The most common mental health problems among children in publicly-funded community-based outpatient services are disruptive behavior problems (DBPs; e.g., aggressive, oppositional, argumentative), which are core elements of disruptive behavior disorders (Garland et al. 2001
) but can also be present in children who have internalizing disorders (Jackson et al. 2000
; Verduin and Kendall 2003
). Children with DBPs are at elevated risk for many negative outcomes with significant individual, family, and societal costs (Earls 1994
). Fortunately, more evidence-based practice (EBP) treatments are available for DBPs than any other childhood problem area (Eyberg et al. 2008
) and there is currently a focus on incorporating evidence-based treatments into community settings (Kazak et al. 2010
). Efforts to improve the quality of community-based care are critical as meta-analyses have found that treatment is minimally effective in usual care and the improvement rates are negligible compared to the effects in research trials (Weisz and Jensen 2001
A common feature of most EBPs for DBPs is parent or caregiver (hereafter referred to as parent) involvement in which parents are taught to change their own parenting behavior and/or to support changes their children are making (Eyberg et al. 2008
; Garland et al. 2008
). Parent involvement refers to regular attendance in family or parent-focused interventions as well as active participation both in treatment sessions and in implementing treatment strategies between sessions (Nock and Ferriter 2005
). Parent involvement has consistently been associated with improved child outcomes (Dowell and Ogles 2010
; Karver et al. 2006
). Specifically, a large meta-analysis study that compared individual child treatment to treatments that included parents found that youth who received parent–child interventions improved significantly more than those who received individual treatment (Dowell and Ogles 2010
). Thus, parent involvement in treatment can be conceptualized as an “evidence-based process” that can improve care and complement efforts to implement many EBPs in community-based care (Huang et al. 2005
Attention to parent involvement in child treatment is not new to community therapists; two decades ago 78% of surveyed therapists reported involving parents in child treatment (Kazdin et al. 1990
). Likewise, our recent observational study of community-based care across treatment up to 16 months found that parents were present in at least part of 70% of sessions (Garland et al. 2010b
) The most frequently observed therapeutic strategies targeting parents across treatment included information gathering (observed in 94% of the 851 coded sessions with parents), psychoeducation (81%), establishing and reviewing goals (74%), and addressing the child’s external care (69%). Of those four therapeutic strategies, only one (psychoeducation) was delivered on average at moderate intensity; the other three were delivered at low intensity. Thus, research indicates that parents are often involved to some degree in therapy sessions for their children, and our previous work on the observed frequency of therapeutic strategies across a child’s treatment episode identifies some of the common ways parents are involved (e.g., information gathering, psychoeducation, etc.). However, the extent
to which therapeutic strategies are being directed to parents within treatment sessions is not known, and factors associated with parent involvement in treatment sessions in community-based care are also unknown.
Because parent involvement is considered a critical component to EBPs and child mental health treatment more broadly, it can be conceptualized as a focal point within the treatment process. As Southam-Gerow et al. (2006)
have described in their ecological framework model of mental health care, treatment processes take place within a multilayered context that includes client-level factors such as symptoms and functioning, provider-level factors such as experience and background, intervention-specific characteristics such as treatment modality, service delivery characteristics such as location of services and timing and number of sessions, organizational factors such as culture and climate, and environmental influences such as funding policies (Southam-Gerow et al. 2006
We draw from this ecological framework to identify potential factors that may be associated with therapists’ involvement of parents in usual care. More specifically, we focus on client-level factors including child, parent, and family functioning at service entry and provider-level factors including experience and background and hypothesize that factors within both levels will contribute to therapists’ involvement of parents. The extant research on predictors of treatment processes is extremely limited, but does provide some direction regarding specific hypotheses for predictors within both levels.
In terms of child functioning at entry, research suggests that increased severity and complexity would be associated with more parent involvement from therapists. For example, we found that therapists serving children with higher disruptive behavior problem scores at entry tended to provide more intensive delivery of therapeutic strategies consistent with evidence-based practice elements to parents (Brookman-Frazee et al. 2010
). Further, Richards et al. (2008)
found that caregivers of children with greater initial impairment attended more meetings and treatment sessions within an integrated school/clinic/home intensive outpatient program. Thus, we hypothesize that severity and complexity of child problems at entry will be positively associated with parent involvement.
Regarding parent functioning at entry, research indicates that addressing parent functioning concomitantly with child treatment can enhance outcomes, suggesting that poor parent functioning can be a hindrance to effective treatment if not adequately addressed (Beauchaine et al. 2005
; Reyno and McGrath 2006
). Poor parent functioning may prohibit parents’ ability to actively participate in treatment and/or therapists may focus more on working with children when parents have mental health problems. Our study of predictors of the intensity of delivery of strategies consistent with evidence-based practices found more intensive delivery of strategies to children when parents reported higher alcohol use (Brookman-Frazee et al. 2010
), which supports this notion. Alternatively, parents with mental health problems may elicit more general support and attention from therapists. Thus, we do not have a specific directional hypothesis regarding parent functioning and therapists’ involvement of parents in treatment.
When considering family functioning at entry, Richards et al. (2008)
found positive associations between impairments in parents’ ability to provide for their child and parent involvement in treatment. These results suggest that higher levels of strain and stress in the family may be associated with greater therapist involvement of parents; parents who are experiencing strain related to caring for their child may require more support to enable them to make required changes for the child’s benefit. Thus, we hypothesize positive associations between poor family functioning and parent involvement.
In terms of therapist characteristics associated with parent involvement, our study of predictors of the intensity of delivery of strategies consistent with evidence-based practices found that therapists with less experience tended to provide more intensive delivery of strategies to parents (Brookman-Frazee et al. 2010
). These results suggest that therapists with less experience may involve parents more in treatment. Given the focus on family systems within the Marriage and Family Therapy (MFT) discipline, it is also hypothesized that therapists from the MFT discipline and therapists who identify as having a family systems orientation may involve parents more in treatment.
Overall, the extant literature indicates the importance of increasing knowledge about the degree to which parents are involved in community-based treatment for children with DBPs and suggests that a number of child, parent, and family functioning factors as well as therapist characteristics may be associated with parent involvement. We contribute to the knowledge base in two important ways: (1) by examining parent involvement, defined as the proportion of time therapists’ spend on parent-directed strategies per session within community-based outpatient child treatment; and (2) by testing for client-level (child, parent, and family functioning) and provider-level (therapist experience and background) factors associated with parent involvement in community-based care, controlling for demographic characteristics at both levels.