Effects of a brief parent intervention to increase attendance, positive outcomes, and satisfaction with their child's therapy treatment

This study examined the effects of a brief parent psycho-educational intervention on therapy attendance rates, clinical outcome ratings, and parent satisfaction assessed after 13 weeks of treatment. Eighty-four parents were recruited from a mental health clinic that provides services to children who were allegedly abused. Parents were randomly assigned to either the experimental or control condition. Parents in the experimental condition received an intervention booklet, which described beneficial outcomes they could expect for their child when they engaged in research-supported treatment. The booklet also let parents know that their participation was integral to their child's treatment, and attempted to increase parent's motivation and self-efficacy to communicate with their child's therapist. Furthermore, it aimed to increase parents' motivation and ability to overcome barriers that might impede bringing their children to treatment on a regular basis. Parents were guided through the booklet to ensure that they read the information and completed the problem-solving exercises for overcoming barriers that might make it difficult to talk to their child's therapist and obstacles that might prevent attendance. Results indicated that there was little difference in rates of attendance, clinical outcomes, and satisfaction between parents who received the intervention and those who did not.

EFFECTS OF A BRIEF PARENT INTERVENTION TO INCREASE ATTENDANCE, POSITIVE OUTCOMES, AND SATISFACTION WITH THEIR CHILD'S THERAPY TREATMENT by Sheryl Rae Schindler A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Psychology The University of Utah December 2010 Copyright © Sheryl Rae Schindler 2010 All Rights Reserved Th e Uni v e r s i t y o f Ut a h Gr a dua t e S cho o l STATEMENT OF THESIS APPROVAL The thesis of Sheryl Rae Schindler has been approved by the following supervisory committee members: Donald S. Strassberg , Chair 10/28/2010 Date Approved Keith D. Renshaw , Member 10/21/2010 Date Approved Patricia K. Kerig , Member 10/22/2010 Date Approved and by Cynthia Berg , Chair of the Department of Psychology and by Charles A. Wight, Dean of The Graduate School. iii ABSTRACT This study examined the effects of a brief parent psycho-educational intervention on therapy attendance rates, clinical outcome ratings, and parent satisfaction assessed after 13 weeks of treatment. Eighty-four parents were recruited from a mental health clinic that provides services to children who were allegedly abused. Parents were randomly assigned to either the experimental or control condition. Parents in the experimental condition received an intervention booklet, which described beneficial outcomes they could expect for their child when they engaged in research-supported treatment. The booklet also let parents know that their participation was integral to their child's treatment, and attempted to increase parent's motivation and self-efficacy to communicate with their child's therapist. Furthermore, it aimed to increase parents' motivation and ability to overcome barriers that might impede bringing their children to treatment on a regular basis. Parents were guided through the booklet to ensure that they read the information and completed the problem-solving exercises for overcoming barriers that might make it difficult to talk to their child's therapist and obstacles that might prevent attendance. Results indicated that there was little difference in rates of attendance, clinical outcomes, and satisfaction between parents who received the intervention and those who did not. TABLE OF CONTENTS ABSTRACT……………………………………………………………………….......... iii EFFECTS OF A BRIEF PARENT INTERVENTION TO INCREASE ATTENDANCE, POSITIVE OUTCOMES, AND SATISFACTION WITH THEIR CHILD'S THERAPY TREATMENT…..………………………………………………………………….……. 1 Effective Treatments………………….………………………………….………. 1 Social Learning Theory as a Theoretical Framework…………………….……… 3 Barriers to Treatment…………………………………………………….………. 6 Hypotheses…………………………………………………………………….…. 8 METHOD…………………………………………………………………….………...... 9 Participants…………………………………………………………….………… 9 Materials…………………………………………………………….…….......... 10 Procedure……………………………………………………………………….. 14 RESULTS………………………………………………………………………………. 17 Evaluation of Attendance ………………………………………………………. 17 Evaluation of Outcomes……………………………………………………........ 17 Evaluation of Satisfaction……...……………………………………………….. 20 DISCUSSION………………………………………………………………………..…. 25 First Hypothesis - Attendance………………………………….………………. 25 Second Hypothesis -- Clinical Outcomes…………..……………………...…… 26 Third Hypothesis - Satisfaction………………………………………………… 27 Limitations……………………………………………………………….……... 28 Future Directions…..…………………………………………………………… 29 v Appendices A: PARTICIPANT FLOWCHART….….…………………………………..…………. 32 B: SUCCESSFUL TREATMENT BOOKLET.........................………….…..…….….. 33 C: TRI-FOLD BROCHURE…………………………………………………………… 50 D: HISTORY AND FUNCTIONING QUESTIONNAIRE: FIRST SESSION…..…... 53 E: WEEKLY PROGRESS REPORT………………………………………………….. 56 F: THIRTEEN-WEEK OUTCOME RATINGS FOR PARENTS IN TREATMENT CONDITION…………………………………………………………………………… 59 G: THIRTEEN-WEEK OUTCOME RATINGS FOR PARENTS IN CONTROL CONDITION…………………………………………………………………………… 62 H: THIRTEEN-WEEK THERAPIST OUTCOME RATINGS………………….……. 65 ENDNOTES……………………………………………………...…………………..…68 REFERENCES……………………………………………………………………….…69 EFFECTS OF A BRIEF PARENT INTERVENTION TO INCREASE ATTENDANCE, POSITIVE OUTCOMES, AND SATISFACTION WITH THEIR CHILD'S THERAPY TREATMENT Child abuse and neglect are common problems in the United States. Nearly one million cases of child abuse are substantiated annually out of three million reported (Child Welfare Information Gateway, 2008; Wekerle, Miller, Wolfe, & Spindel, 2006). Victims of child abuse and neglect are at risk for a wide range of overlapping physical, psychological, behavioral, and social problems (Child Welfare Information Gateway, 2008; Wekerle, et al., 2006). From a developmental perspective, a child's poor resolution at an earlier stage will lead to a higher probability of problems, including biological, cognitive, behavioral, and interpersonal domains in later stages of development with the possibility of persisting into adulthood. Therefore, early treatment is particularly important in mitigating the effects and developmental delays associated with child abuse (Barth, Scarborough, Lloyd, Casanueva, & Mann, 2008). Effective Treatments Evidence based treatments have been associated with significant improvements in treatment of children who have experienced maltreatment (Children's Hospital-San 2 Diego, Chadwick Center for Children and Families, & National Call to Action, 2004; The National Child Traumatic Stress Network, 2008). Three therapies have emerged as having the greatest empirical, theoretical, and clinical support in the treatment of abused children1 (Chaffin & Friedrich, 2004; Children's Hospital-San Diego, et al., 2004; The National Child Traumatic Stress Network, 2008). Others (e.g., Child Parent Psychotherapy) have been identified as promising interventions (The National Child Traumatic Stress Network, 2008). Furthermore, work by Chorpita, Daleiden and Weisz (2005) offers the promise of improved outcomes for abused children by identifying and ensuring common elements across evidence based treatments. Although abused children benefit from treatment (Children's Hospital-San Diego, et al., 2004), an estimated 33-61% of their families fail to enter treatment following assessment and recommendation to obtain services (Barth, et al., 2008; Kopiec, Finkelhor, & Wolak, 2004; MacNaughton & Rodrigue, 2001). Of families who begin treatment, 40-60% terminate prematurely (Kazdin, Holland, & Crowley, 1997; Kazdin, Holland, Crowley, & Breton, 1997). These troubling failures to seek or complete treatment are at rates comparable to those seen for a variety of pediatric chronic health conditions (Kahana, Drotar, & Frazier, 2008). Premature treatment termination is associated with a variety of negative sequelae including poorer therapeutic outcomes for children and their families, decreased staff productivity, and decreased cost effectiveness (Nock & Ferriter, 2005; Nock & Kazdin, 2005). One study attempting to increase treatment attendance by utilizing an educational intervention failed to show increased attendance (Shuman & Shapiro, 2002). In this study, researchers used two informational forms of education, a video tape and brochure, 3 to prepare parents for their child's therapy. They found that the interventions in combination but not alone increased the parents' accuracy about the expectation of their child's treatment. Ultimately, however, it had no effect on attendance rates. In contrast, parent and child interventions using behavioral methods (e.g., problem-solving, parent training) and multi-component methods (e.g., behavioral combined with educational, social-support, social skills training, or family therapy) have been shown to be effective in improving treatment adherence for children with chronic illnesses (Kahana, et al., 2008) and youth with behavioral problems (McKay, Pennington, Lynn, & McCadam, 2001; Nock & Ferriter, 2005). Children rarely have complete control over their mental health access, participation, and their clinical outcomes, whereas their parents exercise significant influence and control. Besides providing daily guidance and management for their children, parents are responsible for acting upon the referral, giving legal consent, providing transportation, managing appointment attendance, and payment for services. Since children have limited control over their participation in the process, engaging the perceptions and expectations of parents about the therapeutic treatment of their children offers a potential opportunity to alter the behavior of the parents for the benefit of their children (Nock & Kazdin, 2005). Social Learning Theory as a Theoretical Framework Social Learning Theory provides a theoretical framework to understand how expectations and perceptions affect the probability that a behavior will occur (e.g., Bandura, 1977, 2004; Rotter, 1966). An expectation that there is a causal link between a 4 given behavior and a desired outcome increases the likelihood that individuals will engage in the behavior. This is especially true for tasks requiring skill for individuals with an internal locus of control, which is a general belief that outcomes are contingent on behavior or skill rather than chance (Rotter, 1966, 1975). Bandura (1977) postulated that an increased belief that one can execute the behavior to produce change, increases the probability of the behavior. In facilitating client satisfaction and involving the patient as a collaborator to achieve treatment goals, Meichenbaum and Turk (1987) identified the importance of understanding the patient's concerns, perceptions, expectations, and promoting a patient's sense of self-efficacy. Consistent with Bandura's theory, their research suggested that clients who perceived that their actions influenced a positive outcome developed an expectation that a particular outcome would follow if they behave in a particular manner (Meichenbaum & Turk, 1987). Furthermore, such clients were motivated to be assertive and take action toward achieving that outcome. Therefore, in an attempt to increase children's success in treatment, it may be advantageous to affect parents' concerns, perceptions, expectations, and their sense of self-efficacy in the treatment of their children. Perceptions and expectations can be changed through modeling and the use of problem-solving strategies to promote completion of treatment (D'Zurilla & Nezu, 1999, p. 38; Gully, Price, & Johnson, 2008; Holman & Lorig, 1992; Mason, Butler, & Rollnick, 2010). An individual's expectations about their personal efficacy affects whether coping strategies will be initiated, the amount of effort they exert, and how long they will persist when faced with aversive conditions and obstacles (Bandura, 1977). People fear and 5 avoid threatening situations that they believe exceed their coping skills, whereas they engage in activities for which they determine themselves capable (Bandura, 1977, 2004). However, positive expectations alone may not produce positive outcomes in the absence of an adequate skill set and additional incentives. When skills and incentives are present, a person's expectations for self-efficacy can then play a major role in determining a their choice of activities, how much effort they will expend, and how long they will persist in an activity (Bandura, 1995). Thus, Bandura's theoretical position about self-efficacy expectations complements Rotter's seminal work about probability of behavior being a function of expectations for causality, coupled with the perceived reinforcement value of the outcome. Motivational Interviewing is a mechanism based on social learning theory that can be used to enhance a person's sense of self-efficacy and the possibility that change can occur. Miller and Rollnick (2002, p. 25) describe Motivational Interviewing as "a brief client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence." According to this model, a client's ambivalence arises out of choosing between potentially conflicting courses of action that have differing costs and benefits. Motivational Interviewing encourages clients to identify and articulate their unique conflicts, and then find acceptable solutions which can lead to self-efficacy. If people experience self-efficacy and perceive that they can make changes, they will often pursue change through behavioral means (Miller & Rollnick, 2002, p. 11). Furthermore, research suggests that clients who engage in Motivational Interviewing early in treatment are more likely to remain in treatment longer, are more persistent in working towards goals, are more likely to adhere to recommendations, and experience 6 better outcomes compared to patients who receive the same treatment but do not engage in motivational interviewing prior to treatment (Miller & Rollnick, 2002, p. 25). But that might not be enough when there are real barriers to pursuing treatment. Barriers to Treatment Barriers to mental health treatment, such as events that interfere with attending and participating in treatment, treatment demands, perceived relevance of the treatment, and relationship with the therapist, are predictive of negative clinical outcomes including early therapy termination, higher cancellation rates, and missed appointments (Kazdin, Holland, & Crowley, 1997; Kazdin, Holland, Crowley, et al., 1997; Kazdin & Mazurick, 1994). Families who perceive and experience more barriers have been shown to have a higher attrition rate, with the number of barriers proving significantly predictive while the type of barrier did not (MacNaughton & Rodrigue, 2001). Using problem-solving techniques as a method of addressing barriers and access has been shown to influence behavioral changes, producing a significantly higher rate of attendance (Kazdin, 2003) and improved parent satisfaction (Gully, et al., 2008). Research suggests that that people can use problem-solving skills to reduce barriers to treatment. In part, the belief that one can affect or impact what happens becomes an important variable for behavioral change when problem-solving skills are developed (Chang, D'Zurilla, & Sanna, 2004, p. 21; Rotter, 1966, 1978). Problem-solving has been used has been effectively used to alter expectations and relate them to outcomes (Rotter, 1978). Problem-solving has been found to contribute to well-being including self-efficacy, optimism, and perceived control (D'Zurilla & Nezu, 1999, p. 71). Problem- 7 solving skills can serve to increase a parent's sense of mastery and control of a situation, thereby contributing to positive psychological adjustments (Nezu, Palmatier, & Nezu, 2004). As an adjunct to forensic medical examinations, Gully, Price, and Johnson (2008) implemented a nurse-mediated protocol that educated parents and utilized problem-solving skills to address barriers to evidence-based mental health treatment. Parents receiving the protocol, unlike those in the control group, reportedly discussed evidence-based treatments with their mental health providers, and reported significantly greater satisfaction with the subsequent forensic medical examination. These results suggest that an active educational and behavioral adjunct intervention can change behavior while increasing satisfaction. Parental perception of the therapeutic relationship has been shown to be influential in their decision whether or not to prematurely terminate their child's mental health treatment (Garcia & Weisz, 2002; Kazdin, Marciano, & Whitley, 2005; Nock & Ferriter, 2005). Harwood and Eyeberg (2004) found that parents who actively discussed their concerns and expectations about their child's treatment with therapists early in the therapeutic process had lower rates of attrition and greater perceived ability to actively participate in treatment compared to parents who passively answered closed-ended questions. Bandura (1977) described this process as performance accomplishment. This process is influential in building self-efficacy because it is based on personal mastery of experiences that occurs early in a course of events in which successes raise expectations and failures lower expectations. Elevated expectations of success can potentially increase a patient's willingness to repeatedly engage in prerequisite behavior (Bandura, 1977; 8 Rotter, 1966). Therefore, increasing a parent's self-efficacy in their child's therapy may facilitate parents becoming more active participants in the therapy process Hypotheses The proposed study was designed to test whether a brief intervention would lead to improved participation in treatment, better clinical outcomes, and improved satisfaction with services by parents of abused children. It was designed to do so through: (1) altering parents' expectations for self-efficacy about their ability to communicate with their child's therapist and bring their child to treatment regularly, (2) learning that their participation in therapy will benefit their child, and (3) helping parents develop reasonable and achievable goals for therapy. Parents were also encouraged to ask the therapist questions so the therapist could help them become an active participant in their child's treatment. It was hypothesized that the intervention would (1) increase regular attendance, (2) improve clinical outcomes for the children, and (3) produce greater parental satisfaction with treatment. METHOD Participants Participants (see Appendix A) were 84 parents or primary caregivers, here after referred to as parents (70 women, 14 men, M = 36 years, SD = 8.1, age range: 19-58 years, one declined to provide her age) recruited from referrals to Primary Children's Center for Safe and Healthy Families (SHF), an outpatient mental health service for child maltreatment located in Salt Lake City, Utah. Ninety-four parents were initially invited to participate in the study. However, 10 parents chose not participate; six declined, one was excluded due to a language barrier, one child was in the custody of Division of Child and Family Services, one parent's appointment was missed due to scheduling conflicts, and one parent was excluded because their insurance only authorized three visits. Parents' completed questionnaires related to their child's behavior and perceptions of treatment (48 girls, 42 boys, M = 8 years, SD = 4.0, age range: 2-17 years). Among the children, 68 were European American, nine were Hispanic American, two were Multiracial, one was African American, and four did not specify their ethnicity. In none of the cases was the parent known to be an abuser. A power analysis using G*Power 3, indicated a total of 84 parents, 42 in each of two conditions, was needed to obtain a medium to large effect size (Faul, Erdfelder, Lang, & Buchner, 2007). 10 SHF's intake coordinators recruited eligible parents to participate in the study during initial telephone contact with the family. Only parents proficient in English were recruited. Furthermore, families court-ordered to receive treatment were excluded from the study. If multiple children from the same family were being seen simultaneously by SHF, the parent and one randomly selected child were included for participation. A research assistant met families 15 minutes before their first appointment. When multiple parents accompanied the child to the session, the researcher identified the primary caregiver, and directed all study procedures to this parent. The research assistant then administered informed consent and assigned the families to either the treatment or control condition using a pre-generated number set (Urbaniak & Plous, 2009). Materials Successful treatment booklet. We developed a booklet (see Appendix B) designed to increase parent satisfaction with therapy, improve clinical outcomes, increase the number of appointments attended, and reduce the number of missed appointments and cancellations. We adapted this booklet from one used by Gully, Price, and Johnson (2008). Their booklet was designed to educate parents about evidence-based treatments available for children suspected to be sexual abuse victims and encouraged parents to seek these therapies for their own children. Their booklet proved effective at increasing parents' willingness to discuss evidence-based mental health treatment for their children and increased their satisfaction with the services they received. In contrast, families in our study were already receiving evidence-based treatments as a part of routine treatment. Therefore, while our booklet was similar to that used by Gully, et al. in that both 11 educated parents about the benefits of engaging in evidence-based treatment, yet different because we further involved parents in exercises that we anticipated would positively impact their participation in treatment. We wrote the booklet at an eighth grade reading level and divided it into three sections. The booklet was specifically designed so that it did not require administration by a mental health professional and could be administered by researchers or support staff. The first section described potential benefits from evidence-based mental health treatment (The National Child Traumatic Stress Network, 2008) followed by the 10 elements of therapy that are most apt to be helpful in achieving the family's goals for therapy such as "Everyone agrees on the goals and tasks of treatment." Experts, in evidence-based treatment models, identified and endorsed these 10 elements as critical to achieving positive therapeutic outcomes with abused children.2 In the second section of the booklet, parents were first asked to decide which of the 10 therapy elements was most important to them for meeting their treatment goals. To encourage them to discuss this information with the therapist, they were prompted to identify any obstacles that made it difficult to for them to talk with their therapist. Then the booklet led them through a problem-solving exercise designed to help parents "brainstorm" multiple solutions to these obstacles (D'Zurilla & Nezu, 1999, pp. 28-29). The third section of the booklet introduced another problem-solving exercise in which parents were acquainted with a number of obstacles that commonly prevent families from regularly attending therapy (Gully, et al., 2008; Kazdin, Holland, Crowley, et al., 1997; Lai, Chan, Pang, & Wong, 1997) To encourage them to identify barriers that their family might face, parents were prompted to check any barriers that might make it difficult for 12 them to attend therapy or to write down others not listed. Then the booklet led them through another problem exercise to "brainstorm" a variety of solutions. Additional blank problem solving exercises were provided at the back of the booklet. Parents were encouraged to use them to problem-solve future obstacles to their treatment. Tri-fold brochure. Building Your Child's Self-Esteem is a tri-fold brochure (see Appendix C) administered to caregivers in the control condition. Primary Children's Medical Center originally created the brochure as part of the Hold on to Dear Life campaign. The brochure provided parents with helpful suggestions that could be used to increase their child's self-esteem. Examples included using phrases such as "You're a good listener" and giving "pats on the back." Attendance documentation. Treatment attendance, cancellations, and missed appointments were documented from therapist records. SHF therapists scheduled appointments directly with families and maintained attendance records in their charts as part of routine procedures. If a family did not show up for an appointment, therapists recorded it as a missed appointment. If the family notified the clinic in advance that they could not make an appointment, therapists recorded it as a cancellation. History and functioning questionnaire: First appointment. The History and Functioning Questionnaire Form (HFQ) (see Appendix D) is a six item scale that parents completed at their first appointment. Three scales measure the child's interpersonal behavior and traumatic symptoms, and parent functioning. Scale items for the child's interpersonal behavior were adapted from the Social Behavior Inventory (SBI; Gully, 2003); traumatic symptom items were adapted from the UCLA Posttraumatic Stress Disorder Reaction Index (UCLA-PTSD RI; Pynoos, Rodriguez, Steinberg, Stuber, & 13 Frederick, 2001); and parent functioning items were adapted from the Child Abuse Potential Inventory (CAP; Milner, 1986). Additionally, two items assess a parent's current concern about their child's potential for self-harm and drug or alcohol use, and one item inquires about parental satisfaction with services. Parents also provided their child's background information including traumatic experiences on the HFQ: First Appointment. Weekly progress report. The Weekly Progress Report (see Appendix E) is a weekly version of the HFQ used to detect change in the six item scales, parent's concern about their child's potential for self-harm and drug or alcohol use, and a satisfaction rating for the previous week's services. The background and trauma history were omitted. Thirteen Week outcome ratings for parents in experimental condition. This 20- item questionnaire (see Appendix F) asked parents to assess the achievement of therapeutic objectives at 13 weeks. The measure included the ten therapeutic objectives from the booklet, the six items from the weekly progress report, four questions about the use of the booklet during treatment, and estimated number of canceled appointments. Thirteen Week outcome ratings for parents control condition. The control version (see Appendix G) contained the same questions as the experimental version minus the questions about the booklet. Thirteen Week therapist outcome ratings. The 13 Week Therapist ratings (see Appendix H) contained the same questions as the experimental version minus the questions about the booklet but included a question about no show appointments. 14 Procedure Upon referral, a SHF intake coordinator gathered information from the parent or caregiver of the referred child to ensure a good fit between client and services. The intake coordinator interviewed parents over the telephone to obtain basic identification information and details about the abuse. At this time, the intake coordinator invited parents to participate in the proposed study, if there was a reported history of abuse or exposure to violence. Prospective participants were informed that their participation in the study was completely voluntary and services being offered for treatment were independent of participation. Parents were mailed a consent form along with the standard SHF intake forms (HFQ, and "Informed Consent" form) to be completed and returned at the time of their intake appointment. Therapists trained in evidence based practices (two-PhD level psychologists, one- Licensed Clinical Social Worker, one-Licensed Professional Counselor, one-Clinical Social Worker, one-Psychology Intern, one-Social Work Intern, and one-Psychology Trainee) reviewed new referrals at a weekly staff meeting and selected clients, depending on their caseloads. Therapists contacted the clients directly to schedule an intake appointment. Therapists instructed parents to arrive 15 minutes before their intake appointment to complete forms. When families arrived for their intake appointment, they were met by one of five (four male, one female) undergraduate research assistants or the researcher; who verified willingness to participate and administered informed consent. Willing parents were randomly assigned to either the experimental or control condition then escorted to a small conference room. Parents in the experimental condition received the intervention booklet 15 and were guided through the booklet by a research assistant to ensure that parents read it and completed the problem-solving exercises. With the help of a research assistant who used motivational interviewing techniques, parents practiced initiating a discussion with the therapist and implementing solutions obtained through the problem-solving exercises in their booklet. Researchers praised parents in the experimental condition at least three times during administration of the booklet for engaging in the exercises. When parents voiced questions during the experimental protocol, researchers were trained to encourage parents to discuss them with their child's therapists. Parents in the control group received the tri-fold brochure. A research assistant guided them through the brochure to ensure that they had a similar experience to the experimental condition. However, in contrast to the control condition, research assistants were trained to go through the brochure without providing feedback to the participants. All research assistants demonstrated the ability to adhere to protocol and administer the materials within 15 minutes through role-playing exercises prior to beginning the study. They continued to practice their skills and review study procedures at bi-weekly meetings. At random intervals, the researcher observed research assistants administering the materials for 17% of the participants to retain protocol adherence. Upon completion of the intervention, participants were escorted to their therapist's office.3 Therapists met with parents and child for approximately 2 hours to complete developmental histories and any additional paperwork. As a routine function of SHF's intake procedures, parents completed standardized self-report questionnaires designed to assess the child's level of emotional distress and behavioral functioning prior to finalizing a treatment plan with the 16 therapist. These questionnaires include the History and Functioning Questionnaire (Gully, 2009). As a function of SHF's ongoing routine procedures, all participants completed the HFQ prior to each therapy session. At 13 weeks, parents in both conditions also completed the appropriate 13 week outcome rating form after their appointment. As a manipulation check, parents in the experimental condition were asked if they brought the booklet to therapy sessions and completed any additional problem-solving exercises. Therapists also rated families at 13 weeks using the therapist version of the outcome rating form. RESULTS Evaluation of Attendance To test the first hypothesis, that the intervention would increase attendance, we analyzed attendance using a two tailed, independent sample t-test for the total number of sessions attended between groups (t = -1.093, p = .277). Results did not support the hypothesis that children whose parents received the intervention (M = 6.62, SD = 3.79) attended more therapy sessions than children whose parents did not (M = 7.48, SD = 3.39). Evaluation of Outcomes To test the second hypothesis, that children whose parents received the intervention would have improved clinical outcomes compared to children whose parents did not receive the intervention, we separately analyzed therapist's ratings and parent's ratings using a 2 x17 (Condition x Outcome Items) one-way multivariate analyses of variance (MANOVA). First, therapist rated outcomes were analyzed using a one-way MANOVA which revealed no significant multivariate group effect, Wilks' λ = .767, F(17,65) = 1.164, p = .318, partial eta squared = .233. Given the exploratory nature of this study, we inspected the univariates (see Table 1). 18 Table 1 Mean and standard deviations per group on the 17 items from the Therapist Outcome Questionnaire at 13 Weeks Treatment (n=42) Control (n=41) F p Items M SD M SD 1. Has everyone agreed on the goals and tasks of treatment? 3.92 1.52 4.00 1.45 .05 .83 2. Has the parent learned skills to be more sensitive to the needs of their child? 3.52 1.35 3.73 1.34 .50 .48 3. Have the parent and their child learned ways to talk and listen to each other better? 3.24 1.21 3.51 1.34 .96 .33 4. Have the parent and child learned ways to increase safety for the child? 3.31 1.35 3.71 1.40 1.73 .19 5. Has the parent learned ways to reinforce and praise their child? 3.52 1.38 3.71 1.50 .34 .56 6. Have the parent and child learned to identify and challenge beliefs, perceptions, judgments, and expectations that can maintain physically abusive or aggressive behavior? 2.33 1.14 2.63 1.18 1.40 .24 19 Table 1 continued Treatment (n=42) Control (n=41) F p Items M SD M SD 8. Has the parent learned to develop plans to manage their child's behavioral problems? 3.02 1.37 3.51 1.47 2.46 .12 9. Have the parent and child been taught healthy ways to control anger or anxiety? 2.83 1.51 3.20 1.42 1.26 .27 10. Has the parent learned strategies to prevent relapse and developed plans for continued improvement? 1.90 1.16 2.51 1.47 4.37 .04 11. Has this child become less scared or sad and more happy? 3.12 1.23 3.22 1.17 .14 .71 12. Is this child more safe from harm? 3.43 1.25 3.51 1.23 .09 .76 13. Is this child better able to have friends, which includes not harming other children? 2.71 1.07 2.80 1.08 .15 .70 14. Is this child more likely to not violate the privacy and/or private body parts of other people? 2.79 1.14 2.83 1.07 .03 .86 15. Did a parent or primary caretaker become more competent 3.38 1.34 3.56 1.36 .37 .55 16. Do you think that the parent/caretaker has skills to be assertive with you to get what they and their child need from therapy? 4.05 1.21 3.88 1.33 .37 .54 17. Do you think that the parent/caretaker has strategies to help ensure that they are able to attend therapy regularly? 3.62 1.56 3.93 1.35 .92 .34 20 We used a conservative p value <.01 owing to the large number of tests run. Although none reached significance, it revealed that in 16 of 17 comparisons, therapists rated the parents in the control condition higher than those in the experimental condition. It is worth noting that the single variable on which therapists gave the parents in the experimental group higher (although not significantly so) ratings was on item number 10: "Do you think that the parent/caretaker has skills to be assertive with you to get what they and their child need from therapy?" Interestingly, this item most closely reflects at the goal of the intervention. Next, the 17 parent-rated outcomes were analyzed as a function of group using a one-way MANOVA, which revealed no significant multivariate group effect, Wilks' λ = .329, F(17,14) = 1.681, p = .166, partial eta squared = .671. Only parents who filled out the 13-week outcome ratings were used for this analysis. We recognize the speculative nature of conducting this analysis with only 16 parents in each group, but given the exploratory nature of this study, we chose to examine this information for future direction. As seen in Table 2, although none of the univariate analyses were significant (utilizing a conservative p value <.01 owing to the large number of tests run), the means were higher for the control group on all 17 items. Evaluation of Satisfaction To test the third hypothesis, that parents who received the intervention would have higher ratings of satisfaction compared to parents who did not receive the intervention, we used an independent sample t-tests. 21 Table 2 Mean and standard deviations per group on the 17 items from the Parent Outcome Questionnaire at 13 Weeks Treatment (n=16) Control (n=16) F p Items M SD M SD 1. Has everyone agreed on the goals and tasks of treatment? 3.75 1.48 4.81 .75 6.54 .02 2. Has the parent learned skills to be more sensitive to the needs of their child? 4.19 1.33 4.63 1.02 1.09 .31 3. Have the parent and their child learned ways to talk and listen to each other better? 4.13 1.36 4.56 1.03 1.05 .31 4. Have the parent and child learned ways to increase safety for the child? 3.69 1.20 4.38 .96 3.22 .08 5. Has the parent learned ways to reinforce and praise their child? 4.06 1.29 4.75 1.00 2.84 .10 6. Have the parent and child learned to identify and challenge beliefs, perceptions, judgments, and expectations that can maintain physically abusive or aggressive behavior? 3.50 1.15 4.31 .87 5.04 .03 7. Has the family learned effective communication and problem-solving skills as part of their daily routines? 3.75 1.18 4.50 .82 4.36 .05 22 Table 2 Continued Treatment (n=16) Control (n=16) F p Items M SD M SD 8. Has the parent learned to develop plans to manage their child's behavioral problems? 3.87 1.09 4.50 1.33 2.78 .11 9. Have the parent and child been taught healthy ways to control anger or anxiety? 3.62 1.5 4.43 .89 5.00 .03 10. Has the parent learned strategies to prevent relapse and developed plans for continued improvement? 3.5 1.26 4.25 1.06 3.29 .08 11. Has this child become less scared or sad and more happy? 3.44 1.26 4.44 1.09 5.73 .02 12. Is this child more safe from harm? 3.93 1.24 4.25 1.06 .59 .45 13. Is this child better able to have friends, which includes not harming other children? 3.75 1.24 4.43 .89 3.25 .08 14. Is this child more likely to not violate the privacy and/or private body parts of other people? 4.00 1.21 4.13 1.26 .08 .78 15. Did a parent or primary caretaker become more competent 3.88 1.36 4.43 1.09 1.66 .21 23 Table 2 Continued Treatment (n=16) Control (n=16) F p Items M SD M SD 16. Do you think that the parent/caretaker has skills to be assertive with you to get what they and their child need from therapy? 4.12 1.31 4.56 1.03 1.10 .30 17. Do you think that the parent/caretaker has strategies to help ensure that they are able to attend therapy regularly? 4.31 1.35 4.56 1.03 .35 .56 There was virtually no difference in parent satisfaction ratings at their second session as a function of group (i.e., experimental group M = 4.50, SD = .86 and control group M = 4.48, SD = .75, t(43) = .08, p = .939). However, there was a significant difference in the parent satisfaction scores at week thirteen in favor of the control condition (M = 4.86, SD = .36) compared to the experimental condition (M = 4.31, SD = .63); t(25) = 2.80, p = .013. In other words, parents in the experimental condition were less satisfied with services than parents in the control condition when asked at week 13. At 13 weeks, we also examined four questions about parents' self-reported use of the booklet while their child was in treatment. Sixty one percent (i.e., 18 out of 42) of parents in the experimental condition reported that (1) the booklet problem-solving exercises helped them talk to their child's therapist, (2) that the booklet helped them work effectively with their therapist, (3) and that the booklet helped them ensure that their child attended appointment on a regular basis. Thirty two percent reported (4) that they brought their booklet to at least some of their sessions. DISCUSSION The goal of this study was to evaluate whether a brief psycho-educational booklet administered to parents of allegedly abused children could improve attendance, positively affect clinical outcomes, and increase parental satisfaction with services. Statistical analysis revealed that none of the three hypotheses were supported. Overall results indicated that there was little significant difference between the experimental and control groups and when a difference did occur, it was in favor of the control group. Each hypothesis is discussed in more detail below. First Hypothesis - Attendance The present findings failed to support the first hypothesis that children whose parents received a brief intervention would have higher rates of attendance compared to children whose parents did not receive the intervention. One possible explanation for this finding is that parents who attended their first appointment were already highly motivated to bring their children to therapy. During the same time period, 30% of parents who contacted SHF's intake coordinator to arrange for therapy services failed to follow through even with a first appointment. Therefore, the remaining 70% of parents who participated in the study and attended their first appointment may have been predisposed to bring their children to therapy and may not represent the larger population of parents 26 whose children were allegedly abused. Previous research has shown that as many as 61% of families who are recommended to seek services never make it to this stage (Barth, et al., 2008; Kopiec, et al., 2004; MacNaughton & Rodrigue, 2001). Therefore, all families who showed up for a first appointment may have already been sufficiently motivated to attend therapy and the modest intervention we used may not have had much additional effect. In light of this consideration, administering the intervention earlier (e.g., during the initial phone contact) in the process might benefit those for whom attendance is most challenging and who fail to attend even their first appointment. Second Hypothesis - Clinical Outcomes The present findings also failed to support the second hypothesis. It was expected that the parents in the experimental condition would rate their child's clinical outcomes higher since they were instructed on what they could expect to achieve and were engaged in problem-solving exercises about attendance barriers and potential problems when communicating with their child's therapist. Even though a research assistant guided parents through the booklet and ensured that they engaged in the problem-solving exercises, we did not collect additional data to ascertain how much of this information they retained. It was not an idea that we overlooked. Rather, we intentionally decided to keep the intervention as brief as possible to avoid burdening parents or therapists with excessive paperwork or negatively impacting a family's clinical experience. Therefore, it is possible that although parents successfully completed the exercises, they may not have retained the information for very long or used it again. This possibility could be tested 27 through a questionnaire to determine parents' retention of the key elements of the intervention. Another possibility is that parents in the experimental group had elevated expectations that may have exceeded their children's actual improvement. Parents who received the intervention were better informed about what outcomes to expect. Therefore, they might have been more discriminating about their therapeutic experiences and outcomes. If the intervention raised parents' expectations, it may have led to more critical assessments of outcomes and therefore slightly lower ratings than those given by parents in the control condition. However, based on the data collected, we are unable to demonstrate that one group knew what to expect compared to the other. Third Hypothesis - Satisfaction The study also failed to support the third hypothesis, that parents who received the brief intervention would report greater satisfaction with services they received than would parents who did not receive the intervention. Results demonstrated that parents in both groups were quite satisfied with services they received. One explanation for the high level of satisfaction of both groups is that parents who seek services for their abused children may experience a great deal of relief, and consequently satisfaction when they finally meet with their child's therapist. It is not uncommon for parents to be extremely upset and emotional about their child's trauma or abuse (Banyard, Rozelle, & Englund, 2001). Following allegations of abuse, parents may have interacted with a number of agencies such as schools, child protective services, law enforcement, insurance companies, and Primary Children's Hospital prior to speaking with SHF's intake 28 coordinator. Parents had to be motivated, persistent, and able to navigate numerous and complex systems to finally talk to a therapist about their child's abuse. It follows that they would be satisfied to speak to a person who could directly help their child and would explain why none of the parents in either condition reported being dissatisfied with services. One unexpected finding was that parents in the experimental condition had slightly (but not significantly) lower satisfaction ratings at 13 weeks than parents who did not receive the intervention. Again, a possible explanation for this is that the intervention (as anticipated) increased parents' expectations for specific benefits from therapy. While highly motivated and glad to be in treatment, it is possible that parents in the experimental group had higher expectations than parents in the control group. Any perceived failure to meet those expectations might have led to slightly lower satisfaction ratings compared to parents in the control condition, who did not have specific benefits in mind. Limitations This study was designed to evaluate the effectiveness of a brief psycho-educational intervention with parents to positively impact psychotherapy for their children who have a history of abuse. However, the study may have been overly ambitious in its aim by attempting to use too brief (i.e., a one-time, 15 minute) an intervention to impact several aspects of a child's treatment. It still might be possible for a brief intervention to have an impact if the focus is limited to a single variable such as attendance or satisfaction rather than attempting to impact several. 29 We chose to conduct our study within a working clinical environment although it created certain constraints. Doing so limited the amount of control we had over therapists, participants, and the information we could gather. Although clinicians were cooperative about filling out forms, we had to be judicious about how much of their time we requested. Furthermore, we had to integrate our study into an existing clinical protocol. We had to be flexible and ensure that our intervention did not interfere with SHF's staff or clinical time. Therefore, we had to selectively choose what data to collect and what to forfeit (such as parent retention of the booklet information) even though we thought it would have been informative. Among the therapists who participated in the study, there was considerable variance in their amount of formal training. Clinicians ranged from PhDs to social work interns. We had no control over therapist participation or which clients were ultimately seen by which therapists. For example, because of insurance criteria, some therapists were ineligible to work with certain clients. Although the clinic attempted to find the best match possible between client and therapist, there was a potential for individual therapists to have impacted outcomes. In addition, the number of clients seen by a therapist varied greatly from 3 to 25. Future Directions In keeping with the aims of this study, future research ideas to explore might include multiple brief interventions. A series of brief interventions might be effective where a single one was not. Multiple brief interventions could be administered while parents wait in the reception area during their child's therapy appointment. Alternatively, 30 we could create a series of informational DVDs that parents could review. The first session could be a longer instructional video with multiple brief follow-ups at specifically designated times. Parents could check out a portable DVD player at the reception desk along with a DVD that corresponds to their child's therapeutic session number or week in treatment. To verify that parents received and understood the information, they could fill out an electronic or paper questionnaire. This method would alert the research team if parents did not understand a particular component. Furthermore, a DVD would allow for repeated presentation and review of information. Use of a DVD would also allow researchers to present concrete examples of successful and unsuccessful methods of interacting with the therapeutic process. Actors could be used to model both effective and ineffective methods. It would ensure that all parents received consistent information without variance that can occur when presented by a team of real people. These ideas are potentially promising but they come with their own challenges such as how to handle parent questions and remediation should a parent's responses indicate that they did not understand the information or engage in the process. As mentioned earlier, to try and motivate more parents to show up for their first appointment, the first intervention might have been more impactful if it was administered earlier in the process. It could be administered between the time of request for services and prior to the first appointment. To accomplish this, we would need to utilize a different method of intervention delivery. Potentially, research assistants could telephone the parents or use a computer video telephone service such as Skype™ to administer the intervention outside of the clinic setting. Another possibility would be to provide an online interactive video that parents can view at their convenience prior to their first 31 appointment. Of course, utilizing such remote technologies will also entail additional logistical challenges. Finally, there is the question of the impact of the Tri-fold brochure (i.e., the control material). Could this simple message about increasing a child's self-esteem have had an impact on parents and have become an effective brief intervention as well? It was intended to serve as an attentional control (i.e., by providing these parents with at least some personal attention) but perhaps its message was clearer and more positive than we anticipated or even more effective than the experimental intervention. Even if there was a positive effect from the experimental intervention, it is possible that it was masked if the brochure also had a positive impact. Could the brochure have affected parent's interaction with their child's therapist? This seems a reasonable question for further research. Overall, there was little difference between the experimental and control groups and when it occurred, it was in favor the control group. This suggests that our intervention may have been overly ambitious; that we tried to do too much in too a limited an amount of time. We attempted to build on previous research and created an intervention that did not rely on education alone (Shuman & Shapiro, 2002) but included an interactive component that has proven effective in other environments (Kahana, et al., 2008; Nock & Ferriter, 2005) while trying to keep it as brief as possible (Gully, et al., 2008). A logical next step would be to test the effects of multiple brief interventions or a longer or an earlier intervention aimed at impacting a single variable, such as attendance. Although this study did not support the hypotheses, it has provided some direction for future research with this population. APPENDIX A PARTICIPANT FLOWCHART Assessed for eligibility (n = 94 parents) Excluded for not meeting inclusion criteria due to language barrier, child in DCFS custody, RA missed appt., and insurance preauthorization for only 3 sessions (n = 4) Declined to participate (n = 6) Enrollment Random Assignment (n = 84) Assigned to experimental group (n = 42) Received treatment (n = 42) Assigned to control group (n = 42) Received control brochure (n = 42) Analyzed Parent Ratings (n = 16) Analyzed Therapist Ratings (n = 42) Analyzed Parent Ratings (n = 16) Analyzed Therapist Ratings (n = 41) Analysis Allocation Follow-Up Terminated before week 13 (n = 26) Terminated before week 13 (n = 24) APPENDIX B SUCCESSFUL TREATMENT BOOKLET 34 What You Do Matters Parents play an important role in children's therapy for abuse and family violence. Your participation can contribute to better outcomes for your child. This booklet will help you learn: 1. Ten objectives that are important parts of successful therapy. 2. A way to solve problems so therapy accomplishes these 10 objectives. 3. A way to solve problems so you and you child regularly attend therapy. 35 Evidence-Based Mental Health Treatment Scientific studies show that children in evidence-based therapies have positive outcomes. Four evidence-based therapies are designed for child abuse and children seeing family violence. Trauma-Focused Cognitive Behavioral Therapy Abuse-Focused Cognitive Behavioral Therapy Parent-Child Interaction Therapy Child-Parent Psychotherapy Some of the positive outcomes from these four therapies include: • Increased social skills. • Increased positive parent-child interaction and communication. • Decreased negative emotions like shame, fear, depression, and aggression. • Decreased oppositional and defiant behavior. 36 10 Common Objectives Trauma-Focused Cognitive Behavioral Therapy, Abuse-Focused Cogni­tive Behavioral Therapy, Parent-Child Interaction Therapy, and Child­Parent Psychotherapy share 10 objectives. You can use the list in this booklet to help you talk with your child's therapist about these 10 important objectives. Therapy is likely to produce better results if you help ensure: 1. Everyone agrees on the goals and tasks of treatment. 2. I learn how to be more sensitive to the needs of my child. 3. My child and I learn ways to talk and listen to each other better. 4. My child and I learn ways to increase safety for my child. 37 1. I learn how to reinforce and praise my child. 2. My child and I learn to identify and challenge beliefs, perceptions, judgments, and expectations that can maintain physically abusive or aggressive behavior. 3. My family learns effective communication and problem­solving skills as part of our daily routines. 4. I am helped to develop plans to manage my child's behavioral problems. 5. My child and I are taught healthy ways to control anger or anxiety. 6. We discuss strategies to prevent relapse and plans for continued improvement are discussed at the end of therapy. 38 Talking with Your Child's Therapist about Objectives You can help ensure the best treatment for your child by talking with your child's therapist and saying what you want to happen in therapy. As the first step, choose one objective from the 10 objec­tives just presented that you think is important for therapy for your child, or list one of your own. Today, the objective that I would like to discuss with the therapist for my child is: __________________ _ 39 Problem Solving Objective: Talking with Your Child's Therapist Sometimes, it is difficult to talk about issues and what you want to hap­pen. Problem-solving is a skill that you can learn to overcome barriers and to use your strengths to solve problems. The objective that you just selected is important to you and your child. Problem-solving can help ensure your therapist includes important objectives as part of therapy. • First, what might make it difficult to talk to your child's therapist? • Next, list all the possible solutions you can identify from the most extreme ideas to moderate ones. Once you have listed them all, choose what you think is the best solution from all of the ideas generated. 40 Problem-Solving Example EXAMPLE PROBLEM: "Not knowing what to say I want as part of therapy for my child." SOLUTIONS: A. Extreme ideas: "My child's therapist will know what to do so I'll just agree when we work on important objectives." "Ask my child's therapist to tell me what I should want out of therapy, so I can agree or not. " B. Moderate ideas: "Write a letter or leave a phone message fOr my child's therapist. " "Make a list befOre the session to go over with my child's therapist. " C. Most Reachable ideas: "Use this booklet to talk with my child's therapist about the objectives that I want to achieve. " 41 Problem Solving Objective: Talking with Your Child's Therapist PROBLEM: -------------------------------- POSSIBLE SOLUTIONS: A. Extreme ideas: _________________________ _ B. Moderate ideas: __________________________ _ C. Most Reachable ideas: ______________________ _ 42 Problem-Solving Attendance: Talking with Your Child's Therapist Research has shown that in order to benefit from therapy, it is important to attend appointments regularly. Problem-solving is an effective way to find solutions to ensure you and your child attend therapy regularly without missing appointments. 43 44 Additional Barriers to Attendance Are there other problems or barriers that might interfere with regular attendance for you or you child? Please list them: 1. -------------------------------------------- 2. -------------------------------------------- 3. __________________________________________ __ 45 Problem-Solving Attendance Example PROBLEM: "j 'll just need to miss some appointments if j can't get off work." SOLUTIONS: A. Extreme ideas: "Quit my job!" "Stop coming to therapy because of the hassle." "Just don't go to that appointment. " B. Moderate ideas: "Call to cancel as soon as possible and ask to re­schedule." "Work longer hours one day to make time for therapy on the scheduled dav." "Ask about evening or weekend appointments. " C. Most Reachable ideas: "Talk to mv supervisor and arrange to leave early one day a week. " "Trade shifts with a colleague." "Dis­cuss the problem ahead of time with my child s therapist and ask for help exploring solutions. " 46 47 Future Problem-Solving Please use this page for problem-solving future situations to ensure the objectives you want in therapy are part of therapy and that you are able to attend therapy regularly. PROBLEM: POSSIBLE SOLUTIONS: A. Extreme ideas: B. Moderate ideas: ---------------------------------- C. Most Reachable ideas: 48 Future Problem-Solving Please use this page for problem-solving future situations to ensure the objectives you want in therapy are part of therapy and that you are able to attend therapy regularly. PROBLEM: __________________________________ _ POSSIBLE SOLUTIONS: A. Extreme ideas: B. Moderate ideas: ________________ _ C. Most Reachable ideas: ______________ _ 49 Better Outcomes Bring this booklet to each session. Reviewing it repeatedly can promote better outcomes for your child and help make sure that your needs and goals are met. APPENDIX C TRI-FOLD BROCHURE 51 QuickTime™ and a are needed to see this picture. 52 Building a Child's Se!f-Csteem Tips for parents - words that encourage and build a child's self-esteem: You did it You make me smile Fantastic You worked hard Please I'm impressed with you Thank you Tell me about it Good work You're a good listener Exactly right I like that You're marvelous Great idea I trust you You're important to me I understand You're a good friend Well done You're so smart Excellent And, don't joYzget these * A smile * Pat on the back * A big hug * A big kiss * A wink of the eye * Write a note * High five * Hand shakes For more information, contact Primary Children's Medical Center's Child Advocacy department, [phone]. APPENDIX D HISTORY AND FUNCTIONING QUESTIONNAIRE: FIRST SESSION 54 HISTORY AND FUNCTIONING QUESTIONNAIRE: First Appointment CASE #: CHILD: DATE OF BIRTH: TODAY'S DATE: NAME OF RATER: RELATIONSHIP (Circle one.) Mother Father Other THE LANGUAGE YOU AND THE CHILD USE MOST OFTEN: CHILD GENDER: MALE FEMALE BACKGROUND 1. Child's racial/ethnic background (check one): American-Indian/Alaska-Native Asian Black/African-American White/European-American Hispanic-Latino/a Multiracial Other Unknown Yes No Unknown 2. Is this child developmentally disabled or delayed? 3. Can you and this child communicate in English? 4. Are you or this child deaf? 5. Is this child currently receiving mental health treatment outside of this service? TRAUMA and EXPERIENCE Likely-No Possibly-No Unsure Possibly-Yes Likely-Yes 1. Do you believe that this child has been sexually abused? 2. Do you believe that this child has been physically abused? 3. Do you believe that this child has sexually abused or sexually victimized another child? 4. Do you believe that this child has physically assaulted or tried to physically harm another person? 5. Rate the number of times this child has observed another family member physically attacked or harmed? 0 1 2 3-5 6-10 11-20 More-Than-20 6. Check any other traumatic events you believe this child has likely experienced or "NONE": Neglect Exposure to toxic drugs/chemicals Loss/lack of primary caregiver Injury/illness/accident Community violence/war Significant verbal fighting Disaster/terrorism NONE Other (list): 7. Rate the number of times this child has been painfully slapped, spanked, or hit by anyone? 0 1 2 3-5 6-10 11-20 More-Than-20 55 CHILD MENTAL HEALTH AND FUNCTIONING (Skip to number 4 if the child is 2 years of age or younger.) 1. Check "Yes" or "No" if the issue is a current concern about the child: Yes No Yes No a. Talks about killing/hurting self or tries to kill/hurt self b. Alcohol abuse or illegal/misuse of drugs 2. Rate how often the behaviors have happened in the last week for the child: NEVER RARELY SOMETIMES OFTEN ALMOST-ALWAYS ALWAYS a. POSITIVE SOCIAL BEHAVIOR (like accepted responsibility for a problem, compromised, listened and was truthful): b. NEGATIVE SOCIAL BEHAVIOR (like blamed problems on others and was manipulative): 3. Estimate how often the child has done, felt, or experienced the following in the last week: NEVER RARELY SOMETIMES OFTEN ALMOST-ALWAYS ALWAYS a.HEALTHY EMOTIONS (like slept well and was calm with caregivers): b. PHYSICAL REACTIONS (like stomachaches), AND STRONG EMOTIONAL REACTIONS WHEN REMEMBERED OR WAS REMINDED OF A PAST EXPERIENCE, AND AVOIDED REMINDERS AND SITUATIONS RELATED TO A PAST EXPERIENCE: 4. Rate how often you had these thoughts, feelings, behaviors, or concerns in the last week: NEVER RARELY SOMETIMES OFTEN ALMOST-ALWAYS ALWAYS a. WAS SENSITIVE TO THE NEEDS OF THE CHILD, PROMOTED CHILD'S SAFETY INCLUDING CHILD BEING ASSERTIVE AND TALKING ABOUT PROBLEMS, AND EFFECTIVELY USED POSITIVE REINFORCEMENT WITH THE CHILD: b. WAS FRUSTRATED WITH THE CHILD, LACKED SKILLS TO MANAGE OR TALK WITH THE CHILD, AND EXPERIENCED PERSONAL DISTRESS (due to own personal trauma or feelings of depression): SHF HFQ 8-24-09 first appointment APPENDIX E WEEKLY PROGRESS REPORT 57 PROGRESS REPORT CHILD: DATE OF BIRTH: TODAY'S DATE: NAME OF RATER: RELATIONSHIP (Circle one.) Mother Father Other Therapist, please report the number of appointments that there have been for the child including today's appointment counting all appointments for the child including testing and those attended without the child: . SATISFACTION (Please rate.) Have you been satisfied with the most recent services? (Check one.) Definitely-No Probably-No Unsure Probably-Yes Definitely-Yes 1 2 3 4 5 CHILD MENTAL HEALTH AND FUNCTIONING (Skip to number 4 if the child is 2 years of age or younger.) 1. Check "Yes" or "No" if the issue is a current concern about the child: Yes No Yes No a. Talks about killing/hurting self or tries to kill/hurt self b. Alcohol abuse or illegal/misuse of drugs 2. Rate how often the behaviors have happened in the last week for the child: NEVER RARELY SOMETIMES OFTEN ALMOST-ALWAYS ALWAYS a. POSITIVE SOCIAL BEHAVIOR (like accepted responsibility for a problem, compromised, listened and was truthful): b. NEGATIVE SOCIAL BEHAVIOR (like blamed problems on others and was manipulative): 58 3. Estimate how often the child has done, felt, or experienced the following in the last week: NEVER RARELY SOMETIMES OFTEN ALMOST-ALWAYS ALWAYS a. HEALTHY EMOTIONS (like slept well and was calm with caregivers): b. PHYSICAL REACTIONS (like stomachaches), AND STRONG EMOTIONAL REACTIONS WHEN REMEMBERED OR WAS REMINDED OF A PAST EXPERIENCE, AND AVOIDED REMINDERS AND SITUATIONS RELATED TO A PAST EXPERIENCE: 4. Rate how often you had these thoughts, feelings, behaviors, or concerns in the last week: NEVER RARELY SOMETIMES OFTEN ALMOST-ALWAYS ALWAYS a. WAS SENSITIVE TO THE NEEDS OF THE CHILD, PROMOTED CHILD'S SAFETY INCLUDING CHILD BEING ASSERTIVE AND TALKING ABOUT PROBLEMS, AND EFFECTIVELY USED POSITIVE REINFORCEMENT WITH THE CHILD: c. WAS FRUSTRATED WITH THE CHILD, LACKED SKILLS TO MANAGE OR TALK WITH THE CHILD, AND EXPERIENCED PERSONAL DISTRESS (due to own personal trauma or feelings of depression): MEDICAL CHANGES 1. List any changes in medical conditions, allergies to food, medications or environment since the child's last visit: 2. List any changes to medications since the child's last visit: APPENDIX F THIRTEEN-WEEK OUTCOME RATINGS FOR PARENTS IN TREATMENT CONDITION 60 Parent Outcome Questionnaire Parent/Primary Caretaker's Name: Child's Name: Therapist: Date: Since your child began therapy approximately 13 weeks ago, please rate the following items. After you have completed the form, please place it in the attached envelop, seal it, and give it to your therapist. Since the beginning of therapy. Definitely No = 1 Probably No = 2 Unsure =3 Probably Yes = 4 Definitely Yes = 5 1. Has everyone agreed on the goals and tasks of treatment? 2. Have you learned skills to be more sensitive to the needs of your child? 3. Did you and your child learn ways to talk and listen to each other better? 4. Have you and your child learned ways to increase safety for your child? 5. Did you learn ways to reinforce and praise your child? 6. Have you and your child learned to identify and challenge beliefs, perceptions, judgments, and expectations that can maintain physically abusive or aggressive behavior. 7. Has your family learned effective communication and problem-solving skills as part of your daily routines? 8. Have you learned to develop plans to manage your child's behavioral problems? 9. Have you and your child been taught healthy ways to control anger or anxiety? 10. Have you learned strategies to prevent relapse and developed plans for continued improvement? 11. Has your child become less scared or sad and more happy? 12. Is your child more safe from harm? 13. Is your child better able to have friends, which includes not harming other children? 14. Is your child more likely to not 61 violate the privacy and/or private body parts of other people? 15. Did you become more competent? 16. Do you believe you have the skills to be assertive with your therapist to get what you and your child need from therapy? 17. Do you feel like you have strategies to help ensure that you are able to attend therapy regularly? At the beginning of therapy, you received a booklet describing the elements of therapy with problem-solving exercises. Please answer the following questions about the booklet titled Successful Treatment. Did the booklet problem solving exercises help you talk to your therapist? Yes No Did the problem-solving exercises in the booklet help you work effectively with your therapist? Yes No Did the booklet help you ensure that your child attended appointments on a regular basis? Yes No Did you bring the booklet to any of your sessions? Yes No Please estimate the number of appointments you missed or needed to cancel: _______ We would like to improve the quality of the booklet. If you have any suggestions on how we can improve it, please give us your suggestions. Feel free to use the back side of the form. Thank you for your participation. 62 APPENDIX G THIRTEEN-WEEK OUTCOME RATINGS FOR PARENTS IN CONTROL CONDITION 63 Parent Outcome Questionnaire Parent/Primary Caretaker's Name: Child's Name: Therapist: Date: Since your child began therapy approximately 13 weeks ago, please rate the following items. After you have completed the form, please place it in the attached envelope and seal it and give it to your therapist. Since the beginning of therapy: Definitely No = 1 Probably No = 2 Unsure =3 Probably Yes = 4 Definitely Yes = 5 1. Has everyone agreed on the goals and tasks of treatment? 2. Have you learned skills to be more sensitive to the needs of your child? 3. Did you and your child learn ways to talk and listen to each other better? 4. Have you and your child learned ways to increase safety for your child? 5. Did you learn ways to reinforce and praise your child? 6. Have you and your child learned to identify and challenge beliefs, perceptions, judgments, and expectations that can maintain physically abusive or aggressive behavior. 7. Has your family learned effective communication and problem-solving skills as part of your daily routines? 8. Have you learned to develop plans to manage your child's behavioral problems? 9. Have you and your child been taught healthy ways to control anger or anxiety? 10. Have you learned strategies to prevent relapse and developed plans for continued improvement? 11. Has your child become less scared or sad and more happy? 12. Is your child more safe from harm? 13. Is your child better able to have friends, which includes not harming other children? 14. Is your child more likely to not 64 violate the privacy and/or private body parts of other people? 15. Did you become more competent? 16. Do you believe you have the skills to be assertive with your therapist to get what you and your child need from therapy? 17. Do you feel like you have strategies to help ensure that you are able to attend therapy regularly? Please estimate the number of appointments you missed or needed to cancel: _______ APPENDIX H THIRTEEN-WEEK THERAPIST OUTCOME RATINGS 66 Therapist Outcome Questionnaire Research Study Parent/Primary Caretaker's Name: Child's Name: Therapist: Date: Please rate these items based on your judgment about this family over the course of therapy. . Definitely No = 1 Probably No = 2 Unsure =3 Probably Yes = 4 Definitely Yes = 5 1. Has everyone agreed on the goals and tasks of treatment? 2. Has the parent learned skills to be more sensitive to the needs of their child? 3. Have the parent and their child learned ways to talk and listen to each other better? 4. Have the parent and child learned ways to increase safety for the child? 5. Has the parent learned ways to reinforce and praise their child? 6. Have the parent and child learned to identify and challenge beliefs, perceptions, judgments, and expectations that can maintain physically abusive or aggressive behavior? 7. Has the family learned effective communication and problem-solving skills as part of their daily routines? 8. Has the parent learned to develop plans to manage their child's behavioral problems? 9. Have the parent and child been taught healthy ways to control anger or anxiety? 10. Has the parent learned strategies to prevent relapse and developed plans for continued improvement? 11. Has this child become less scared or sad and more happy? 12. Is this child more safe from harm? 13. Is this child better able to have friends which includes not harming other children? 14. Is this child more likely to not violate the privacy and/or private body parts of other people? 67 15. Did a parent or primary caretaker become more competent? 16. Do you think that the parent/caretaker has skills to be assertive with you to get what they and their child need from therapy? 17. Do you think that the parent/caretaker has strategies to help ensure that they are able to attend therapy regularly? Estimated number of session cancelations (less than 24 hrs.)________________ Estimated number of session no shows ___________________ ENDNOTES 1 Abuse Focused-Cognitive Behavioral Therapy (AF-CBT: Kolko, 1996), Parent Child Interaction Therapy (PCIT: Eyberg, 2009; Eyberg et al., 2001), and Trauma Focused-Cognitive Behavioral Therapy (TF-CBT: Cohen & Mannarino, 1998). 2 These endorsements were conveyed through personal communication with Kevin Gully. Information about AF-CBT was provided by D. Kolko (personal communication, May 2006); information about TF-CBT was provided by A. Mannarino (personal communication, May 2006); information about PCIT was provided by V. Funderburk (personal communication, July, 2005); and information about CPP was provided by P. Van Horn (personal communication, July 2005). 3 Therapists were not informed about the experimental conditions but they may not have remained blind. Parents were not discouraged from using the materials given to them and therefore may have exposed the therapists to the intervention booklet and control brochure. REFERENCES Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. [Print]. Psychological Review, 84(2), 191-215. Bandura, A. (1995). Exercise of personal and collective efficacy in changing societies. In A. Bandura (Ed.), Self-efficacy in changing societies (pp. 1-45). New York: Cambridge University Press. Bandura, A. (2004). Health Promotion by Social Cognitive Means. [Print Electronic; Print]. Health Education & Behavior, 31(2), 143-164. Banyard, V. L., Rozelle, D., & Englund, D. W. (2001). Parenting the traumatized child: Attending to the needs of nonoffending caregivers of traumatized children. Psychotherapy: Theory, Research, Practice, Training, 38(1), 74-87. doi: 10.1037/0033-3204.38.1.74 Barth, R. P., Scarborough, A., Lloyd, E. C., Losby, J., Casanueva, C., & Mann, T. (2008). Developmental Status and Early Intervention Service Needs of Maltreated Children (pp. 67). Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Chaffin, M., & Friedrich, B. (2004). Evidence-based treatments in child abuse and neglect. [Print Electronic; Print]. Children and Youth Services Review, 26(11), 1097-1113. Chang, E. C., D'Zurilla, T. J., & Sanna, L. J. (2004). Social problem solving: Theory, research, and training. Washington, DC: American Psychological Association. Child Welfare Information Gateway. (2008). Long-Term Consequences of Child Abuse and Neglect. Retrieved from http://www.childwelfare.gov/pubs/factsheets/long_term_consequences.cfm Children's Hospital-San Diego, Chadwick Center for Children and Families, & National Call to Action. (2004). Closing the quality chasm in child abuse treatment: Identifying and disseminating best practices. In E. M. K. Foundation (Ed.), (pp. 44). Kansas City, MO: Ewing Marion Kauffman Foundation. 70 Chorpita, B. F., Daleiden, E. L., & Weisz, J. R. (2005). Identifying and Selecting the Common Elements of Evidence Based Interventions: A Distillation and Matching Model. [Electronic Electronic; Print]. Mental Health Services Research, 7(1), 5- 20. Cohen, J. A., & Mannarino, A. P. (1998). Interventions for sexually abused children: Initial treatment outcome findings. [Print]. Child Maltreatment, 3(1), 17-26. D'Zurilla, T. J., & Nezu, A. M. (1999). Problem-solving therapy : a social competence approach to clinical intervention (2nd ed. ed.). New York, NY: Springer Pub. Eyberg, S. M. (2009). Parent-Child Interaction Therapy (PCIT) Retrieved March 6, 2009, from http://www.pcit.org/ Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T. L., McNeil, C. B., Querido, J. G., & Hood, K. K. (2001). Parent-child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. [Print Electronic; Print]. Child & Family Behavior Therapy, 23(4), 1-20. Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. [Print Electronic; Print]. Behavior Research Methods, 39(2), 175-191. Garcia, J. A., & Weisz, J. R. (2002). When youth mental health care stops: Therapeutic relationship problems and other reasons for ending youth outpatient treatment. [Print Electronic; Print]. Journal of Consulting and Clinical Psychology, 70(2), 439-443. Gully, K. J. (2003). Social Behavior Inventory: Professional manual. Salt Lake City, UT: PEAK Ascent, L.L.C. Gully, K. J. (2009). History and Functioning Questionnaire. (Available from Kevin J. Gully, Primary Children's Medical Center, Center for Safe and Healthy Families, 675 East 500 South, Suite 300, Salt Lake City, UT 84102). Gully, K. J., Price, B. L., & Johnson, M. K. (2008). Increasing abused children's access to evidence-based treatment: Diffusion via parents as consumers. Child Maltreatment, 13, 280-288. Harwood, M. D., & Eyberg, S. M. (2004). Therapist verbal behavior early in treatment: Relation to successful completion of parent-child interaction therapy. [Electronic Electronic; Print]. Journal of Clinical Child and Adolescent Psychology, 33(3), 601-612. 71 Holman, H. R., & Lorig, K. (1992). Perceived self-efficacy in self-management of chronic disease. In R. Schwarzer (Ed.), Self-efficacy: Thought control of action. (pp. 305-323). Washington, DC: Hemisphere Publishing Corp. Kahana, S., Drotar, D., & Frazier, T. (2008). Meta-Analysis of Psychological Interventions to Promote Adherence to Treatment in Pediatric Chronic Health Conditions. Journal of Pediatric Psychology, 33(6), 590-590. Kazdin, A. E. (2003). Problem-solving skills training and parent management training for conduct disorder. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 241-262). New York, NY: Guilford Press. Kazdin, A. E., Holland, L., & Crowley, M. (1997). Family experience of barriers to treatment and premature termination from child therapy. [Print]. Journal of Consulting and Clinical Psychology, 65(3), 453-463. Kazdin, A. E., Holland, L., Crowley, M., & Breton, S. (1997). Barriers to Treatment Participation Scale: Evaluation and validation in the context of child outpatient treatment. [Print]. Journal of Child Psychology and Psychiatry, 38(8), 1051-1062. Kazdin, A. E., Marciano, P. L., & Whitley, M. K. (2005). The Therapeutic Alliance in Cognitive-Behavioral Treatment of Children Referred for Oppositional, Aggressive, and Antisocial Behavior. [Electronic Electronic; Print]. Journal of Consulting and Clinical Psychology, 73(4), 726-730. Kazdin, A. E., & Mazurick, J. L. (1994). Dropping out of child psychotherapy: Distinguishing early and late dropouts over the course of treatment. [Print]. Journal of Consulting and Clinical Psychology, 62(5), 1069-1074. Kolko, D. (1996). Individual Cognitive Behavioral Treatment and Family Therapy for Physically Abused Children and their Offending Parents: A Comparison of Clinical Outcomes. Child Maltreatment, 4(1), 322-342. Kopiec, K., Finkelhor, D., & Wolak, J. (2004). Which juvenile crime victims get mental health treatment? [Print Electronic; Print]. Child Abuse & Neglect, 28(1), 45-59. Lai, K. Y. C., Chan, T. S. F., Pang, A. H. T., & Wong, C. K. (1997). Dropping out from child psychiatric treatment: Reasons and outcome. [Print]. International Journal of Social Psychiatry, 43(3), 223-229. MacNaughton, K. L., & Rodrigue, J. R. (2001). Predicting adherence to recommendations by parents of clinic-referred children. [Print Electronic; Print]. Journal of Consulting and Clinical Psychology, 69(2), 262-270. 72 Mason, P., Butler, C., & Rollnick, S. (2010). Health behavior change : a guide for practitioners (2nd ed.). Edinburgh ; New York: Churchill Livingstone/Elsevier. McKay, M. M., Pennington, J., Lynn, C. J., & McCadam, K. (2001). Understanding Urban Child Mental Health Service Use: Two Studies of Child, Family, and Environmental Correlates. Journal of Behavioral Health Services & Research, 28(4), 9p. Meichenbaum, D., & Turk, D. C. (1987). Facilitating treatment adherence: A practitioner's guidebook. New York, NY: Plenum Press. Milner, J. S. (1986). Child Abuse Potential Inventory (CAP). Lutz, FL: PAR, Inc. Nezu, C. M., Palmatier, A. D., & Nezu, A. M. (2004). Problem-Solving Therapy for Caregivers. In E. C. Chang, T. J. D'Zurilla & L. J. Sanna (Eds.), Social problem solving: Theory, research, and training. (pp. 223-238). Washington, DC: American Psychological Association. Nock, M. K., & Ferriter, C. (2005). Parent management of attendance and adherence in child and adolescent therapy: A conceptual and empirical review. [Electronic Electronic; Print]. Clinical Child and Family Psychology Review, 8(2), 149-166. Nock, M. K., & Kazdin, A. E. (2005). Randomized controlled trial of a brief intervention for increasing participation in parent management training. [Electronic Electronic; Print]. Journal of Consulting and Clinical Psychology, 73(5), 872-879. Pynoos, R. S., Rodriguez, Steinberg, A. M., Stuber, & Frederick. (2001). University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (UCLA-PTSD RI). Los Angeles, CA: National Center for Child Traumatic Stress. Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. [Print]. Psychological Monographs: General & Applied, 80(1)(1), 1-28. Rotter, J. B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. [Print]. Journal of Consulting and Clinical Psychology, 43(1), 56-67. Rotter, J. B. (1978). Generalized expectancies for problem solving and psychotherapy. [Print]. Cognitive Therapy and Research, 2(1), 1-10. Shuman, A. L., & Shapiro, J. P. (2002). The effects of preparing parents for child psychotherapy on accuracy of expectations and treatment attendance. [Print Electronic; Print]. Community Mental Health Journal, 38(1), 3-16. 73 The National Child Traumatic Stress Network. (2008). National Child Traumatic Stress Network Empirically Supported Treatments and Promising Practices Retrieved July 29, 2010, from http://www.nctsnet.org/nccts/nav.do?pid=ctr_top_trmnt_prom#q3 Urbaniak, G. C., & Plous, S. (2009). Research Randomizer, 2009, from http://www.randomizer.org/form.htm Wekerle, C., Miller, A. L., Wolfe, D. A., & Spindel, C. B. (2006). Childhood maltreatment. Ashland, OH: Hogrefe & Huber Publishers.