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

Aditi Sinha, M.S.Karen M. O’Brien, Ph.D.Amy R. Murrell, Ph.D.

University of North TexasContextual Psychology Group

Introduction & Rationale

•Parental Stress Parent & Child psychopathology

•Limitations of Behavioral Parent Trainings (BPT)

•Early success of mindfulness based therapies with parents

•Limited studies of ACT with parents (2)

Hypotheses (Summarized)

•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 (FBSS)

• 1 to 3 children • Reporting high levels of

parenting stress ▫ >2SD above mean

• 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

Characteristic Percentage FrequencyMarital Status (n=17)

Single 26.3 5

Married 26.3 5

Divorced 21.1 4

Separated 5.3 1

Other 10.5 2

Education (n=17)

Some high school 26.3 5

High school grad/GED 26.3 5

Some college 21.1 4

Four-year College Grad 10.5 2

Grad school 5.3 1

Income (n=17)

Less than 15K 52.6 10

15,001-30,000 26.3 5

30,001 – 50,000 5.3 1

50,001 – 75,000 5.3 1

Procedure• ACT daily diary (25 days pre / 25 days post)• Package of Self-Report Instruments (Pre/Post/Follow-

up)• Pre-treatment Reading▫ The Joy of Parenting: An Acceptance and Commitment

Therapy Guide to Effective Parenting in the Early Years Coyne and Murrell (2009)

▫ Parent Adherence Check

•Two,12-hour, 2-day weekend workshops in group format▫Karen O’Brien & Amy Murrell

Treatment Utility & Satisfaction Interview Therapist Adherence Check

DesignSingle-case experimental

Within-Ss, Repeated Measures

• Interrupted time series data

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

observations

• 1 group, 3 time points• 10 measures:

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

Compensation

•$10 per day of treatment•$20 at 3-month follow-up•Lunch during first day of workshop•Childcare for duration of workshop•Copy of The Joy of Parenting

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 Deserted Island

• How do you want to be remembered?

• Notice the words

• Whatever it takes

Treatment ProtocolDay One: • Reading check• Group rules and

expectations• Overview of ACT

perspective on human suffering and an ACT philosophy of parenting.

• Chapter 3, “Parenting Values: What Matters Most.”

• Lunch• Chapter 4 “Is the Goal

Control? Managing Feelings vs. Managing Behavior.”

Treatment ProtocolDay Two• Chapter 5, “Being Mindful:

Appreciating Your Child” • Chapter 6, “Doing What

Works, Not What’s Easy: Standing for Your Child”

• Conclusion and Commitment

• Posttest and Interview

Treatment ProtocolHorizon Metaphor

“…Valuing is like sailing toward the horizon…Because it’s always shifting, you can never reach it— you can only move toward it. When you’re heading toward the horizon…You feel … Your behavior doesn’t always have to match your values flawlessly; if you are generally heading in the direction of what you want your life to stand for, you will feel the importance in that.”

ACT Daily Diary 

 

Describe any particularly stressful interactions with your child today and how you handled them:

SufferingRate how upset and distressed you were today overall:None Extreme amount 0 1 2 3 4 5 6 7 8 9 10 StruggleRate how much effort was put into making these upsetting

feelings or thoughts go away (for example, thought suppression; distraction; reassurance):

None Extreme amount 0 1 2 3 4 5 6 7 8 9 10 Workability If life in general were like this day, to what degree would

today be part of a vital, workable way of living? Not at all Extreme amount 0 1 2 3 4 5 6 7 8 9 10  Valued ActionRate how effective you were in taking actions that are

consistent with your values today: Not at all Extreme amount 0 1 2 3 4 5 6 7 8 9 10 

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 not expected to change and struggle

decrease

Workability and valued action increase

c) Post-intervention trend lines in the expected directions

Diary Results Summary• Some caseworkers referred <25 days prior

• Lack of parent compliance

▫Only 1 parent provided all 50 data points (Parent B)

▫Only 6 parents had both baseline and post-

intervention data

• Complete visual inspection criteria not met for any

parent on any domain

Diary Results Summary

• Struggle/Experiential Avoidance▫ Only 1 parent (F) had data that was interpretable▫ Clear intervention effect stable baseline data/mean and level changes

in expected directions

• Workability/Behavioral Effectiveness▫ Only 1 parent (A) met all 3 criteria to conclude that changes in

magnitude were due to the intervention ▫ Demonstrated mean and level changes in expected directions

Parent F

Baseline Baseline Trend Baseline Mean

Post-Intervention Post-Intervention Trend Post-Intervention Mean

Time in Days

Str

ug

gle

Rati

ng

s

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

Hypotheses 2,3,4, and 5:

•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

RM ANOVA: ACT-related variables

Pretest Posttest Follow-up F df P Cohen’s D

M SD M SD M SD

AFQ 19.33 11.10 15.33 8.81 17.19 7.27 1.39 2 .29 .40 (1-2)

.23 (1-3)

VLQ 53.71 17.75 63.37 17.27 57.53 21.83 2.79 2 .08 .55

.19

MVM

87.83 13.99 92.50 11.70 92.00 15.46 3.54 2 .047* .36

.28

KIMS 127.02 16.54 123.71 18.96 129.11 18.58 1.13 2 .34 -.18

.12

DERS

76.16 23.28 72.21 16.75 72.00 17.47 .39 1.43 .61 .19

.20

RM ANOVA: Child behaviorPretest Posttest Follow-up F df p Cohen’

s d

M SD M SD M SDBASC_Int***

59.10 13.20 55.90 11.50 51.20 10.49 2.44 2 .12 .26

.66BASC_Ex*

65.60

16.65 61.50 12.70 52.70 8.46 5.42 1.17 .04**

.28

.98BASC_BSI

64.00

12.89 61.20 11.34 55.00 8.38 4.57 2 .03**

.23

.83BASC_Adap

44.10 9.73 40.90 7.74 42.90 8.67 1.77 2 .20 .34

.13

Reliable changeMeasure

% change Pre- to Post-test

% change Pre to Follow-up

Total # of parents that evidenced reliable change

AFQ 73.9 42.9 1; parent M

MVM 77.8 75 2; J and M

VLQ 76.5 66.7 2; J and I

DERS 52.6 50 2; M and I

DASS-21 52.6 28.6 1; N

APQ-9 47.4 50 2; A and B

PLOC (PE) 47.4 57.1 2; L and I

PSI-SF 57.9 64.3 1; M

BASC-2 Ex 76.9 80 1; I

BASC-2 In 61.5 70 0

Acceptance (AFQ)

1 2 30

5

10

15

20

25

30

35

40

45

Parent M

AF

Q S

co

res

• 73.7% of the sample

changed in the desired

direction pre- to post

• 42.9% pre- to follow-up

• Gains not maintained

▫MORE TREATMENT

• Reliable change

observed for Parent M

at post-test & follow-up

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

Emotion Regulation (DERS)•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

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

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)

• DASS-21 scores predicted

treatment outcome

1 2 30

5

10

15

20

25

30

35

40

45

50

Parent N

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

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 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

Externalizing Behavior (BASC-2 Ex)

• CLINICALLY AND

STATISTICALLY

SIGNIFICANT CHANGE

▫ 76.9% pre- to post-test

▫ 80% pre- to follow-up

• Consistent with pilot data

(Murrell & colleagues,

2009)1 2 3

0

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

Summary of results

•Clear intervention effect for valuing behavior (MVM) and childhood externalizing behavior (BASC-2 Ex)

•10 parents had clinically significant change on at least 1 measure

•Parents M and I evidenced clinically significant change on 4 measures

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

• Role of emotion regulation in parenting behavior