Engagement in Behavioral Parent Training: Review of the Literature and Implications for Practice

Engagement in behavioral parent training (BPT), including enrollment, attrition, attendance, within-session engagement, and homework completion, has long been a critical issue in the literature. Several estimates of various aspects of engagement have been suggested in the literature, but a systematic review of the available literature has never been accomplished. This review examines engagement data across 262 studies of BPT. Recruitment attrition, program attrition, attendance, and within-session engagement are examined across studies, with particular emphasis on the impact that SES, study purpose (efficacy vs. effectiveness), treatment format (individual vs. group), and age of child may have on those rates. Results of this review suggest that the significant amount of attrition occurs prior to enrollment in BPT, with at least 25 % of those identified as appropriate for BPT not enrolling in such programs. An additional 26 % begin, but drop out before completing treatment. Still the combined dropout rate of at least 51 % leaves at best half of identified parents completing treatment. While SES status had a small effect on attrition, other variables were not found to meaningfully impact engagement. Information on within-session engagement (homework and ratings of participation) was not often reported in studies. Key issues in this literature (e.g., varying definitions of engagement, limited attention to reporting key aspects of engagement) are discussed, and recommendations are made to further improve this important area of research and clinical practice.     

Optimizing Engagement in Behavioral Parent Training: Progress Toward a Technology-Enhanced Treatment Model

Low-income families are more likely to have a child with an early-onset Behavior Disorder (BD); yet, socioeconomic strain challenges engagement in Behavioral Parent Training (BPT). This study follows a promising pilot to further examine the potential to cost-effectively improve low-income families’ engagement in and the efficiency of BPT. Low-income families were randomized to (a) Helping the Noncompliant Child (HNC; McMahon & Forehand, 2003), a weekly, mastery-based BPT program that includes both the parent and child or (b) Technology-Enhanced HNC (TE-HNC), which includes all of the standard HNC components plus a parent mobile application and therapist web portal that provide between-session monitoring, modeling, and coaching of parent skill use with the goal of improved engagement in the context of financial strain. Relative to HNC, TE-HNC families had greater homework compliance and mid-week call participation. TE-HNC completers also required fewer weeks to achieve skill mastery and, in turn, to complete treatment than those in HNC without compromising parent satisfaction with treatment; yet, session attendance and completion were not different between groups. Future directions and clinical implications are discussed.     

Enhancements to the Behavioral Parent Training Paradigm for Families of Children with ADHD: Review and Future Directions

Behavioral parent training (BPT) is one of the empirically supported psychosocial treatments for ADHD. Over many years and in many studies, BPT has been documented to improve both child ADHD behavior and maladaptive parenting behavior. In some studies, BPT has also been found to result in benefits in additional domains, such as parenting stress and child classroom behavior. However, the BPT literature on children selected as having ADHD lags behind research conducted on BPT for children selected as having oppositional defiant and conduct disorders (ODD and CD, respectively) with regard to examination of factors that may limit treatment attainment, compliance, and outcomes, such as single parenthood, parental psychopathology, and child comorbidity. Because of the high degree of comorbidity between ADHD and ODD/CD, it is difficult to separate the two BPT literatures. The parameters of BPT (e.g.. format and setting), parent factors, and child factors that may contribute to treatment outcomes for families of children with ADHD are reviewed here and recommendations for future BPT research in the area of ADHD are made.     

A Comparison of Behavioral Parent Training Programs for Fathers of Children With Attention-Deficit/Hyperactivity Disorder

Few behavioral parent training (BPT) treatment studies for attention-deficit/hyperactivity disorder (ADHD) have included and measured outcomes with fathers. In this study, fathers were randomly assigned to attend a standard BPT program or the Coaching Our Acting-Out Children: Heightening Essential Skills (COACHES) program. The COACHES program included BPT plus sports skills training for the children and parent-child interactions in the context of a soccer game. Groups did not differ at baseline, and father ratings of treatment outcome indicated improvement at posttreatment for both groups on measures of child behavior. There was no significant difference between groups on ADHD-related measures of child outcome. However, at posttreatment, fathers who participated in the COACHES program rated children as more improved, and they were significantly more engaged in the treatment process (e.g., greater attendance and arrival on time at sessions, more homework completion, greater consumer satisfaction). The implications for these findings and father-related treatment efforts are discussed.     

Research to Practice: Implementation of Family School Success for Parents of Children With ADHD

“Family-School Success” (FSS) is an efficacious intervention improving the home and school functioning of children with ADHD in grades 2–6. An extension of this intervention designed for a younger population also showed positive effects for kindergarten and first grade students in a pilot study. Following the completion of these trials, FSS was implemented in a fee-for-service tertiary care ADHD center. The implementation process included adapting the manual and treatment procedures to be feasible outside the structure and support of a federally funded randomized control trial (RCT). The current study examines the process of adapting the treatment protocol and examines the acceptability and effectiveness of the adapted FSS, as well as predictors of family treatment response including parent engagement in treatment (as measured by attendance and homework adherence). A case study illustrates the adaptations to the intervention and its implementation in the clinic-based setting. In line with findings from clinical trials, families reported high satisfaction with the adapted FSS intervention and showed significant improvement in parental self-efficacy, child academic homework performance, and reduction in child impairment. Additionally, as in the initial FSS RCT, parental attendance in the adapted FSS program predicted child attention to academic homework, controlling for parental adherence to between-session homework. Furthermore, controlling for attendance at FSS sessions, parent adherence to between-session homework assignments predicted improvements in parent self-efficacy as well as child’s homework productivity. These results replicate those of the original RCT and confirm that both session attendance and between-session homework completed are important for improvement during the program. Overall, this study provides support for the acceptability and effectiveness of this treatment model and suggests that future work toward dissemination to community-based settings would be worthwhile.     

Behavioral Parent Training Engagement Among Young Children With Autism Spectrum Disorder

The purpose of the current study was to examine engagement with Behavioral Parent Training (BPT) for families of children with Autism Spectrum Disorder (ASD) and assess openness to novel delivery formats for BPT (e.g., telehealth, group). Participants were caregivers of 501 children with ASD (ages 2–6) enrolled in the SPARK (Simons Foundation Powering Autism Research for Knowledge) online national registry. The study assessed: (1) rates of child disruptive behavior diagnoses, (2) engagement and satisfaction with BPT, (3) parent and child factors (e.g., diagnostic history), and (4) openness to novel delivery formats. Almost 25% of young children with ASD in this sample had disruptive behavior problems rising to the level of a diagnosis of ADHD or ODD and thus would benefit from BPT. However, only one third of these families had actually been referred to BPT. Families indicated high level of interest in participating in BPT, with a particular interest in Parent Child Interaction Therapy (PCIT) as well as novel delivery formats such as telehealth and group. Specific components of the therapy and delivery formats were indicative of parent satisfaction (e.g. groups, longer treatment sessions, longer treatment length). Specific parent and child characteristics were predictive of openness to novel formats (e.g. parental depression, more severe behavioral challenges, lower verbal skills). Results underscore the need for increased referrals and access to BPT programs the ASD population. Both parent and child characteristics are important for determining appropriate delivery formats.     

Classroom Changes in ADHD Symptoms Following Clinic-Based Behavior Therapy

This study examined classroom behavioral outcomes for children with Attention-Deficit/Hyperactivity Disorder (ADHD) following their participation in a manualized, 10-week intervention called Family Skills Training for ADHD-Related Symptoms (Family STARS). Family STARS combined behavioral parent training (BPT) and child-focused behavioral activation therapy (CBAT). Participants were children ages 7–10 diagnosed with ADHD-Combined Type. Pre- and post-treatment teacher ratings of ADHD symptoms were compared using a single group, within-subjects research design. Intervention effectiveness was analyzed using paired-samples t-tests. Results indicated statistically significant classroom improvements for externalizing behaviors and attention problems with medium and large main effects (respectively) for the intervention. Possible implications for combining CBAT with BPT for the treatment of ADHD are discussed as well as the relevance of these results for improving the effectiveness and portability of empirically supported interventions.     

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent–child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study’s limitations, and future directions for research are further discussed.     

Bending the Curve: A Community-Based Behavioral Parent Training Model to Address ADHD-Related Concerns in the Voluntary Sector in Denmark

Limited access to evidence-based behavioral parent training (BPT) for addressing attention deficit/hyperactivity disorder (ADHD) has been a growing concern internationally. Models to improve access to BPT are needed, particularly those that can be readily implemented in community settings and that leverage the potential workforce to increase capacity to deliver BPT. The purpose of this study was to evaluate a BPT model which included oft-used content, methods, processes of BPT (common-elements), non-professionally delivered (task-shifted/shared) BPT intervention, and an efficient ancillary support system (training, fidelity, and supervision methods) for families of youth with parental concerns about ADHD. In a randomized controlled trial of 161 families of children (79% male; mean age 7.04 [1.55]), the Caring in Chaos (CiC) BPT model, delivered by community volunteers across 12 community-based sites in Denmark, was compared to a wait-list control condition on key child and parent outcomes at immediate post-treatment and 4-month follow-up assessment points. Results suggested that the CiC model led to significantly greater improvement in parenting behavior, parenting sense of competence, child functional impairment, parental stress and parental depressive symptoms compared to the wait list condition at immediate post-treatment, with maintenance of gains in most of these areas at follow-up assessment. No effect of intervention was found on ADHD symptoms. The results of this study suggest that developing efficient BPT intervention models, such as the CiC model, can result in readily implemented interventions by a variety of individuals in community settings. Such models are necessary to bend the curve on addressing unmet needs of families of youth with concerns about ADHD.     

Willingness to Use ADHD Self-Management: Mixed Methods Study of Perceptions by Adolescents and Parents

Little is known about perceptions surrounding self-management for attention deficit hyperactivity disorder (ADHD), although such interventions appear commonly used and are considered essential components of the chronic care model. Our research is part of a mixed methods study that followed students at high and low risk for ADHD over 11 years. During the final study years, area-representative samples of 148 adolescents (54.8 % participation; 97 ADHD high-risk group; 51 low-risk peers) and 161 parents (59.4 % participation; 108 parents of high-risk adolescent; 53 parents of low-risk peer) completed a cross-sectional survey on community-identified self-management interventions for ADHD (activity outlets, sleep regulation, dietary restriction, homework help, family rules, and prayer). Respondents also answered open-ended questions addressing undesirable self-management effects, which were analyzed using grounded theory methods. High-risk adolescents expressed significantly lower willingness towards all self-management interventions than did adult respondents, except for increased activity outlets. They also reported lower receptivity towards sleep regulation and dietary restriction than did their low-risk peer group. No gender or race differences in self-management willingness were found, except for higher receptivity to prayer in African American respondents. Cost, perceived ineffectiveness, disruptions to routines, causation of interpersonal conflicts, and reduced future self-reliance were seen as potential undesirable effects. Findings suggest that activity-based ADHD interventions appear particularly acceptable across all demographic and risk groups, unlike sleep regulation and dietary approaches. Further research on self-care effectiveness is needed to incorporate adolescents’ viewpoints about ADHD self-management, as interventions may be acceptable to adults, but resisted by adolescents.     

Programmes de formation aux habiletés parentales pour les parents d’enfant avec un TDA/H : considérations pratiques et implications cliniques

The pharmacological treatment advocated for children affected by attention-deficit/hyperactivity disorder (ADHD) has now demonstrated its efficiency. However, its limitations and the impact of ADHD on family well-being, linked with parenting practices, make it necessary to establish an alternative treatment. Numerous studies agree about the effectiveness of Behavioral Parent Training programs (BPT). The purpose of this review, based on the literature describing BPT, is to analyze the factors that could influence the outcome of such interventions. Thus, the parameters of BPT, the characteristics of parents and children, will be mentioned in order to produce recommendations for clinicians and researchers interested in BPT within the framework of ADHD.     

Preparing Families for Evidence-Based Treatment of ADHD: Development of Bootcamp for ADHD

Objective: Many families of children with attention-deficit/hyperactive disorder (ADHD) do not initiate evidence-based treatments (EBTs), placing these children at risk for poor outcomes. Bootcamp for ADHD (BC-ADHD) is a novel, four-session, group intervention designed to prepare parents as informed consumers to engage in multimodal EBTs for ADHD. This paper describes the theory of change and the development of BC-ADHD, outlines its components, and provides an initial proof of concept of the program. Method: Participants were 11 families of children with ADHD (ages 5–11; 55% male; 91% non-Hispanic; 55% White, 27% Black, 18% more than one race) who were the initial participants receiving BC-ADHD during a small-scale, randomized controlled trial. Parent-report outcome measures assessed parental empowerment, treatment preferences, affiliate stigma, intention to pursue treatment, and treatment initiation at baseline, posttreatment, and 6-week follow-up. Results: Parent engagement was high, as indicated by an 86% session attendance rate and high ratings of program satisfaction. Parents reported an increase in empowerment to access systems of care. Ratings of acceptability for behavior therapy increased at posttreatment and follow-up with minimal or no concerns about feasibility. The acceptability of medication was high at each assessment, although parents expressed increased concerns about stigma and adverse effects of medication at posttreatment and follow-up. Nonetheless, there was a marked increase in parental intention to use medication at posttreatment and follow-up. Accounting for ceiling effects, parents reported substantial increases in intention to use medication, behavioral parent training (BPT), and school services. Changes in treatment initiation were in the expected direction. Conclusions: BC-ADHD has the potential to promote family empowerment in seeking services and increase their intent to initiate EBTs, as well as actual initiation of these treatments.     

Father participation in behavioral parent training for ADHD: review and recommendations for increasing inclusion and engagement.

Research on parenting has generally focused on mothers, with fathers' parenting approaches and interventions for fathers being relatively less studied. To investigate the involvement of fathers in behavioral parent training (BPT), the literature on BPT for attention-deficit/hyperactivity disorder (ADHD) was reviewed. A systematic review of this literature (N = 32) indicated that the majority of research studies are composed of mothers as participants in treatment and raters of outcome (87% of reviewed studies did not include information on father-related outcomes). Present barriers to father participation in BPT (e.g., content of classes, characteristics of fathers) are discussed. Strategies for increasing father participation are offered and include establishing the expectation that fathers will be involved in treatment at initial clinical contacts, collecting treatment-related information from both parents, conducting BPT classes that focus on issues of direct relevance to fathers, and integrating parent-child interactions in recreational settings into BPT programs.     

Homework Completion,Patient Characteristics,and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.     

Examining Latino Family Participation in Treatment for Childhood ADHD: The Role of Parental Cultural Factors and Perceptions

Attention-deficit/hyperactivity disorder (ADHD) is a common mental health disorder in childhood. Unfortunately, Latino youth and their families are at increased risk of demonstrating poor treatment outcomes. The current study examined the impact of parental cultural factors and perceptions on Latino family participation in a psychosocial intervention for childhood ADHD. Sixty-one Latino youth and at least one of their primary parents and teachers participated in the current study. Results indicated that parental acculturation, attitudes regarding treatment, and baseline severity of child symptomatology and functional impairment were related to treatment participation outcomes. Implications and future directions are discussed.     

Combined cognitive and parent training interventions for adolescents with ADHD and their mothers: A randomized controlled trial

This study examined the individual and combined effects of two nonpharmacological treatments for attention deficit/hyperactivity disorder (ADHD): Cogmed working memory training (CWMT) for adolescents and behavioral parent training (BPT) for mothers. Ninety-one adolescents (ages 11–15) and their mothers were randomized to one of four CWMT and BPT treatment and active control (placebo) group combinations of 5-week interventions. At pre- and posttest, mothers and teachers completed rating forms, and adolescents completed neuropsychological measures of working memory (WM). Individual intervention effects showed that treatment CWMT significantly improved WM spans, whereas there were no significant differences for treatment or control BPT on reports of parent-related outcomes. Combined treatment effects indicated an overall pattern of greatest improvements for the control CWMT/treatment BPT group, as compared to the other three groups, on adolescent WM deficit, behavioral regulation problems, and global executive deficit. Most significant effects for outcomes were main effects of improvements over time. A combination of CWMT and BPT did not result in increased treatment gains. However, potential effects of combined treatment may have been masked by greater perceived benefits arising from lack of struggle in the nonadaptive, CWMT active control condition. Future combined intervention research should focus on specific, theoretically driven WM deficits among individuals with ADHD, should include possible adaptations to the standard CWMT program, should examine effectiveness of cognitive treatments combined with contextual interventions and should utilize appropriate control groups to fully understand the unique and combined effects of interventions.     

Dopamine transporter gene moderates response to behavioral parent training in children with ADHD: a pilot study

There is great variability in the degree to which children with attention deficit/hyperactivity disorder (ADHD) improve through behavioral treatments. This study investigates the influence of the dopamine transporter gene (SCL6A3/DAT1) on outcome of behavioral parent training (BPT). Study subjects were a subsample (n = 50, for whom DAT1 genotypes were available) of a randomized controlled BPT effectiveness study (N = 94) comparing BPT plus ongoing routine clinical care (RCC) versus RCC alone in referred children (4-12 years old) with ADHD. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Presence of 2 versus no or 1 DAT1 10-repeat allele served as moderator variable. Time × Treatment × Genotype effect was analyzed with repeated-measures analysis of variance, controlling for baseline medication status. Results indicate that DAT1 moderated treatment response (p = .009). In children with no or 1 DAT1 10-repeat allele, superior treatment effects of BPT + RCC compared with RCC alone were present (p = .005), which was not the case in children with 2 DAT1 10-repeat alleles (p = .57). Our findings suggest that genetic differences in DAT1 in children with ADHD influence their susceptibility to a behavioral intervention directed at shaping their environment through their parents. The role of the dopamine system in motivation and learning and in the aberrant sensitivity to reinforcement in children with ADHD may explain this moderating effect, given that the management of contingencies is typically addressed in BPT.     

Offender engagement in group programs and associations with offender characteristics and treatment factors: A review

The aim of this review is to establish how offender engagement within group programs has been conceptualized, defined or assessed, and the factors that are associated with it. Existing models describe determinants of engagement and the process of behavioral change, but there is little in the way of theory explaining the process of engagement in treatment and change. Forty-seven studies were reviewed and revealed inconsistent definitions and assessments of engagement as well as inconsistent use of measures which contributes to confusion about the scope of engagement and reflects the lack of theory. Attendance, completion or dropout rates were frequently relied upon, but may not reliably infer engagement. Participation and out of session behaviors in conjunction with one another, reflecting a series of active responses to treatment, may more reliably reflect engagement in treatment and change. A model for offender engagement is presented which might help clarify the role of engagement variables. Offender demographics appeared to be of little value in predicting engagement, with only a small number of psychosocial factors (hostility, impulsivity) predicting low levels of engagement and most others (anger, anxiety) having little influence. Treatment factors (therapeutic relationship, program objectives) were more consistently related to engagement, but are under-researched.     

Implementing Group CBT for Depression Among Latinos in a Primary Care Clinic

Depression in low-income Latino populations can be treated using group cognitive behavioral therapy (GCBT). However, effective delivery of GCBT for depression in primary care settings is often impeded by high dropout rates and poor homework adherence. In this study, we describe the structure, processes, and outcomes (including attendance, homework completion, and symptom measures) of GCBT for Spanish-speaking Latino patients with depression in an urban public sector primary care setting. For this study, 96 Latino patients in a primary care clinic participated in at least 1 session of GCBT. Although depressive symptoms among these patients, as measured by the PHQ-9, significantly decreased during treatment, attendance and homework completion were limited. Even with a strategy in place to allow patients to continue in treatment after missing several sessions, 23% of patients dropped out of therapy following their initial session, and approximately half of all patients completed less than 50% (or 8) therapy sessions. Homework was only completed 23% of the time it was checked. Greater session attendance prospectively predicted lower depressive symptoms over time. We discuss potential strategies to increase engagement, treatment effects, and symptom reduction for depression in primary care settings.     

Homework

In commemoration of Dr. Aaron T. Beck’s enormous contributions to our field, I comment on the state of our knowledge regarding the role of homework in cognitive behavioral therapy. The available evidence suggests homework is a contributor to positive therapeutic outcomes in cognitive behavioral therapy. Although therapists play an important role in facilitating clients’ engagement with homework as they develop greater facility with CBT skills, little is known about the contributions of specific approaches to promoting homework engagement. I highlight some of these strategies and discuss the need for researchers to empirically evaluate them.