Ronald J. Prinz

Treatment fidelity in outcome studies

Abstract Fidelity of treatment in outcome research refers to confirmation that the manipulation of the independent variable occurred as planned. Verification of fidelity is needed to ensure that fair, powerful, and valid comparisons of replicable treatments can be made. The central purpose of this article is the evaluation of outcome studies from 1980 to 1988 to determine the extent to which investigators are attending adequately to the issue of treatment fidelity. The evaluation covered 359 treatment outcome studies from major journals in four domains: clinical psychology, behavior therapy, psychiatry, and marital and family therapy. The studies were evaluated with respect to: (a) the training of treatment implementors, (b) the procedures used to promote fidelity, (c) the aspects of treatment verified, (d) the methods for assessing fidelity, and (e) the utilization of fidelity assessment in the interpretation of results. Although there were significant increases over the decade in the percentage of studies that checked adherence to treatment and used supervision to promote fidelity, the majority (55%) of the studies essentially ignored the issue of treatment fidelity. Furthermore, only one out of eight studies in the most recent period (1986–1988) combined the use of treatment manuals, supervision of treatment agents, and checking of adherence to protocol. Finally, attention given to the aforementioned aspects of fidelity did not differ significantly across journal domains. The overall implication of the review of existing practices is that investigators, reviewers, and journal editors need to give even greater consideration to the issues associated with fidelity. Specific recommendations for improving the promotion and verification of treatment fidelity in outcome studies were offered.

Population-Based Prevention of Child Maltreatment: The U.S. Triple P System Population Trial

The prevention of child maltreatment necessitates a public health approach. In the U.S. Triple P System Population Trial, 18 counties were randomly assigned to either dissemination of the Triple P—Positive Parenting Program system or to the services-as-usual control condition. Dissemination involved Triple P professional training for the existing workforce (over 600 service providers), as well as universal media and communication strategies. Large effect sizes were found for three independently derived population indicators: substantiated child maltreatment, child out-of-home placements, and child maltreatment injuries. This study is the first to randomize geographical areas and show preventive impact on child maltreatment at a population level using evidence-based parenting interventions.

Family-Based Treatment for Childhood Antisocial Behavior: Experimental Influences on Dropout and Engagement.

Antisocial behavior in childhood and adolescence is an unquestionably serious problem for society. Family-based treatments are promising but face the challenging obstacle of premature parental dropout. To systematically study dropout, we randomly assigned 147 families with a markedly aggressive child (age 4 to 9 years) to a standard family treatment (SFT) focusing exclusively on parental management or to an enhanced family treatment (EFT) that also promoted frequent discussions of adult issues. EFT produced a significantly lower dropout rate than SFT overall, but particularly for high-adversity families. Dropouts were clearly distinguishable from completers on several dimensions. The results underscore the importance of addressing contextual variables such as family adversity in the treatment of childhood antisocial behavior.

School Bonding in Children and Adolescents: Conceptualization, Assessment, and Associated Variables

School bonding refers to the “connections” that youth have with their schools and various aspects of their academic lives. School bonding may be an important concept in prevention because it has been linked to various developmental and adjustment outcomes. This paper reviews conceptualizations, measurements, and theories of school bonding. Also considered are empirical studies that have linked school bonding to a variety of outcomes (substance use, delinquency, antisocial behavior, self-esteem). The review includes examination of how school bonding serves as a mediator in these relations and, in turn, is moderated by other variables. Despite inconsistencies in conceptualization and measurement, it is concluded that school bonding is an important construct and an appropriate target for intervention. Recommendations are offered regarding future research on school bonding, especially with respect to positive developmental outcomes and examination of variables that might moderate school bonding.

Measurement of parental discipline and nurturance.

This paper reviews the measurement of parental discipline and nurturance over the past 20 years. Discipline and nurturance are two of the most heavily referenced constructs in the parenting research literature, but there are varying ways to operationalize them with respect to both method and content. The review considered 76 questionnaires that purported to assess discipline, nurturance, or both. The evaluation included examination of a total of 27 interview schedules that used either in-person or telephone structured questions or a vignette format and focused on discipline and nurturance or discipline only. A total of 33 observational systems were reviewed, the majority of which addressed both discipline and nurturance. All measures were profiled, and several noteworthy instruments were discussed. Recommendations were offered regarding how to strengthen measurement and scientific understanding of discipline and nurturance, including the need for greater attention to cultural variation and measurement equivalence issues.

Coping and adjustment during childhood and adolescence

This paper reviews research published within the last 10 years on child and adolescent strategies for coping with commonly occurring stressors in nonclinical populations and the relationship of these strategies to adjustment. Current conceptual and classification schemes for childrens coping strategies are analyzed and compared. Studies of child coping are reviewed in three clusters: (a) descriptive and taxonomic studies, (b) age-group comparisons, and (c) evaluations of coping-adjustment relationships. Developmental commonalities and changes are identified across studies and conceptual models. Conceptual models compatible with problem-focused/ emotion-focused and approach/avoidance frameworks have proven to be useful for descriptive purposes. However, it is of concern that categories in the current classification systems do not distinguish coping strategies that promote adjustment from ones that limit adjustment. Future directions for addressing this issue and developmental considerations are suggested, including an alternative model pertaining to coping competence.

Promoting Intervention Fidelity Conceptual Issues, Methods, and Preliminary Results from the EARLY ALLIANCE Prevention Trial

Fidelity refers to the demonstration that an experimental manipulation is conducted as planned. In outcome research, an intervention can be said to satisfy fidelity requirements if it can be shown that each of its components is delivered in a comparable manner to all participants and is true to the theory and goals underlying the research. Demonstrating the fidelity of an intervention is a key methodologic requirement of any sound prevention trial. This paper summarizes key conceptual and methodologic issues associated with intervention fidelity, and describes the steps taken to promote fidelity in EARLY ALLIANCE, a large-scale prevention trial currently testing the effectiveness of family, peer, and school interventions to promote competence and reduce risk for conduct disorder, substance abuse, and school failure. The paper presents preliminary results (Trial Year 1) that demonstrate content and process fidelity for two of these interventions, and discusses how the EARLY ALLIANCE methodology may be generalized to address fidelity issues in other prevention studies.

Enhancement of social learning family interventions for childhood conduct disorder.

Social learning family intervention (SLFI) is the treatment of choice for young children exhibiting severe conduct disorder and antisocial behavior. Despite the reported success of this intervention, high levels of resistance, poor engagement, and inadequate maintenance of improvements are observed for a substantial proportion of distressed families. These obstacles have inspired enhancement efforts to improve basic social learning family-intervention models. The present review identifies promising approaches for maximizing treatment gains for the conduct-disordered child. Relevant studies were organized into 3 approaches: enhancements and expansions (a) within a dyadic (parent-child) interaction model, (b) within a broad-based model that acknowledges a wider range of family influences, and (c) through a multisystems model. SLFI enhancements within the dyadic model have centered on either the strengthening of parental skills already included in the SLFI regimen or the adding of new interactional strategies. Some gains, but only partial success, have been achieved with the dyadic model supplements. SLFI expansions from a broad-based model have focused on parental adjustment, parental expectations during treatment, and social-environmental stressors. The multisystems adjuncts to SLFI include cognitive-behavioral interventions to affect peer relations and ecological approaches to sweep across domains. The broad-based and multisystems expansions have produced promising but undertested treatment regimens. Related areas of investigation included therapy process research, medication combined with SLFI, and the involvement of fathers in treatment. Recommendations are offered for improvement of SLFI research. The apparent theoretical crossroads for SLFI treatment of childhood conduct disorder are discussed.

Home Chaos: Sociodemographic, Parenting, Interactional, and Child Correlates.

We conducted 2 studies to (a) establish the usefulness of the construct of home chaos, (b) investigate its correlates, and (c) determine the validity of the Confusion, Hubbub, and Order Scale (CHAOS) used to measure the construct in each study. Study 1 relied on a sample of European American preschoolers and their mothers and Study 2 on a sample of African American school-age children and their caregivers. Home chaos was associated with less effective parental discipline; elevated behavior problems, limited attentional focusing, and reduced ability to understand and respond to social cues in children; and reduced accuracy and efficiency in a cooperative parent–child interactional task, after controlling for potential confounds. It is concluded that (a) home chaos is not a proxy for adverse social or psychological circumstances but a useful construct in its own right; (b) home chaos is associated with multiple detrimental correlates in parents and children; and (c) the CHAOS scale provides an adequate and economical measure of home confusion and disorganization that should prove useful in clinical research with diverse populations.

The Impact of Childcare and Parent–Child Interactions on School Readiness and Social Skills Development for Low-Income African American Children

Abstract Low-income and African American children are at increased risk for school readiness deficits in terms of both cognitive and social development. This study examined the roles of childcare involvement and parent–child interaction quality on the development of school readiness and social skills among a low-income, minority sample of kindergarten children. Findings provide mixed evidence on the role of childcare exposure, with early entry into childcare predicting higher levels of social skills ratings and increased time per week in such settings predicting lower levels of social skills development. Childcare exposure had positive, although trend-level, relationships with other readiness-related outcomes after accounting for demographic characteristics of children and their families. Parent–child interactions characterized as structured and responsive to the childs needs and emotions were positively related to school readiness, social skills, and receptive communication skills development after accounting for demographic characteristics and childcare exposure. Implications for preventive intervention program development and the role of school psychologists in the areas of consultation and intervention are discussed.