Child Problem Behaviour with Parenting Stress as Treatment Moderator
Predictor
Post-tests Problem Behaviour
Internalizing Problems Externalizing Problems Total Problems
∆R2 β ∆R2 β ∆R2 β
Test of moderatora
Pre-test Behaviour Problemsb x
Pre-test Parenting Stress Child Domain
<.001 -.015 .007 .083 .001 .027
Pre-test Behaviour Problemsb x
Pre-test Parenting Stress Parent Domain
<.001 .009 .001 .027 .001 -.027
Pre-test Behaviour Problemsb x Pre-test Total Parenting Stress
<.001 -.008 .004 .058 <.001 -.002
n 100 100 100
Note. aBefore testing the moderators, first was controlled for treatment (day or ambulant) and for appurtenant pre-tests. bThe pre-test always refers to the post-test associated with it (e.g. looking at the post-test results for Internalizing Problems, the pre-test referred to is the pre-test Internalizing Problems).
Discussion
The primary aim of this study was to evaluate outcomes of day treatment and
ambulant treatment programs for young children with behaviour problems and their families. Previous studies have acknowledged the need for investigating such existing interventions (e.g., Tse, 2006), because of its common practice in clinical treatment centres.
As reported by parents, children demonstrated significant decreases in their
behavioural problems over the course of treatment. In the day treatment group medium effect sizes were found for externalizing problems, whereas the ambulant treatment group showed small to medium effect sizes. In both treatment groups small to medium effect sizes were found for internalizing problems. In addition, parenting stress decreased significantly over the course of treatment. Small to medium effect sizes were found in the day treatment group for both domains of parenting stress, whereas the ambulant group showed medium effect sizes on these domains. No significant differences in decreases of child problem behaviour and
parenting stress child domain were found between the two treatments. However, the ambulant treatment group did show a slightly larger but significant decrease of the parent domain of parenting stress, with a small to medium effect size. In conclusion, the findings indicate that day treatment and ambulant treatment are promising approaches that show beneficial
outcomes for young children with behaviour problems and stressed parents.
A secondary aim of this study was to investigate child problem behaviour and
parenting stress as treatment moderators. Pre-test externalizing problem behaviour was found to be a significant moderator of the changes in total parenting stress and parenting stress child domain, over the course of treatment. These significant moderating effects indicate that pre-test externalizing problem behaviour influences outcomes of parenting stress.
Together, these results contribute to our understanding of treatment outcomes in clinical practice, and the influence of child behaviour problems on outcomes of parenting
stress. The findings of treatment outcomes in this study are in accordance with previous studies that investigated day treatments (Martin et al., 2013; Tse, 2006) and ambulant treatments (Veerman et al., 2005), and provide preliminary support for the effectiveness of such treatments for young children and their families. In addition, it is striking that the
ambulant treatment group showed a slightly larger decrease on the parent domain of parenting stress compared to the day treatment group. The latter can be explained by the amount of parenting goals in ambulant treatment. The focus in ambulant treatment is more on the parent level rather than the child level, which is the case in day treatment. This provides preliminary insight in the beneficial elements of ambulant treatment. That is, ambulant treatment might be more beneficial in reducing parenting stress on the parent domain for highly stressed parents.
The finding of pre-test externalizing problem behaviour as moderator of the changes in parenting stress child domain, is in accordance with theoretical explanations of the mutually escalating effect of maladaptive child behaviour and parenting stress (Baker et al., 2003). While maladaptive child behaviour contributes to higher rates of parenting stress, an improvement of child behaviour problems seems to contribute to a decrease in parenting stress. In other words, the decrease of child problem behaviour seems an important factor in improvements of parenting stress. In contrast, this study did not show pre-test parenting stress as moderator on child problem behaviour. That is, pre-test parenting stress does not seem to influence the decrease in child problem behaviour, while previous literature mentioned that parenting stress contributes to increases in child problem behaviour (Baker et al., 2003; Hastings, 2002). This suggests that the decrease of problem behaviour of children with highly stressed parents at pre-test is not smaller than for children with less stressed parents at pre-test.
One of the strengths of this study is that psychometrically sound pre-test and post-test measures were used. The measures for child problem behaviour as well as for parenting stress are well validated measures used in a variety of previous studies. Furthermore, this study
responded to the request of Tse (2006) for investigating existing interventions in clinical practice to clarify the role of these programs in child psychiatry clinics and to shed light on optimal methods of service delivery (Tse, 2006, p. 485). This study was the first in comparing day treatment and ambulant treatment, which are two existing interventions in clinical
practice that needed evaluation. In addition, a strength of this study is that routine outcome monitoring (ROM) data were used. ROM data have been recommended in studying the phenomenology of psychiatric disorders and the outcome of treatments delivered in everyday practice, and it is currently considered to be necessary and important in clinical treatment (De Beurs et al., 2011).
Limitations
A major weakness of this study is the lack of a control group. Therefore, it is difficult to determine to what extent the positive changes can be attributed to the day treatment or ambulant treatment programs versus passage of time, maturation or some form of a placebo effect. A randomized controlled study (RCT), which is widely considered to be the gold standard in terms of evaluating the effectiveness of interventions (Bayer et al., 2009), would better determine whether the positive changes can be attributed to the treatment programs. However, to allow for a no-treatment control group, withholding treatment would be
necessary. It is ethically not justifiable to withhold treatment from children and their families who are referred to treatment for behaviour problems, so an RCT seems not appropriate in this case. Instead, multiple baseline single-subject designs (Kazdin, 1978) would be appropriate, as is discussed below.
Another weakness of this study is that the sample as well as the treatments were not homogeneous. Although children all were referred to treatment because of their behaviour problems, they varied in the severity of these problems, and some of them also were referred because of speech-language problems besides their behaviour problems. Given their age, the
children often did not have a diagnosis yet, which made it impossible to sort by specific diagnoses. Therefore, the selection criteria were based on a general category of behaviour problems. With regard to the treatments, there too was heterogeneity due to the tailored approach for each child and family.
Future research
Acknowledging the lack of possibility for a control group, and the heterogeneity of the children in the treatment groups, investigating effectiveness of treatments by using single subject designs would be complementary in providing insight in the processes of change. In a single-subject design it is investigated how the intervention changes the behaviour of a
participant over time and across conditions (Kazdin, 2011, in Evans & Axelrod, 2012). Such a design seems appropriate for effectiveness research in treatments centres, because the focus is on individual children (Borckardt, 2008; Horner et al., 2005). In group designs there are individuals whose behaviour remains unaffected by the treatment, while single subject research allows detailed analysis of nonresponders as well as responders. In single-subject designs participants are their own controls, and each subject’s data are typically analyzed individually. Moreover, knowledge about the possible existence of subgroups and subject by treatment interactions can be advanced with single subjects designs (Horner et al., 2005).
Multiple baseline designs in particular seem appropriate in the context of existing treatments at treatment centres. These designs demonstrate the effect of the intervention without withdrawing treatment, which fits the ethical point of view. In multiple baseline designs, the effect of the intervention is demonstrated by showing that behaviour change accompanies introduction of the intervention at different points in time (Kazdin, 1978). Such designs allow for the assessment of the process of change (Horner et al., 2005), which would add valuable knowledge in the effectiveness of treatments. That is, multiple baseline designs would show processes of change better than pre-post-test designs. This insight in the
processes of change is consistent with the idea of ROM, which treatment centres are now using more frequently (De Beurs et al., 2011). The moderating effect of pre-test externalizing child behaviour on the changes in parenting stress, found in this study, could also be
investigated more precisely at individual level with multiple baseline designs. For example, such designs could clarify whether decreases in child problem behaviour across treatment result in decreases of parenting stress or vice versa.
As mentioned earlier, it was striking that the characteristics of the day treatment group and the ambulant treatment group were already different at pre-test, with the ambulant group having higher scores on child behaviour problems as well as on parenting stress. It is possible that the measurement times have influenced these different scores on the pre-tests, because often the treatment already started when the questionnaires were filled out by the parents. In addition, the focus of the two treatments are different. Day treatment is more focused on the child, while ambulant treatment is more focused on the family or parents. Children of the day treatment group are away from their parents for a few hours a day, which could have provided some immediate rest for parents. In contrast, parents in the ambulant treatment groups are having in depth conversations about their problems. The differences in treatment content, together with the measurement times, might explain the differences between the groups on pre-tests. However, further research is needed to suggest possible reasons for these groups being so different from each other. For example, parental psychopathology might be important to take into account in explaining these differences.
Implications for clinical practice
Acknowledging the limitations of this study, the findings provide insight in the benefits of existing day and ambulant treatment interventions in practice. While findings provide a generally optimistic view of these treatments for young children, some children and their families still remained in the clinical range of scores on child behaviour problems or
parenting stress at post-test. In these cases, ROM could be used more effectively, since it provides the possibility to monitor each patients’ progress during treatment. Examples of a more effective ROM approach could be periodical assessment instead of only pre- and post-tests, and using both ratings of independent observers as well as self-reports (De Beurs et al., 2011).
It is important to acknowledge the differences between the two treatment groups already at admission. Strikingly, the day treatment group overall did not show clinical admission scores at pre-test, though there was a large variation. As a group, they remained within the normal range of problem scores at post-test. On the one hand, this raises questions about the use of only subjective measurements (i.e., questionnaires) of child problem
behaviour. Extra questionnaires on child problem behaviour, filled out by the group teacher, would provide a more accurate indication of problem behaviour. In addition, taking
independent observers into account, would aid to the objectivity of child problem behaviour measurements. For example, observing behaviour in structured play situations. These extra measurements could clarify whether these normal scores were appropriately given to these clinic-referred children. On the other hand, for clinical practice it highlights the importance of specifying for each individual child which treatment would be appropriate. Centres might also take into account that ambulant treatment is a less expensive treatment that could be
beneficial if such a treatment is appropriate. Moreover, it would be of interest for clinical practice to further investigate the unexpected normal scores by means of ROM. For example, exact and identical moments of pre-test measurements would provide a more precise
indication of problems at admission. In addition, frequency of measurement times could be extended, which might be important in explaining problem scores over the course of treatment. Furthermore, extra characteristics could be taken into account, because differences within the day treatment group might exist on characteristics that were not measured in this study.
In sum, this study has contributed to the literature by investigating existing
interventions for clinic-referred young children with behaviour problems. Promising benefits of these programs have been shown for children as a group. For attaining more knowledge focused on individual children, multiple baseline single subjects designs are suggested.
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Appendix
Table 7
Correlations of Internalizing and Externalizing Problems, Total Problems, and Parenting Stress (Child domain, Parent domain, and Total Stress)
Variable 1 2 3 4 5 6 7 8 9 10 11
1. Internalizing problems pre-test
2. Internalizing problems post-test .640**
3. Externalizing problems pre-test .573** .438**
4. Externalizing problems post-test .418** .743** .678**
5. Total problems pre-test .864** .612** .863** .616**
6. Total problems post-test .580** .897** .615** .929** .691**
7. Parenting stress child domain pre-test .644** .607** .783** .683** .797** .693**
8. Parenting stress child domain post-test .491** .715** .624** .799* .614** .811** .756**
9. Parenting stress parent domain pre-test .484** .528** .522** .552** .600** .593** .731** .700**
10. Parenting stress parent domain post-test .292** .488** .415** .600** .410** .595** .521** .775** .744**
11. Total parenting stress pre-test .602** .608** .696** .662** .746** .689** .926** .780** .935** .682**
12. Total parenting stress post-test .425** .648** .587** .757** .575** .760** .685** .941** .771** .942** .783** ** p < 0.01
