Research Paper 3 [Back to Resources Page]
"Group Intervention Program For
Oppositional, Noncompliant and Aggressive Preschoolers""
ABSTRACT
The READY program is an innovative group
treatment program designed for aggressive and non-compliant preschool aged
children. Building upon the work of Hembree-Kigin and McNeil, READY is a twelve
week program, with additional booster sessions two and four weeks after
completion of the weekly sessions. Treatment is intensive and targets
behavioural difficulties at several levels. The treatment comprises of (1) group
instruction of specialised behaviour management techniques for parents, (2)
social skills training and techniques to improve self-esteem for the children,
and (3) a supportive psychotherapy group for parents.
Professional Areas / Key Words: Clinical
Psychology, Preschoolers, Child & Family Health.
Please Note: A version of this article was published in Clinical
Psychologist, Summer 1999, Vol. 3 No. 2, p 30-34.
Introduction
| INTRODUCTION |
Behaviour problems account for 33-75% of child and adolescent referrals to mental health services (Wells and Forehand, 1985). Oppositional, aggressive, disruptive, antisocial and conduct disordered are all terms used in the literature to describe what are broadly known as externalising behaviours or conduct disorders. The prevalence of conduct problems in the child population varies depending on sample population, assessment methods and the severity of the behaviour, however is estimated to range from 2-16% (American Psychiatric Association, 1994).
Behavioural difficulties in childhood are associated with peer rejection (Coie and Koeppl, 1990) along with reading and academic difficulties (Campbell, 1990). In addition, children exhibiting oppositional and externalising type behaviours frequently possess poor social skills (Elliot, Barnard and Gresham, 1989; Vaughn, Hogan, Lancelotta and Shapiro, 1992). Longitudinally, behaviour problems in preschoolers have been found to be predictive of problems in adolescence (Lerner, Inui, Truipin and Douglas, 1985). Children displaying conduct problems are more likely in adulthood to become involved in crime, suffer poor physical health and develop drug and alcohol problems as well as developing antisocial personality disorder (see Kazdin, 1985; Kazdin, 1987a for a review). In addition, studies are now showing that conduct problems are transmitted across generations (Kazdin, 1987b).
Externalising problem behaviour which occurs in the preschool years has been shown to be stable throughout infancy and childhood (Campbell, Ewing, Breaux and Szumowski, 1986; Campbell and Ewing, 1990; Rose, Rose, Feldham, 1989), and is maintained in later childhood and adolescence (Egeland, Kalkoske, Gottesman and Erikson, 1990; Fischer, Rolf, Hasazi and Cummings, 1984). These findings suggest that behaviours which are predictive of later difficulties can be identified in early childhood. This offers researchers and clinicians some hope of being able to prevent the development of more serious behaviours by initiating interventions at the preschool level.
A number of studies utilising predominantly preschool aged samples have demonstrated that parent training is often an effective method of addressing behavioural disturbances (eg. Eyberg, Bogg and Algina, 1995; Webster-Stratton, Hollinsworth and Kolpacoff, 1989). However, there remains a proportion of parents who do not appear to benefit from parent training programs (Webster-Stratton, 1991). A number of factors have been implicated in poor treatment outcome. These include difficulty generalising behaviour management skills (Brody and Forehand, 1985); parental socioeconomic status (Dumas, 1986), as well as single parent status, low income and limited education (Webster-Stratton, 1985). Life stress, parental depression, and marital conflict have also been implicated (Webster-Stratton and Hammond, 1990). On average 28% of participants drop out of standard parent training programs (Forehand, Middlebrook, Rogers and Steffe, 1983).
Some parent training programs have developed treatment regimens to address the difficulties associated with poor treatment outcome. Griest, Forehand, Rogers, Breiner, Furey and Williams (1982) targeted mothers’ personal and marital adjustment in addition to teaching behavioural management techniques. To augment the generalisation of child management skills of parents in both stable families (Sanders and Christensen, 1985; Sanders and Dadds, 1982) and ‘multi-stressed parents’ (Dadds, Sanders and James, 1987) ‘planned activities’ have been developed. By offering such additions, it is hoped that parent training programs will be made more effective, aiding more families, and preventing premature drop-out. Despite moderate successes investigations of the efficacy of programs often suffer from limited sample size. These programs have continued to focus on parent training techniques with additional adult components, however, they miss the additional opportunities available by providing direct intervention with the children.
| THE READY PROGRAM |
The READY program aims to augment the effectiveness of an already established treatment for behaviourally disturbed preschool-aged children (Parent-Child Interaction Therapy - described in detail by Hembree-Kigin and McNeil, 1995).
The ‘Redbank Early intervention program for Aggressive and oppositional Difficulties in Young children’ (READY) utilises a variety of treatment modalities to target oppositional, aggressive and noncompliant behaviour on a variety of fronts. Treatment modalities include:
(1) Specialised behaviour management techniques.
(2) Child-directed play skills for parents
(3) Group format and peer support for both parents and children to aid in the acquisition of (relationship) skills.
(4) Preschool social skills training and preschool skills group
(5) Visit to public settings to aid generalisation.
(6) Adult supportive psychotherapy group for parents.
The program is designed to include follow-up of clients at three month, six month and twelve months post treatment; and then again at primary school entry, late primary and high school entry.
| THE SETTING/STAFFING |
Redbank House, Department of Child, Adolescent and Family Psychiatry, Westmead Hospital, Sydney provides a tertiary service for Western Sydney and the Blue Mountains. The Early Childhood Unit (ECU) is a specialised Unit that services under five year old children and their families. The READY program was designed for 2 - 4 year old oppositional children and runs as a one day per week program (10am - 2.15 p.m.) for twelve weeks. It has the following staff: 3 Clinical Psychologists, 1 Occupational Therapist/Psychologist, 2 Registered Nurses, 2 Clinical Psychology Students and 2 Volunteers (Preschool teachers or Psychology interns). In total the program requires 12 staff hours per week (below follows the break-up of these).
| PROGRAM OUTLINE |
The program consists of two streams - the parent and child stream:
| 1. PARENT STREAM |
The parent stream consists of one two hour training session and one 1.5 hour therapy group:
I. Parent Training Group:
This part of the treatment program was based on the work of Dr. Sheila Eyberg, which was then standardised by Hembree-Kigin and McNeil (1995). Their program became known as Parent-Child Interaction Therapy (PCIT). PCIT, normally designed as an individual treatment program, has been adapted for the first time to be used in a group context for the READY program. The PCIT program has two main parts. The first, Child Directed Interaction, aims to teach parents the play skills of differential attention, following the child's lead, describing play, reflecting back the child's verbalisations, selective attention, ignoring and praising appropriate behaviours. These skills are considered essential, to promote a warm responsive relationship between parent and child.
‘Child Directed Interaction’ provides the relationship basis necessary for the successful implementation of the discipline part of the program, that is Parent Directed Interaction. This teaches parents how to give clear instructions to their child and provide consistent consequences for oppositional behaviour. The treatment involves direct coaching by one clinician with each parent and their preschooler. An innovative additional component introduced by the team, is that the remaining parents watch the training from behind a one-way screen with a second clinician. The observing group are encouraged to discuss their observations in order to promote learning of the treatment strategies and to foster group member support and encouragement. An educational session is provided at the beginning of each week when the previous weeks homework is also reviewed. After practising new skills, discussion of the necessary homework at the conclusion of the group follows (2 clinical psychologists). Handouts summarising skills learned and homework are also given out.
The third stage focuses on generalising the specific skills learned at the centre, to problems in the home and outdoor activities. Therapist assisted excursions into shopping malls and other public areas conclude the weekly attendance (one staff member per family, 1 bus and driver).
II. Parent Psychotherapy Group:
This group focused on facilitating the parents’ in telling their own story. Parents were supported in sharing their life story highlighting common and unique themes of loss and rejection, failure and success and difficulties in forming close relationships. The objective of the group was to facilitate a more coherent telling of one’s own story. Diaries and collages were used as part of the treatment, with parents working on three major themes: their current experience as a parent, their experience as a child with their parents and how they would like things to be in the future between themselves and their child (also when s/he has grown up). Through this process parents were encouraged to be more autonomous and therefore able to transcend their past experiences (1 psychiatrist & 1 other staff member).
| 2. PRESCHOOLERS STREAM |
This stream aims to encourage preschool and social skills in two to four year old children (four groups per day were run). It provided children with the opportunity to participate in a structured preschool type program, and hence develop the skills necessary for them to be accepted into mainstream preschools. Often the children had been expelled from numerous preschools and the aim of the program was to get them back into a preschool environment so that parents could return to work.
Each child was supported and encouraged in separating from their parent, remaining in the group, joining in activities, playing constructively and safely with toys and making the transition between activities as requested. The program included indoor constructive activities, craft time, pretend play and outdoor play activities. During the activities, staff actively described and praised each child’s play, thus paralleling the skills which the parents were learning through the child-directed play component of the Parent training group.
The social skills component of the program fostered developmentally appropriate prosocial skills through play and group activities using contingency-based positive reinforcement, modelling and behavioural rehearsal. Each session focused on the development of a particular social skill including listening, talking in a friendly way, asking for help, sharing and taking turns (2 clinical psychologists/or clinicians & 2 volunteers per group).
| ASSESSMENT/OUTCOME MEASURES |
The following baseline/follow-up questionnaires were used: Barkley’s Semi-structured Parent Interview (Barkley, 1991), Achenbach Child Behaviour Checklist - Parent and Teacher Form (Achenbach, 1992, 1991 a&b), Parenting Stress Index (Abidin, 1995), Beck Depression Inventory (Beck & Steer, 1993) for the primary caregivers, Barkley’s ODD Symptom Checklist (1991), and the ADHD rating scale (DuPaul, 1990), as well as the Home Situations Questionnaire - Modified (Matthey, 1996). Preliminary data for families who participated in the first three programs will hopefully be published soon.
| COMMENTS & DISCUSSION |
Preliminary data analysis of the first program shows consistently that extreme levels of stress (in the vicinity of the 99th percentile) attributed to the difficulties in raising a child (child domain on PSI) were reported by parents over all assessment periods. This is in contrast with decreases in stress associated with parent factors for some parents. This suggests that children were still viewed by parents as being particularly difficult yet parents appeared more confident in managing them. There appeared to be a decrease in the number of settings child behaviour was perceived to be a difficulty (measured by the percentages of problem settings from the HSQ-M) from baseline to post-treatment.
Qualitative reports by parents stated that the program had helped them and that their children’s behavioural difficulties had improved. Staff ratings for improvement were not supported by the formal measures used, even though considerable improvements were noted. In terms of the above design, improvements could be made. The use of objective and independent measures is essential to determine whether parent reports are a true reflection of change (or lack thereof).
The families in the program were characterised by extreme levels of stress (financial, pregnancy, depression) with children with severe behaviour difficulties (Redbank being a tertiary referral service). By three months follow-up many of these families had been through so many other life crises, that it was hard to measure what the benefits of the program may be.
The subject of a more formal study is the generalisation of treatment (Contact: Reg Nixon). Observer video ratings will be employed and will hopefully be able to shed more light on the real outcomes, i.e. compliance may have increased but the parents remain negatively biased towards the child.
It also needs to be noted that 50% of the families continued to receive individual treatment after the program finished. The work, however, had shifted from a purely behavioural management type focus to mending the parent-child relationship. The group program assures the clinician that the parent has the parenting skills to manage the child so that the latter work can begin. All children were able to be re-integrated into a preschool environment.
| AUTHORS & ACKNOWLEDGEMENTS |
VERA AUERBACH, Clinical Psychologist Private Practice & Honorary Fellow, Department Psychology, Wollongong University
REG NIXON, Department of Psychology, Sydney University
KAREN FORREST, REDBANK HOUSE, Westmead Hospital
SHYLAJA GOOLEY, REDBANK HOUSE
GUNDULA GEMKE, UNIVERSITY OF DRESDEN, GERMANY
CONTACT NAME FOR CORRESPONDENCE: Vera Auerbach
ACKNOWLEDGEMENT: The authors would like to acknowledge the work of the following individuals in developing and running the program: DR. JOHN BRENNAN, SHARRON PEARCE, JENNY KNEIB, KATHY SZIGMUND, LISA LUSTICA, the teachers of Redbank School for Specific Purposes and CAROLINE MCSHERRY.
| REFERENCES |
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