increases in parent attendance to behavioral parent training due to concurrent child treatment...

ORI GIN AL PA PER

Increases in Parent Attendance to Behavioral ParentTraining Due to Concurrent Child Treatment Groups

Scott A. Jensen • Lisa K. Grimes

Published online: 7 April 2010� Springer Science+Business Media, LLC 2010

Abstract Though behavioral parent training has been demonstrated to be an effective

intervention for child behavior problems, it continues to suffer from high attrition rates.

Few variables have been found to predict or decrease high attrition rates from parent

training classes. The present study found 43–52% increases in attendance rates for parents

whose children were concurrently enrolled in child treatment groups (social skills training

or homework skills training) in comparison to parents of children who received childcare

only. Similar increases in homework completion were also found for these groups. Possible

reasons for these increased attendance rates as well as implications for clinical practice and

future research are discussed.

Keywords Parent training � Attrition � Engagement � Child intervention

Introduction

Behavioral parent training (BPT) has been demonstrated to be one of the most effective

interventions for a variety of child behavior problems including Attention Deficit Hyper-

activity Disorder (ADHD; Anastopoulos et al. 1993), antisocial behavior (Serketich and

Dumas 1996), and conduct problems (Eyberg et al. 2008; Reid et al. 2004). In addition to

child symptom reduction, Baydar et al. (2003) found that parent-training programs also

produce significant changes in parenting behavior among parent populations with multiple

mental health risk factors (i.e. anger, depression, history of abuse as a child). Of the

identified Empirically Based Treatments for ADHD and other Disruptive Behavior Dis-

orders, most treatments at least include a BPT component, with many of the programs

having BPT as the main intervention strategy (Eyberg et al. 2008; Pelham and Fabiano

S. A. Jensen (&) � L. K. GrimesDepartment of Psychology, University of the Pacific, 3601 Pacific Ave., Stockton, CA 95211, USAe-mail: [email protected]

Present Address:L. K. GrimesDepartment of Psychology, Bowling Green University, Bowling Green, OH, USA

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Child Youth Care Forum (2010) 39:239–251DOI 10.1007/s10566-010-9101-y

2008). BPT emphasizes the parent’s role in both the development of child behavior and the

maintenance of that behavior (Serketich and Dumas 1996). A typical BPT program as

described by Chronis et al. (2004), includes specific behavior modification techniques

based on social learning principles including praise, positive attention, tangible rewards,

ignoring, timeout and other nonphysical discipline techniques (p. 1).

There is growing consensus that while BPT programs are effective for those who

complete the programs, perhaps the greatest current issue impacting the effectiveness of

BPT is lack of engagement and high rates of attrition. Several recent reviews have

examined the issue of attrition and engagement in child treatment programs, seeking to

highlight the importance of the issue and laying the groundwork for additional research

(Assemany and McIntosh 2002; Nock and Ferriter 2005; Staudt 2007) This problem is

certainly not specific to BPT programs alone, but is generally true of child treatment

interventions with studies finding that only one third of families in need of services actually

receive them (Leaf et al. 1996). Still, only half of those families actually complete treat-

ment (Armbruster and Kazdin 1994; Harpaz-Rotem et al. 2004; Kazdin and Mazurick

1994). Attrition from treatment interventions not only limits exposure to the interventions

thus decreasing their overall impact, but has also been associated with lower levels of

engagement in treatment prior to early termination (Dumas et al. 2007). It is also important

to note as did Prinz et al. (2001) that large rates of attrition from treatment programs under

investigation can result in non-representative samples and reduce statistical power, thus

making treatment effects more difficult to detect.

Given the empirical support for BPT as a broad intervention strategy, it is imperative

that possible predictors of and strategies for limiting attrition within this treatment context

be explored. Several methods of reducing attrition among intervention programs have been

researched with a few yielding positive results. Researchers have attempted to shorten the

delivery time to increase attendance and decrease attrition. While it is easier for a family to

attend a one- or two-session intervention (Lim et al. 2005), exposure to intervention is

minimal and behavioral support non-existent, reducing both the quality of outcome and the

family’s ability to maintain outcome levels over time. Other programs have attempted to

provide monetary incentives for participation with limited success (Snow et al. 2002).

Some successful attempts at increasing overall attendance include the use of a brief

motivational enhancement intervention that was used by Nock and Kazdin (2007) to

increase parent participation and attendance. Similarly, Chacko et al. (2009) found that an

adjunctive program that included early discussion of motivation and expectations as well

as several other small additions led to significant increases in attendance amongst single

mothers.

Some evidence suggests that programs providing childcare or child treatment may

decrease attrition. Watterson (2001) found that parents rated the provision of childcare as

second only to topics covered in intervention as the basis for their decision to attend.

Research has also shown that parents are more likely to attend parent training when they

believe that their child’s behavior is adversely affecting them as parents and if they believe

there is a potential for the child to change (Rooke et al. 2004). As part of their analysis of

variables that predict engagement in parent training, Miller and Prinz (2003) found that

parents attended a higher percentage of classes when their child was engaged in a child

treatment course as opposed to when parents received treatment alone. In their study, they

had the highest drop-out in the parent-only sessions and the least drop-out in the child-only

sessions. They suggested that often a parent who is seeking treatment for their child finds a

disconnect when the treatment seems to focus only on the parents.

240 Child Youth Care Forum (2010) 39:239–251

123

In a more recent study, Fabiano et al. (2009) explored the impact on engagement of a

BPT program designed specifically to better engage fathers by having them coach their

child in a soccer game as part of the intervention (COACHES program). In comparison to a

traditional BPT program, they found that fathers in the COACHES program attended more

sessions, arrived on time more frequently, completed more homework, and that their

children also attended more sessions. These findings lend support to the idea that when

children are actively involved in treatment, parents are more likely to attend and more fully

engage in the BPT process.

The purpose of this study was to examine parents’ treatment engagement (attendance,

homework completion and participation) based on whether or not their child was receiving

an active treatment versus the childcare control. Based on Miller and Prinz (2003) and

Fabiano et al.’s (2009) findings that parents were more likely to attend child-focused/child-

involved sessions, we hypothesized that parents would be more likely to attend sessions

during the time their child was receiving active treatment in comparison to when their child

was receiving child-care only.

Method

Participants

While studies examining BPT groups usually focus on child behavior, the present study

focuses on parent engagement (attendance, homework completion, and participation) in

connection with their child’s placement in a treatment group versus child care, and thus

parents are considered the main participants in the study. Participant included 82 parents

(59 families) that were consecutive referrals to a behavioral parent-training program using

a slight modification (10 weeks) of the Incredible Years Parents and Child Basic Program

(Webster-Stratton 1990). The sample was fairly diverse, mirroring well the population

characteristics of the community. Parents had a mean of 1.98 children. The incomes of the

families varied significantly with approximately half of the families having a median

yearly income over $50,000/year. Demographic information for the sample is available in

Table 1.

A total of 114 children (all children ages 2–12 from each family participated in the

groups not just one identified child) participated in the children’s groups and child-care.

Thirty-nine percent of the children had been previously diagnosed with a mental disorder,

most of those being diagnosed with ADHD. Approximately 53% of families had previously

sought treatment for their children. The mean total difficulties score on the SDQ was 14.6.

In comparison to Goodman’s (2001) norms, 86% of children in this sample scored above

the mean, with 43% scoring one or more standard deviations above the mean, and 25%

scoring two or more standard deviations above the mean. While this sample is not as severe

as some used in parent training research, it should be noted that the sample includes all

children in the family and not just the identified difficult child. For the identified children,

95% scored above the norm group mean, 81% scored one standard deviation above the

mean, and 39% scored two or more standard deviations above the norm group mean. This

sample is considered to mirror the attributes of a common sample in clinical practice given

that all of the families were self-referred to the clinic.

Child Youth Care Forum (2010) 39:239–251 241

123

Tab

le1

Dem

og

rap

hic

info

rmat

ion

by

gro

up

To

tal

Ch

ild

care

on

lyF

irst

-hal

fco

ncu

rren

tS

eco

nd

-hal

fco

ncu

rren

tF

ull

con

curr

ent

Ch

isq

uar

ed/F

n(P

aren

ts)

82

18

71

54

2

Par

ent

eth

nic

ity

His

pan

ic(%

)4

2.6

31

.04

2.9

42

.94

7.3

v2=

9.5

2,

p=

.39

Wh

ite

(%)

42

.63

7.5

28

.65

0.0

44

.7

Asi

an/p

acifi

cis

lander

(%)

10.7

18.8

14.3

7.1

7.9

Afr

ican

–A

mer

ican

(%)

4.0

12

.51

4.3

00

Mar

ried

/par

tner

(%)

86.7

57.1

71.4

82.1

78.7

v2=

7.0

4,

p=

.32

Att

end

ing

join

tly*

(%)

56

.17

7.8

%0

53

.35

7.7

v2=

12

.45

,p\

.01

Par

ent

educa

tion

Co

lleg

eg

rad

uat

e(%

)3

4.7

37

.52

8.6

30

.83

5.9

v2=

1.8

4,

p=

.93

So

me

coll

ege

(%)

50

.75

6.3

57

.14

6.2

48

.7

Mea

nn

um

ber

chil

dre

n1

.98

(.9

8)

2.0

9(.

70

)2

.14

(1.2

2)

1.5

5(.

93

)2

.07

(1.0

3)

F=

.90

,p

=.4

5

Mea

nag

eo

fch

ild

6.8

7(3

.71

)5

.64

(2.6

2)

7.1

2(2

.06

)7

.18

(3.4

)7

.16

(4.4

7)

F=

4.9

,p

=.6

9

Mea

nS

DQ

tota

ld

iff.

sco

re1

4.5

7(7

.10

)1

3.8

0(6

.61

)1

4.2

2(7

.09

)1

5.0

0(5

.71

)1

4.7

4(7

.57

)F

=.1

1,

p=

.95

SD

QS

tren

gth

san

dD

iffi

cult

ies

Ques

tionnai

re

*p\

.01


123

Procedure

All procedures were approved by the local IRB prior to the beginning of the study. The

program used for the present study was presented to the community as a parent and child

intervention program for children with behavior problems. All families were self-referred

and indicated at the time of first contact that they were struggling with one or more of their

children’s behavior. Marketing was conducted through several methods including flyers

sent home through elementary schools and placed in pediatrician’s offices. The 10-week

course cost $150 per family, with that fee being reduced as needed based on income.

Approximately 70% of families paid the full $150, with most others paying $50 or less.

The 10-week parent training courses were co-conducted by sets of two graduate level

students and were supervised by one of the authors. The supervisor regularly observed

group meetings and met weekly with group leaders to discuss treatment integrity, feedback

from previous sessions, and regular training. The program followed the Incredible Years

Parent and Child Program format (viewing of video vignettes and follow-up discussion of

topics addressed in those vignettes) with a slight alteration in the number of weeks (same

content covered in 10 weeks instead of 12). Based on video and in vivo observations, the

manualized treatment was appropriately followed through all sessions.

Child treatment groups included two different interventions:

Social Skills Group (ages 2–6 Kindergarten)—Social Skills Group interventions were

organized by weekly topics, including listening and following directions, feelings, man-

ners, sharing, joining in play, etc. Activities during the group included craft-time, story-

time, singing-time, and free-play time with the stories and crafts relating to the topic for the

day. The groups also used a behavioral reward system in which children were rewarded for

positive behaviors.

Homework Skills Group (ages First Grade-12 year old)—Homework Skills Group

interventions were also organized by weekly topics including establishing a homework

routine, goal setting, time management, learning styles, etc. Group time included reviewing

of material from packets provided for the group, including several worksheets, free-play,

and active play focused on following directions and the skills taught during the session. A

behavioral reward system was also used for the homework skills groups. Trained under-

graduate students led both groups.

Over the course of the study, these interventions were provided in both 5- and 10-week

formats. The 5-week interventions were originally designed to compare the impact of

concurrent child treatment on behavioral outcomes as well as parent engagement. How-

ever, as noted later, due to the significant negative impact of the first-half concurrent

treatment groups on attendance, they were discontinued, making a statistical analysis of

impact of child concurrent treatment on behavioral outcomes in this study impossible. For

the 5-week interventions, children were randomly assigned to receive the treatment either

during weeks 1–5, or weeks 6–10 of the parenting intervention. Random assignment for

these groups was made by family such that all children from the same family were assigned

to receive treatment at the same time. While this led to greater disparity in participants in

each group, it was determined to be in the best interest of each family for all children to

receive treatment at the same time. When not receiving active treatment, children were

placed in traditional childcare (either weeks 1–5 or weeks 6–10 depending on active

treatment assignment). For the 10-week interventions, random assignment was done by

class, with each class being assigned to have concurrent child treatment or traditional child

care control. Those assigned to the childcare control group were later given access to the

child treatment programs.


123

This use of 5- and 10-week interventions as well as traditional childcare control created

four natural groups useful in comparing the impact of concurrent child treatment groups on

overall engagement: (1) Childcare Control (no concurrent child treatment provided;

n = 18), (2) First-Half Concurrent Child Treatment (active child treatment provided weeks

1–5; n = 7), (3) Second-Half Concurrent Child Treatment (active child treatment provided

weeks 6–10; n = 15), and (4) Full Concurrent Child Treatment (active child treatment

provided weeks 1–10; n = 42). Several concerns with the impact of the First-Half Con-

current Treatment group including the almost universal dropout (six of seven families

dropped out after the first 5 weeks, but before the end of the class), the group was dis-

continued. While this was the right decision clinically for the benefit of the program, it

creates issues with the methodology as will be discussed in the limitations.

Weekly attendance was tracked for all participants. Weekly homework assignments

were made from weeks 1 to 9 and the parent training instructors tracked homework

completion. On a weekly progress note, instructors also tracked level of participation for

each individual based on a 5 point likert-type scale ranging from 1 = minimal partici-

pation to 5 = full participation.

Results

Attendance was tracked for all participants across the 10-week course. Similar to previous

research (Armbruster and Kazdin 1994; Harpaz-Rotem et al. 2004; Kazdin and Mazurick

1994), attrition was high, with only 44% of participants attending at least eight of the ten

sessions. The average participant attended 6.35 of the ten sessions provided. Timing of

drop-outs was evenly distributed across all sessions with approximately 4–7% of partici-

pants dropping out each week and 51% attending through week 10.

Couples attending the course together, in comparison to individuals attending alone

(whether actually married, partnered or single) differed significantly in their distribution

across groups (v2 = 12.45, p \ .01). Couples attending together were over-represented in

the Child-Care Control group (78% of control compared to 56% of sample), underrepre-

sented in the First-Half group (no parents were couples attending jointly), and evenly

distributed across both the Second-Half and Full treatment groups. Though differences in

attendance rates between couples attending together (n = 46; M = 6.78, SD = 2.65) and

individuals attending alone (n = 36, M = 5.81, SD = 2.96), did not reach significance

(F(1,80) = 2.48, p = .12, eta2 = .03), it was decided to use Couples Attendance Status as

a covariate for the group analysis, due to the theoretical likelihood that those attending as a

couple would differ in their attendance habits than those attending alone.

Results for the ANCOVA found that the covariate Couple Attendance Status approa-

ched, but did not reach significance F(1,77) = 3.56, p = .06, eta2 = .04). A significant

main effect was found for child treatment group, F(3,77) = 3.09, p \ .05, eta2 = .11.

Planned comparisons using Tukey’s LSD demonstrated that parents in both the Second-

Half (Madj = 7.23, SE = .69) and Full treatment (Madj = 6.80, SE = .41) groups attended

significantly more sessions than those in the control group (Madj = 4.74, SE = .65) at the

.01 level (see Fig. 1). The First-Half (Madj = 5.97, SE = 1.08) group did not differ sig-

nificantly from any of the other three groups, and the Second-Half and Full treatment

groups did not differ significantly from each other. The less conservative Tukey’s LSD was

used due to the loss of power that would result from more conservative corrections due to

the small n in the First-Half group (n = 7). Similar trends were found for completion of the

full 10-week course, with 62% of those in the Full Concurrent Group attending through the


123

final week of class, 53% (Second-Half Concurrent Group), 39% (Child Care Only), and

14% (First-Half Concurrent Group) of the other groups attending through the final week of

class. A figure depicting the survival rate by group can be found in Fig. 2.

Of special note was the attendance pattern of the seven families enrolled in the First-

Half Treatment Group. During the first five sessions, while their children were attending

the concurrent child treatment, families attended 80% of the sessions. Following termi-

nation of the concurrent child groups and placement in child care, families attended only

26% of the classes, with most of these represented by the one family that attend all

sessions. While the overall attendance rates did not differ statistically from those of the

Second-Half Concurrent or the Full Concurrent treatment groups (probably due to the low

n), the data suggested that the First-Half Concurrent group actually increased the likelihood

that parents would terminate and thus it was discontinued.

Overall homework completion was low, with the average person completing 1.75

homework assignments. Thirty-nine percent of the participants never completed a home-

work assignment (many because they did not return after the first session), and the average

completion rate for the other 61% was 2.87. To control for greater completion of

4.735 5.972 7.234 6.797

0

2

4

6

8

10

Sess

ions

atte

nded

Second-Half Concurrenta

Full Concurrentb

Child-Care Onlya & b

First-Half Concurrent

Group

Fig. 1 Adjusted Attendance Means by Child Treatment Group. a Child-care only and second-halfconcurrent groups differ significantly at the p \ .01 level. b Child-care only and full concurrent groupsdiffer significantly at the p \ .01 level. Note: means adjusted to account for impact of couple attendancestatus (attending alone vs. attending as a couple). Total sessions possible = 10

Fig. 2 Survival Patterns by Group


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homework by those who attend more sessions, average homework completion (homework

completed/weeks attended) was used for the analysis (thus average scores range from

0 = never completed a homework assignment to 1 = completed all homework assign-

ments). A significant effect was found for the covariate Couple Attendance Status

(F(1,54) = 4.38, p \ .05, eta2 = .08) with couples attending jointly completing more

assignments. A significant main effect was also found for child treatment group

(F(3,54) = 3.57, p \ .05, eta2 = .17). Planned comparisons using Tukey’s LSD demon-

strated that parents of children in all three treatment groups completed significantly more

homework assignments than parents in the Childcare Control group at the .05 level (First-

Half Madj = .31, SE = .09; Second-Half Madj = .30, SE = .07; Full treatment Madj = .28,

SE = .04; and Childcare Control Madj = .02, SE = .07). None of the treatment groups

differed significantly from each other.

In regards to ratings of participation, significant differences were also found, though the

interpretation of these differences is unclear. Couple Attendance Status again approached,

but did not reach significance as a covariate (F(1,50) = 3.38, p = .07, eta2 = .06). A

significant main effect was found for child treatment group (F(3,50) = 5.04, p \ .01,

eta2 = .23). Planned comparisons using Tukey’s LSD demonstrated that the First-Half

treatment group (Madj = 3.35, SE = .25) participated significantly less than both the

Childcare Control (Madj = 4.66, SE = .26) and the Full (Madj = 4.31, SE = .18) treat-

ment groups at the .01 level. It approached but did not reach significance in comparison to

the Second-Half treatment group (Madj = 4.20, SE = .35) with a p value of .051. This

difference seems driven by one participant in the First-Half group that was rated as par-

ticipating minimally across multiple sessions. While participants in other groups were rated

similarly, the impact within such a small group on the overall mean was greater. The

Childcare Control and Full treatment groups did not differ significantly from each other or

from the Second-Half treatment group.

Discussion

The current study corroborated previous findings (Fabiano et al. 2009; Miller and Prinz

2003) and further emphasizes the impact of concurrent child treatment on parent

engagement in BPT programs. Parents attended more sessions when their children were

receiving concurrent child treatment in comparison to childcare only. Benefits in home-

work completion were also found in connection with the provision of concurrent child

treatment groups, with parents demonstrating greater engagement in the program by

completing more homework assignments when their child was in a treatment group.

The parents of children in the Full Concurrent and Second-Half Concurrent groups

attended between 43 and 52% more classes over the 10-week period in comparison to

those parents whose children were receiving childcare only. This increased level of

attendance is especially striking in that the comparison group received childcare. Given

that previous research suggests that the availability of childcare is an important factor in

parent attendance, it is likely that a comparison of attrition rates between concurrent child

treatment groups and no childcare provided would be even greater than the results

presented here.

Providing concurrent child treatment during only the second-half of the parent training

program appeared to be just as effective at increasing parent attendance as was the full

concurrent treatment, with parents in the second-half group attending an average of 7.23

sessions, while those in the full concurrent group attended an average of 6.80 sessions. In


123

contrast, parents of children in the first half treatment group attended an average of only

5.97 classes, with a large percentage (71%) discontinuing attendance fairly quickly after

the child treatment groups ended. The fact that the average attendance was still high

demonstrates that parents of children in the first-half treatment groups attended a high

percentage of the first five sessions—during concurrent treatment (80%). The differences

in attendance over the course of the 10 week training between the First-Half and Second-

Half Concurrent treatment groups show that while parents were willing to stay engaged in

the classes while waiting for their children to receiving the concurrent child treatment,

there were no carry-over effects, with most parents dropping out once their child’s treat-

ment was completed. Providing any type of concurrent child services that terminate prior

to parent services seems unwise.

A similar beneficial impact on homework completion from the concurrent treatment

groups was also noted, suggesting that having a child in concurrent treatment helps the

parents to engage more fully in their own training process as well. While parents whose

children received concurrent treatment only completed approximately one-third of their

homework assignments, this was still 14–15 times more than parents whose children were

in childcare only, who completed almost no homework. Fabiano et al. (2009) found similar

low overall homework completion rates, but similar differences between groups that

included children versus those that did not. The lower participation ratings for the First-

Half Concurrent group, as noted were likely driven by one participant, which given the

small n, had a greater impact on the overall mean. Overall, participation ratings were high

and do not appear to have been strongly impacted by child group assignment. More robust

methods of measuring participation should be used in future studies.

Limitations

The present findings are limited by the use of a single parent training/child treatment

curriculum as well as the relatively small sample size. The discontinuation of the First-Half

Concurrent groups was especially problematic in the current study. The decision to dis-

continue the groups, however, was based on the very issues being addressed in the study—

that the First-Half Concurrent groups led to an increase in overall attrition. While it is

possible that the higher rate of dropout was due to variables more present in the group

despite the random assignment, it was determined that the risk to the families of not

receiving services was too great to continue this approach.

An important variable not addressed in the current study is the improvement in child

and parent variables that may result from increased attendance due to the concurrent child

treatment programs. Because follow-up data was not obtained from those who dropped out

of the program, comparisons between those completing and not completing the program

could not be made. Future analyses of the added benefit of concurrent child groups on

outcomes would be beneficial. It is unclear from the present data the specific cause(s) of

the increased attendance in the concurrent child treatment groups. Future research as

discussed below should explore this issue. Of particular importance are whether or not the

child treatment groups provide actual benefit (in terms of improvement on child variables)

when compared to child treatment controls, and whether that benefit exceeds what would

be accounted for by the increased attendance among the parents alone. It is quite possible

that the greatest benefit from child treatment groups may be due to the increase in

attendance rather than improvement from the treatment curriculum.


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Implications/Directions for Future Research

As noted a key direction for future research on the increases in parent engagement that

result from concurrent child treatment is to explore the specific causes these increases.

Several hypotheses hold merit and should be further explored. Three are discussed here: (1)

Parents’ motivation to get treatment for their child makes them more likely to attend, (2)

Children enjoy the groups and encourage their parents to attend, and (3) Concurrent child

treatment leads to faster/greater improvement in child behavior, thus reinforcing

attendance.

Parents who perceive their child as having a problem that needs fixing would be more

likely to attend a group if they knew their child were receiving treatment. Anecdotally,

parents enrolled in these groups conveyed that having their children receive treatment was

a major factor in their engagement in the program. The high dropout rate amongst the First-

Half Concurrent group following termination of concurrent child treatment supports this

hypothesis. Several previous researchers have suggested that parental attributions of the

causes of their child’s behavior problems should predict treatment engagement and

attendance (Morrissey-Kane and Prinz 1999; Mah and Johnston 2008). Johnston and Ohan

(2005) and Johnston et al. (2006, 2009) work has clearly emphasized the impact that

parents’ attributions of their children’s behavior can have on their own responses to that

behavior and that parents of children with conduct problems are much more likely to make

stable, internal, and general attributions for the causes of their children’s behavior prob-

lems. The results of this study lend further support to the idea that parents are more likely

to engage in treatment when it matches their attributions for child behavior and expecta-

tions for appropriate treatment—that the problem is with the child and so the child should

receive treatment.

A second possible cause of increases in engagement to explore is that children

encourage parents to attend because they enjoy the groups. The concurrent child treatment

groups are designed to be more engaging and fun than childcare treatment alone,

employing games, crafts, interactive play and other enjoyable activities as primary treat-

ment tools. As a result, children may encourage their parents to bring them back to the

groups, making them more likely to attend. Pelham et al. (2005) have found in their

research on the Summer Treatment Program for ADHD, that having engaging program-

ming that the children enjoy is helpful in increasing attendance and decreasing missed

treatment days. Bringing their children to engage in activities that they enjoy may also be

reinforcing in and of itself, thus increasing attendance. Again anecdotally, many parent

indicated that their children enjoyed the treatment groups and asked multiple times during

the week when they would be returning. This possibility is also supported by Miller and

Prinz’s (2003) finding that children in the child treatment only group attended more ses-

sions than those in the parent treatment only group.

Third, the increased impact on child behavior that results from the treatment groups may

speed up/increase the overall positive impact of the parent training classes, thus making

them more rewarding to attend. In other words, if a child’s behavior improves at a faster

rate, as a result of the child treatment, this could lead to increased overall engagement as

demonstrated by attendance and homework completion. Further research into these pos-

sible explanations for the increased engagement will help to clarify its causes and lead to

the implementation of the most efficient methods of increasing parent engagement in such

programs.

Perhaps the best known and best validated of the child intervention programs is

Webster-Stratton’s Dinosaur Child Training Program (Webster-Stratton and Hammond


123

1997). While the current authors are not aware of any comparisons of the impact of the

Dinosaur program on parent attendance, Webster-Stratton et al. (2004) have demonstrated

significant improvement in child variables such as problem solving and conflict manage-

ment in children that have been attending the child training courses. They also find

improvements in parent/teacher–child interactions when children have received child

treatment with parents and teachers of children receiving child treatment being less neg-

ative in their interactions.

In overall comparisons, however, they found child training in combination with parent

training and parent training alone produced greater treatment effects than child training

alone (2007). While some might suggest since few differences are found between parent

training alone and combined treatment that parent training alone might be a more cost-

effective intervention. However, the current findings as well as the previously noted

research (Fabiano et al. 2009; Miller and Prinz 2003) suggests that since parents are more

likely to attend when their child is receiving treatment, combined treatments are likely to

be better attended, and thus have an overall greater impact. An exploration of the impact of

the child-treatment groups on parent attendance and how it may mediate/moderate the

impact of child treatment groups would be very useful to the literature.

Webster-Stratton as well as several researchers have recently examined the cost-

effectiveness of parent training and child intervention programs and generally found them

to be cost effective, even at costs over $3,000 per child (Edwards et al. 2007; Foster et al.

2007; Mihalopoulos et al. 2007). The analysis of the impact of child treatment groups on

attendance at parent training groups was not addressed in these cost analyses, as it is too

often a hidden variable in the treatment effectiveness literature. While a full cost analysis

of the current program was not conducted as part of this study, a brief discussion of the

cost-effectiveness of providing concurrent child programs in place of childcare only seems

appropriate. For the current program, differences in program costs (for running the pro-

grams, not cost to the participant) between the Child Care Only condition and the Con-

current Child Treatment Groups were fairly minimal. No increases in staff were necessary

between the programs. The main increases in cost were in supplies (more craft supplies as

well as information and practice packets and rewards used in treatment groups). The cost

of purchasing a child treatment group curriculum could also increase costs, but the pro-

grams used in the current study were developed by staff of the programs at no additional

cost. The 43–52% increases in attendance at the parent-training program certainly warrant

the increased cost of materials for the child treatment groups within this program. Future

cost analyses could better determine the cost effectiveness of providing the child treatment

to increase attendance and the associated improvement in child and parent variables that

result from concurrent child treatment groups.

In the current study, no differences were found between the Full Concurrent Group and

the Second-Half Concurrent Group. If shortened versions of child treatment are used to

limit costs, the current data strongly suggest that the start of such treatment should be

delayed to end in connection with the parent interventions, rather than having the child

groups terminate prior to parent treatment.

The data presented in this study point to the possibility of a major tool for combating

what is currently the major drawback to behavioral parent training courses—high attrition

rates. While further research is necessary to sort out more specific causes of the increases

in attendance that result form providing concurrent child treatment groups, the initial data

regarding this effect are encouraging. Further research should also address whether or not

the advertisement of concurrent child groups increases initial enrollment in behavior parent

training courses in comparison to child-care only and no child care groups.


123

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