Terje Ogden

IMPLEMENTATION OF PARENT MANAGEMENT TRAINING AT THE NATIONAL LEVEL: THE CASE OF NORWAY

This article describes early aspects of the nationwide implementation of an evidence‐based program (EBP) in Norway and the design for studying program fidelity over time. The EBP is the Parent Management Training, Oregon Model (PMTO). The project is a combination of a ‘top down’ initiative at the governmental and ministry level, and a ‘bottom up’ initiative from practitioners seeking effective interventions in the prevention and remediation of behavior problems in children and youth. The main components of the implementation strategy were to (a) establish a national implementation and research center; (b) provide for regional and local participation at county and municipal levels; (c) establish a comprehensive therapist recruitment, training, and maintenance program; (d) create a network for collaboration, supervision, and quality control; (e) conduct clinical outcome research; and (f) study the implementation process. Following the training of three successive generations of PMTO specialists, a study was designed to examine how individual, family, interventionist, organizational, and community characteristics influence program adoption and implementation, as well as how these factors impact upon how PMTO specialists provide the intervention to families with competent adherence to the model. Within the framework of the collaborative North American and Norwegian project, challenges and facilitators in the process of the continental crossing of the PMTO model are discussed.

Treatment Outcomes and Mediators of Parent Management Training: A One-Year Follow-Up of Children with Conduct Problems

This effectiveness study presents the results of a 1-year follow-up of a randomized controlled trial of Parent Management Training. Families of 112 Norwegian girls and boys with clinic-level conduct problems participated, and 75 (67%) families were retained at follow-up. Children ranged in age from 4 to 12 at intake (M = 8.44). Families randomized to the control group received an active treatment alternative as would be normally offered by participating agencies. Multi-informant, multisetting outcome measures were collected and results from both intention-to-treat and treatment-on-the-treated analyses are presented. In two separate indirect effects models, assignment to Parent Management Training—the Oregon model predicted greater effective discipline and family cohesion at postassessment, which in turn predicted improvements in several child domains at follow-up.

Implementing and Evaluating Evidence-Based Treatments of Conduct Problems in Children and Youth in Norway

This article sums up 8 years of experience with evidence-based programs in the treatment of conduct problems in children and youth. A conceptual model describing the implementation components relevant to the Norwegian project is presented and discussed. Next, we describe a case study of the implementation strategy accompanied by outcomes from the clinical trials of Multisystemic Therapy (MST) and Parent Management Training—the Oregon model (PMTO). The national implementation strategy for evidence-based treatment programs is a combination of a ‘‘top-down’’ and ‘‘bottom-up’’ approach to implementation based on collaborative efforts of a national center for dissemination, implementation, and research and the public child and adolescent service system operating in the municipalities. The strategy further includes recruitment of candidates for training through the various service systems and the establishment of permanent networks for collaboration, supervision, and support.

Immediate Impacts of PALS: A school‐wide multi‐level programme targeting behaviour problems in elementary school

The article describes the main outcomes of the intervention programme “Positive behaviour, interactions and learning environment in school” (PALS). PALS is an adapted Norwegian version of the School‐Wide Positive Behaviour Support model, developed in the United States with school‐wide interventions aiming at the prevention of behaviour problems and the promotion of social competence through a supportive learning environment. The effectiveness was evaluated with a quasi‐experimental design in four elementary schools, two years after implementation. An equal number of comparison schools were included in the study. Informants were students (n = 735) in third to seventh grade and teachers working at least 50% (n = 82). The immediate reductions in teacher‐observed problem behaviour ranged from moderate to large, while the results based on student ratings of social competence and classroom climate were less encouraging. Differential effects were found and implementation quality was together with teacher collective efficacy significantly related to better outcomes. The programme and results are discussed in relation to prior research, limitations of study design, and future implementation and research.

A randomized trial of group parent training: reducing child conduct problems in real-world settings.

OBJECTIVE Group-based Parent Management Training, the Oregon model (PMTO, 12 sessions) was delivered by the regular staff of municipal child and family services. PMTO is based on social interaction learning theory and promotes positive parenting skills in parents of children with conduct problems. This study examined the effectiveness of the group-based training intervention in real world settings both immediately following and six months after termination of the intervention. METHODS One hundred thirty-seven children (3-12 years) and their parents participated in this study. The families were randomly assigned to group-based training or a comparison group. Data were collected from parents and teachers. RESULTS The caregiver assessments of parenting practices and child conduct problems and caregiver and teacher reported social competence revealed immediate and significant intervention effects. Short- and long-term beneficial effects were reported from parents, although no follow-up effects were evident on teacher reports. CONCLUSIONS These effectiveness findings and the potential for increasing the number of families served to support the further dissemination and implementation of group-based parent training.

Working alliance and treatment fidelity as predictors of externalizing problem behaviors in parent management training.

OBJECTIVE The study investigated treatment fidelity and working alliance in the Parent Management Training-Oregon model (PMTO) and investigated how these relate to childrens externalizing problem behaviors, as reported by parents and teachers. METHOD Participants were 331 Norwegian parents who rated the client-therapist working alliance at 3 time points (Sessions 3, 12, and 20). Competent adherence to the PMTO treatment protocol was assessed by PMTO specialists from evaluations of videotaped therapy sessions using the Fidelity of Implementation (FIMP) system (Knutson, Forgatch, & Rains, 2003). Parents and teachers reported childrens problem behaviors at baseline and at the end of therapy. Structural equation modeling was used to analyze the repeated measures data. RESULTS Parents reported high and stable levels of alliance and fidelity from Time 1 to Time 3, with no correlational or direct relations between the 2. Treatment fidelity predicted reductions in parent-reported externalizing behavior, whereas working alliance was related to less change in problem behavior. Alliance and fidelity were unrelated to teacher-reported behavior problems. CONCLUSIONS The findings point to treatment fidelity as an active ingredient in PMTO and working alliance as a negative predictor of postassessment parent-reported externalizing behavior. More research is needed to investigate whether these findings can be replicated and extended beyond PMTO.

Measurement of implementation components ten years after a nationwide introduction of empirically supported programs – a pilot study

BackgroundTen years after the nationwide dissemination of two evidence-based treatment programs, the status of the implementation components was evaluated in a cross-sectional study. The aim of the study was to pilot a standardized measure of implementation components by examining the factor structure, the reliabilities of the scores, and their association with implementation outcome variables. The aim was also to compare implementation profiles of the two evidence-based programs based on multi informant assessments.MethodsThe 218 participants in the study were therapists, supervisors, and agency leaders working with Parent Management Training, the Oregon model (PMTO), and Multisystemic Therapy (MST) in Norway. Interviewers filled in an electronic version of the Implementation Components Questionnaire during a telephone interview.ResultsThe factor analysis of the eight one-dimensional subscales resulted in an individual clinical-level factor and an organizational system-level factor. Age, experience, and number of colleagues in the workplace were negatively correlated with positive ratings of the implementation process, but the number of colleagues working with the same program predicted positive ratings. MST and PMTO had different implementation profiles and therapists, supervisors, and managers evaluated some of the implementation drivers significantly differently.ConclusionsThe psychometric quality of the questionnaire was supported by measures of internal consistency, factor analyses of the implementation components, and the comparisons of implementation profiles between programs and respondent groups. A moderate, but consistent association in the expected direction was found with the implementation outcome variables.

Normative development of physical aggression from 8 to 26 months.

This study investigated the normative use and developmental course of physical aggression (PA), defined as use of physical force such as hitting, biting, and kicking, from 8 to 26 months and predictors thereof. We used data from the Behavior Outlook Norwegian Developmental Study, comprising 1,159 children (559 girls and 600 boys). Both mothers and fathers reported frequently about their childs use of PA in personal and telephone interviews. Mean number of reports per child was 7.16 (SD 1.70), with 90% having at least 6 reports. We employed Rasch scaling to construct a single linear PA measure and multilevel growth curve modeling to address the research questions. The results confirm that the development of PA is nonlinear, with a peak in frequency at about 20-22 months, which is followed by a decline toward 26 months. There is both within- and between-child variance in the development of PA. Higher levels of PA were predicted by the presence of a same-age sibling, maternal and paternal mental distress, and difficult child temperament (high activity level and distress due to limitations), whereas the main effect of gender was only trend-significant. Growth of PA across this developmental period was predicted by the presence of a same-age sibling and high activity level. The results both support and transcend previous research within this field.

Sustainability of the effectiveness of a programme of multisystemic treatment (MST) across participant groups in the second year of operation

In order to examine the sustainability of programme effectiveness, we investigated whether the effects of multisystemic treatment (MST) on a second group of adolescents would match those reported in an earlier randomised controlled trial (RCT). Pre‐ and post‐treatment assessments were analysed in a participant group of 105; 55 youths were referred to MST in the programmes second year of operation (MST2), and 50 youths were included in the RCT the first year in which 30 were randomly assigned to MST (MST1) and 20 to regular services (RS).At two project sites, MST clinical outcomes in the second year of programme operation matched and, for key indices of anti‐social behaviour, surpassed those achieved during the first year. In addition the MST treatment delivered in the second year was more effective than regular child welfare services in preventing out of home placement and reducing internalising and externalising behaviour. Together, these results demonstrated sustained effectiveness of the programme as well as indication of programme maturation effects. No group differences were registered for social competence. MST youths treated in the second year were significantly younger than those referred to treatment in the first year (MST1) but age had no moderating effect on the outcomes.

Building strength through enhancing social competence in immigrant students in primary school. A pilot study

In the present pilot study we examined how a school‐wide intervention model, ‘Positive behavior, interactions and learning environment in school’ (Norwegian acronym: PALS) contributed to risk reduction in immigrant students through the promotion of social competence. The aims of the PALS project were to promote social competence through positive behavior support and to prevent and reduce problem behavior in students. Teachers and students in selected grade levels at four elementary schools and four comparison schools participated in a quasi‐experimental evaluation spanning over 20 months. The present study was conducted with a subset of the students, namely the 6.7% (n = 49) immigrant students who had Norwegian as their second language. Consistent with the social learning theory underlying the PALS model, teacher reports indicated that immigrant students in the intervention group were significantly more socially competent than were their counterparts in the comparison group at post‐test when school differences at pre‐assessment were accounted for. A significant decrease in internalizing problem behavior was registered in teacher ratings along with a marginally significant positive trend in teacher‐rated academic progress. No intervention effect was registered in teacher‐rated externalizing problem behavior or in student ratings of social competence. In order to measure potential generalizing effects of school‐wide intervention programs, we discuss the need for larger samples and longer follow‐up periods.