Establishing Treatment Fidelity in Evidence-Based Parent Training Programs for Externalizing Disorders in Children and Adolescents

The current review evaluates the use of treatment fidelity strategies in evidence-based parent training programs for treating externalizing disorders. We used a broad framework for evaluating treatment fidelity developed by the National Institutes of Health Treatment Fidelity Workgroup that includes the aspects of treatment design, treatment delivery, training providers, and assessment of participant receipt of treatment and enactment of treatment skills. Sixty-five articles reporting outcome trials of evidence-based parent training programs met inclusion criteria and were coded for treatment fidelity strategies. The mean adherence to fidelity strategies was .73, which was higher than two previous review studies employing this framework in the health literature. Strategies related to treatment design showed the highest mean adherence (.83), whereas training of providers and enactment of treatment skills had the lowest (.58). In light of an increasing emphasis on effectiveness and dissemination trials, the broader treatment fidelity framework as applied in this review focuses needed attention on areas often overlooked in fidelity practices, such as training providers and generalization of treatment skills. We discuss the strengths and limitations of fidelity practices in parent training studies, implications of these findings, and areas for future research.     

Pausing phenomena: Influence on the quality of instruction

This report summarizes work of 7 years on the influence of a variable called “wait-time” on the development of language and logic of children taking part in elementary science programs. Analysis of over 300 classroom tape recordings showed mean pauses to be on the order of 1 sec; that is, after a teacher asked a question, students had to begin a response within an average time of 1 sec. If they did not, the teacher typically repeated, rephrased or asked a different question, or called on others. A second wait-time is involved: when a student makes a response, the teacher normally reacts or asks another question within an average time of 0.9 sec. This study investigates the consequences of manipulating both species of wait-time. When mean wait-time of 3–5 sec is achieved through training, analysis of more than 900 tapes shows changed values on eight student variables: (1) the length of response (number of words) increases, (2) the number of unsolicited but appropriate responses increases, (3) failures to respond decrease, (4) incidence of speculative responses increases, (5) incidence of student-student comparisons of data increases, (6) incidence of evidence-inference statements increases, (7) frequency of student-initiated questions increases, and (8) the variety in type of verbal moves made by students increases. Servochart plots of recordings show that students discussing science phenomena tend to speak in bursts, with intervals of as much as 3–5 sec between bursts being fairly common provided they are not interrupted. The average post-student-response wait-time of 0.9 sec apparently intervenes between bursts to prevent completion of a thought. The classroom is conceptualized as a two-player game in which the quality of inquiry will tend to improve when there is a better equity in the distribution of moves between the players. The teacher is treated as one player and the collection of students as the second player. Changes in wait-time shift the game toward a more equitable state. Over time, a classroom or instructional group on the prolonged wait-time schedule undergoes certain spontaneous changes. Two teacher variables change: (1) response flexibility scores increase, and (2) teacher questioning patterns becomes more variable. There is some indication that teacher expectations for performance of students rated as relatively slow improves.     

Delivering Parent-Child Interaction Therapy in an Urban Community Clinic

Extensive evidence supports the efficacy of Parent-Child Interaction Therapy (PCIT) for reducing behavior problems in young children; however, little is known about the use of PCIT in a community mental health center (CMHC). This paper provides four clinical case examples of families who were referred to and successfully completed PCIT in an urban CMHC. The families were ethnically and socioeconomically diverse and presented with a wide range of treatment concerns and needs (e.g., autism, severe maternal psychopathology, involvement in child protective services, and complex family configurations) in addition to disruptive behavior. Our data and clinical observations suggest that PCIT decreased behavior problems, improved parent-child interactions, and, in some cases, reduced parental stress, with differing levels of change across families. Overall, the cases demonstrate that PCIT can be transported into a CMHC, and they illustrate supplemental services or minor accommodations to the established treatment protocol used to address individual family needs. Issues regarding the balance between fidelity and flexibility in transporting PCIT to a community setting are discussed, and future research topics are recommended.     

The sound of spiritual care: music interventions in a palliative care setting

The article describes how music has been integrated into spiritual and supportive care for palliative care patients at Brantford General Hospital (Ontario). Numerous case examples illustrate how a song or piece of music can play a vital role in the spiritual dimension of end of life care. The article expands the concept of the "living human document" by positing that a life story has an accompanying soundtrack: a musical memory and sensorial attunement that can be energized when music is offered at the bedside. The writers suggest that music provides an alternate spiritual language for patients whether or not they have a religious affiliation.     

TEACHING BEHAVIORALLY HANDICAPPED PRESCHOOL CHILDREN TO SHARE

We examined the effectiveness of Barton and Ascione's (1979) package for training sharing in a classroom setting with six behaviorally handicapped preschool children, four of whom were also developmentally delayed. Individual responses in sharing and not sharing were examined. Training consisted of initial instructions, modeling, and behavioral rehearsal, followed by teacher prompts and praise regarding sharing directly in a classroom free play period. Introduction of training in a multiple-baseline design across three pairs of children resulted in substantial increases in sharing for five of the six children. Results for negative interactions were less clear but suggested that concomitant decreases occurred for the same five children. The response analysis indicated that (a) individual components of sharing (offers, requests, and acceptances) all increased with training; (b) most children were more likely to initiate sharing through requests than through offers; (c) the proportion of sharing initiatives accepted by peers increased with training despite a much greater absolute number of initiatives; and (d) of the three negative behaviors (opposing play, taking without asking, and aggression) examined as incompatible with sharing, the most prevalent response was opposing other children's play. Individual differences in initial social repertoires and responsiveness to training were examined with respect to their implications for research and practice. Overall, the findings provide an encouraging indication of an intervention program for children with behavioral, social, and developmental handicaps.