Evaluating the effectiveness of a parent training protocol based on an Acceptance and Commitment Therapy philosophy of parenting

Karen M. O’Brien, M.S.Amy Murrell, PhD.

University of North Texas

Introduction & Rationale

•Limitations of Traditional BPT

•Early success of acceptance and mindfulness based treatments, including ACT, with parents

•Success of ACT with a variety of other populations

•Limited studies of ACT with parents (2)

Hypothesis & Purpose

•An ACT for parents intervention will favorably impact…

▫ACT processes (acceptance, mindfulness, valuing)

▫Parenting behavior and distress

▫Child behavior

ParticipantsGeneral Characteristics FLOW

• Collin County Children’s Advocacy Center (CAC), Family Based Safety Services Program

• Young ▫ Mean age: 22.18▫ Range: 18 to 46

• Female (84.2%)• 1-3 children • Reporting high levels of

parenting stress

• 34 parents referred and screened

• 33 parents consented• 23 parents attended at

least one day of either Workshop A or B

• 19 parents completed an entire workshop

• 14 parents completed follow-up measures

DesignSingle-case experimental

Within-Ss, Repeated Measures

• Interrupted time series data

• ACT Daily Diary ▫ 25 baseline observations▫ 25 post-intervention

• 1 group, 3 time points• 10 measures:

▫ AFQ▫ KIMS▫ MVM▫ VLQ▫ DERS▫ DASS-21▫ APQ-9▫ PLOC▫ PSI-SF▫ BASC-2

Procedure- Referral received

- Screening and informed consent at least 25 days prior to intervention

- Parents keep ACT Daily Diary

- 1 week pretest/Reading Assigned

- Intervention

- Posttest (immediately post intervention), including Treatment

- Utility and Satisfaction Interview

- Parents keep ACT Daily Diary for 25 days post 3-4 month follow-up

Treatment ProtocolDidactic Experiential

• ACT Components and Concepts (e.g., valuing, whole, complete and perfect, FEAR)

• Parenting practices that lead to child misbehavior

• The ABC’s of behavior

• Behavioral principles▫ Antecedent control▫ Giving directions

effectively ▫ Shaping▫ Consequences

• Noticing your mind

• Awareness of the smallest sound

• The “just-so pizza”

• How do you want to be remembered?

• Notice the words

• Whatever it takes

Hypothesis 1: ACT Daily Diary Data

Visual inspection of diary ratings will indicate that the

intervention had an impact

a) Stable baseline data for all for domains (suffering,

struggle, workability and valued action)

Stability around mean line

Stable trend line

b) Mean and level changes in the expected directions

Suffering and struggle decrease

Workability and valued action increase

c) Post-intervention trend lines in the expected directions

Diary Results Summary• Caseworkers referred <25 days prior

• Lack of parent compliance

▫Only 1 parent provided 50 data points

▫ 6 parents had both baseline and post-intervention

data

▫ 2 parents post only data

• Unstable baselines (and post-intervention)

• Complete visual inspection criteria not met for any

parent on any domain

Parent A

Baseline

Baseline Trend

Baseline Mean

Post-Interven-tion

Post-Interven-tion Trend

Post-Interven-tion Mean

Time in Days

Wo

rka

bil

ity

Ra

tin

gs

Parent B

Baseline Baseline Trend Post-Intervention

Post-Intervention Trend Baseline Mean Post-Intervention Mean

Time in Days

Su

ffe

rin

g R

ati

ng

s

Parent B

Baseline Baseline Trend Baseline Mean Post-Intervention

Post-Intervention Trend Post-Intervention Mean

Time in Days

Str

ug

gle

Ra

tin

gs

Parent B

Baseline Baseline Trend Baseline Mean

Post-Intervention Post-Intervention Trend Post-Intervention Mean

Time in Days

Valu

es R

ati

ngs

Parent F

Baseline Baseline Trend Baseline Mean

Post-Intervention Post-Intervention Trend Post-Intervention Mean

Time in Days

Str

ug

gle

Rati

ng

s

Hypotheses 2,3,4, and 5:

Clinically & Statistically Significant Change

•RCI for clinically

significant change

•RM ANOVA for

statistically significant

change

Hypothesis Measures

Hypothesis 2: ACT-related variables

AFQ, KIMS, MVM, VLQ & DERS

Hypothesis 3: Parenting variables

APQ-9, PLOC, PSI-SF

Hypothesis 4: Depression, anxiety, and stress

DASS-21

Hypothesis 5: Child behavior

BASC-2

Acceptance (AFQ)

1 2 30

5

10

15

20

25

30

35

40

45

Parent M

AF

Q S

co

res

• 73.7% changed in the

desired direction pre- to

post.

• 42.9% pre- to follow-up

• Reliable change

observed for Parent M at

post-test & follow-up

• Gains not maintained

▫MORE TREATMENT

Emotion Regulation (DERS)•31.6% pre- to post-test•50% pre- to follow-up•Parents I and M had reliable change from pre- to post-test

• Same 2 parents with reliable change on 3 other measures (the most reliable change)

•Emotion regulation as a mediating variable•Differentiate from experiential avoidance

1 2 30

20

40

60

80

100

120

140

160

Parent M

DE

RS

Sco

res

1 2 30

20

40

60

80

100

120

140

160

Parent I

DE

RS

Sco

res

Mindfulness (KIMS)• 36.8% pre- to post-test

• 50% pre-test to follow-up

• Possible incubation effects

• No reliable change (or statistically significant change)

▫ Sample size

▫Measurement issues

▫Coyne & Silva findings

▫NEED MORE TREATMENT

Valuing (MVM & VLQ)

1 2 360

70

80

90

100

110

120Parent M

MV

M S

core

s

1 2 30

10

20

30

40

50

60

70Parent I

VLQ

Score

s

1 2 30

10

20

30

40

50

60

70Parent J

VLQ

Score

s

1 2 360

70

80

90

100

110

Parent J

MV

M S

core

s

Parental Efficacy (PE subscale, PLOC)

•47.4% pre- to post-test

•57.1% pre to follow-up

•Parents L and I had

reliable change from pre

to post-test

•Parent L maintained

those changes at follow-

up

1 2 30

10

20

30

40

50

60Parent I

1 2 30

10

20

30

40

50

60Parent L

Parenting Practices (APQ-9)•APQ-9 demonstrated poor to average internal consistency reliability

•47.4% pre- to post-test•50% pre- to follow-up

•Parents A & B showed reliable change from pre- to post-test

• Need for BOOSTER SESSION or

• MORE TREATMENT

1 2 30

5

10

15

20

25

30Parent A

1 2 30

5

10

15

20

25

30Parent B

Parenting Stress (PSI-SF)

• High pre-treatment levels

(>2SD above mean)

• 57.9% pre- to post-test

• 64.3% pre-test to follow-up

• Parent M showed reliable

change from pre-test to

follow-up

• General decreasing trend

in mean scores1 2 3

0

20

40

60

80

100

120

Parent M

DASS-21

• 52.6% pre- to post-test

• 28.6% pre- to follow-up

• Parent N showed reliable

change, no follow-up data

• Consider pre-treatment

levels

▫ Blackledge & Hayes

(2006)

▫ Murrell & colleagues

(2009)

1 2 30

5

10

15

20

25

30

35

40

45

50

Parent N

Externalizing Behavior (BASC-2 Ex)

• 76.9% pre- to post-test

• 80% pre- to follow-up

• Consistent with pilot data

(Murrell & colleagues,

2009)

1 2 30

20

40

60

80

100

120

Parent I

Internalizing Behavior (BASC-2 Int.)• General decreasing trend

• 61.5% pre- to post-test

• 70% pre- to follow-up

• Internalizing behavior not given as much attention as

externalizing behavior

Adaptive Skills (BASC-2 Adap)

•Age of children? Just

changing over time?

•Not really targeted with

our intervention

•Probably not related to

intervention?

1 2 30

10

20

30

40

50

60

Parent EB

ASC

-2 A

dapti

ve S

kills

1 2 30

10

20

30

40

50

60

Parent K

BA

SC

-2 A

dapti

ve S

kills

Parents said…“Not distressing, but it was emotional…

understanding your emotions, realizing they’re there and what is there, and accepting it.”

“Yes, to allow my thoughts to take place and me to make a good choice.”

“I'm going to be mindful and slow down, talk about our mindsets and feelings.”

“I like the atmosphere of sharing personal experience… I feel more empowered because I learned that my

thoughts and feelings are normal. Thank you for introducing this topic to the general public! I believe

there is a serious need for this to be more available.”

Limitations• Recruitment

• Data collection (logistics)

• Design (stable baseline vs. control group)

• Measurement

▫ Social desirability

▫Reading level

• NOT ENOUGH TREATMENT

Future Directions

• Consider domain specific measures or behavioral

measures

• Use of control group

• MORE TREATMENT

▫ Individual versus group

• Explore relationship between constructs

▫MVM and VLQ

▫DERS and AFQ