The Family Check Up Model: An Evidence-

based Approach to Intervening with Conduct

Disorder. Thomas J. Dishion

Arizona State University

Department of Psychology

&

Child and Family Center

University of Oregon

Presented at:

Video conference 5/28/2013

1

The model building

approach:

Field Observation

Test Constructs

Longitudinal Process Models

Intervention Experiment

Dishion &

Patterson, 1999

2

Four Goals of this Talk.

1-Provide a rationale for family-centered interventions to the treatment of problem behavior in children and adolescents.

2-To provide an overview of the Family Check Up (FCU) model for addressing problem behavior and co morbidities.

3- Review findings from three randomized trials of the effectiveness of the FCU with families of young children and adolescents.

4 – Discuss future directions of the Family Check-up Model to improve intervention effectiveness to address co-morbidity

3

4

Parent

reacts

emotionally

Parent

withdraws,

escalates

Child

problem

behavior

Child

Escalates

Escala

tin

g C

ycle

Figure 2. The Coercive Cycle

5

Family Management as a Mediator of

Contextual Influences.

Economic or

Social Stress

Parent substance use

Parent depression/

Marital conflict

Family Management Child &

Adolescent

Adjustment

6

Effective Family Management Interventions Reduce….

Early

Childhood

Problem

Behavior

Middle

Childhood

Problem

Behavior

Adolescent

Problem

Behavior

Summary of Clinical Trials Focusing on Family Management

7

Treatment Model:

Clinical Service Agencies

Parent

Management

Training

Family

Check

Up

Public Health Model:

Embedded in the Community

Motivation and Tailoring Parent Management Training 8

Process of

Change

Pre-contemplation

Question

Situations,

reframe

Question

pros &

cons,

avoid

arguments

Question

past

efforts

Provide

advice,

support

Support

strengths,

successes,

problem

solve

9

Initial

Interview

Assess

Child &

Family

Feedback

&

Planning

Brief,

tailored

PMT

PMT

Treatment

Child

CBT

Community

Resources

An Overview of the Family Check-Up and Follow-Up Services

The Family Check-Up

10

Three Steps in the Family

Check Up Model

Initial

Interview

Assessment

Session

Feedback Session

Case Conceptualization and

Videotape Feedback Selection

11

Initial Interview

12

Specific Tasks:

Introduce self and explain Family Check Up Process

Respond to family questions

Get to know family by exploring strengths, problem areas and concerns

Motivate to engage in assessment, and schedule future meetings

13

MI Skills for the Initial Interview

Express empathy

“It is a lot, to stay home and manage three young ones”

Develop discrepancy

“On the one hand, you want to let Sammy explore his environment and get messy with his toys, and on the other hand, you want him to start listening when you ask him to stop or pick something up.”

“You’d like to be more positive with Sammy so he’ll listen better, AND at the same time, you’re really stressed which is making you irritable. The neat thing is that you also know that when Sammy listens, you are less stressed.”

Roll with resistance

“I’m hearing that you are aware that Tony is more aggressive than other kids, and also that you want him to be able to stand up for himself and not get pushed around.”

Support self-efficacy

“What tells you that you may need to do something about setting limits?”

“What do you think would help you set limits more consistently?”

14

Gather information to develop case conceptualization

Accurately identify strengths as well as challenge areas

Keep family engaged in the FCU process

Reduce intervention time by identifying specific needs

Collect information from multiple sources

Collect information across multiple contexts

Goals of ecological

assessment

15

Basic Assessment Battery

Conceptual

Domain

Reports

And

Ratings

Directly

Observe

Child Problem

Behavior and

Emotional

Adjustment

Parent

Teacher

Child

Home and school

Family

Context

At home At home

Family

Management

At home At home

16

Case Conceptualization and the

Feedback Session

Strengths-based

Validate and affirm parent strengths and identify strengths that can be further developed.

Case Conceptualization

Create a cohesive story, a narrative

“What is the story I want this parent to hear?”

“What is the effect of this information on the Target Child?”

What are the obstacles for this family?

17

Merging Perspectives to Build

a Case Conceptualization.

Caregiver

Perspective

Youth

Perspective

Teacher(s)

Perspective

Observa-

tions

Family Centered

Case

Conceptualization

18

T=Tailor feedback for client.

H=Harm reduction is the top priority.

I=Integrate information into a parenting frame.

N=Notice and build on parenting strengths.

K=Know and consider functional dynamics in family.

THINK Approach to Case

Conceptualization.

19

Many Effects, One Focus

Family

Management

Child problems

Marital issues

School

issues

Life crises

Depression/

Anxiety

Developmental needs

20

Feedback Delivery

Feedback Process consists of four phases within

a 60 minute session:

1. Self-Assessment

2. Support and explanation of profile

3. Feedback (include videotaped feedback)

4. Exploration of menu and goal setting

21

Showing how a new skill might be useful to the parent

and family.

Improving the performance in an existing parenting skill

Identifying opportunities for using a parenting skill

Supporting a parenting strength of which the parent

may be unaware.

Videotape feedback enhances performance

when attention is drawn to: (Kluger & DeNisi, 1996)

22

Child

and

Family

Profile

23

Setting

Goals

24

Conceptual Framework for Everyday

Parenting Curriculum and FCU (Dishion, Stormshak & Kavanagh, 2011)

Mindful

Parenting

(proactive,

Monitoring)

Positive

Behavior

Support

Setting

Healthy

Limits

Family

Relationship

Building

FCU

25

Everyday Parenting Curriculum

Incentives for Behavior Change

1. Parent requests and child cooperation.

2. Parent praise for child cooperation.

3. Behavior Change Plans/Incentives

4. Behavior Change Plans/Barriers

Limit-setting and Monitoring

5. Monitoring daily activities

6. SANE guidelines for limit setting

7. Proactive Limit Setting

8. Limit setting challenges/regulation

Relationship Skills

9. Negotiating conflict

10. Choosing solutions to family problems

11. Proactive positive routines

12. Shared family routines and activities

26

Parent consultant suggests intervention goals based on assessment

Use parent’s words to ‘own’ goal

Prioritizing intervention goals based on case conceptualization.

Channeling goals into a theme involving parenting

Setting Realistic and Achievable

Intervention Goals with Parents

27

Menu of Follow Up

Interventions

Brochures

Videotapes

Brief family consultation

Parenting groups

Special-topic parent nights

Books

Home-school monitoring system for preschool

Monthly family check-in

Family Management

Parent networking

Community resources

Referral

28

Research at the Child and Family Center Project Alliance 1: Dishion

Project Alliance 2:

Stormshak

Early Steps Pilot: Shaw

Early Steps Multisite:

Dishion, Gardner, Shaw &

Wilson

Shadow Project: Boyd-Ball

Community Mental Health:

Stormshak

Northwest Public

Schools 1995-present

Northwest Public

Schools, 2005-2010

Children involved in

WIC, from age 2 –

school age

AI families in PNW

CMH agencies in

Portland – 120 families

29

ORI, May 2002

Service Systems Affecting Mental Health

of Children and Adolescents

Developmental

Stage

Early

Childhood

Childhood

Early

Adolescence

Adolescence

Public School

Setting

Community

Programs:

Treatment and

Rehabilitation

WIC,

Preschools

30

Design of the Early Steps Multi Site Project (Dishion, Gardner, Shaw & Wilson)

•Study Sample: 731 WIC Families with multiethnic, male and female toddlers

•Design: Longitudinal follow-up age 2 to 7

•Retention: 85% on parent report

31

Primary Caregiver ratings on Problem

Behavior (Dishion, Shaw et al, 2008)

18

17

16

15

14

13

12

11 Age 2 Age 4: Age 2 Age 4

18

17

16

15

14

13

12

11

I = Intervention

C = Control

Inte

ns

ity T

sc

ore

s

I

I

C

C

I I C

C

High Risk Typically Developing

Intervention Effect (.16) 32

A Mediation Model for Reducing Problem Behavior.

(from Dishion, Shaw, Connell et al, 2008)

Observed

Parent

PBS

Age 2

Observed

Parent

PBS

Age 3

Int PB Slope

PB

.88*

-11*

Age 2 Ey. Age 3 Ey. Age 4 Ey.

Proactive

Ratings

Parent Invol.

Ratings

Observed

Pos. Rein

Observed

Int. Eng.

Proactive

Ratings

Parent Invol.

Ratings

Observed

Pos. Rein

Observed

Int. Eng.

Intervention

.20*

33

Intervention Effects Over time on Direct

Observations of Parent-Child Interaction (Stinick et al, in preparation)

Coercion

2

Coercion

3

Coercion

5

PE

2

PE

3

PE

5

Intervention

Group

.42**

.25**

-.10*

.44**

.19

-.19 ** **

**

.25**

Indirect effects:

Group -> PE3 -> CO5= -.012

(p=.076) Chi-square

(df)

RMSEA CFI TLI SRMR

80.66 (25) .054 .953 .919 .050

34

Between group differences on Oppositional Defiant Disorder

factor from Achenbach Teacher Report Form at age 7.5

Dishion, Brennan, Shaw et al,

under review

35

CACE Model of Early Steps Intervention Effects:

Engagement in 6 yearly FCU’s.

(from Dishion, Brennan, Shaw et al, under review)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

2 3 4 5 7.5 8.5

Ch

ild

Ag

gre

ss

ive

-Op

po

sit

ion

al

Beh

avio

r M

ea

n

Age

Nonengagers

Engagers, Control

Engagers, Intervention

36

ORI, May 2002

Service Systems Affecting Mental Health

of Children and Adolescents

Developmental

Stage

Early

Childhood

Childhood

Early

Adolescence

Adolescence

W.I.C, Headstart

Community

Programs:

Treatment and

Rehabilitation

Public

Schools

37

Design of the Project Alliance 1& 2 Studies

•Project Alliance 1 Study and Design (Dishion PI): 999 multiethnic 6th Grade Youth in Three Urban Middle Schools, randomly assigned at the individual level to the FCU intervention.

•Project Alliance 2 Study and Design (Stormshak PI): 650 multiethnic 6th Grade Youth in Three Urban Middle Schools, randomly assigned at the individual level to the FCU intervention.

•Retention: 80% or above to age 23 and 16 respectively.

38

2

Prevention Research in Public Middle

Schools (Project Alliance 1 and 2: Dishion & Stormshak)

Randomly

Assigned

7th 7th ---> 11th Grade

6th Grade

Middle School

Students:

Portland Public

Schools

Control: Middle

school as

usual.

Family

Resource

Room

Offered

Family

Check-up &

FU support

39

Intervention Outcome on Self Reported

Substance Use for High Risk Students

(adapted from Dishion, Kavanagh et al, 2002)

Self

Rep

ort

ed

Su

bsta

nce U

se in

th

e L

ast

Mo

nth

40

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

6 7 8 9

alc

oh

ol u

se

(n

um

be

r o

f d

rin

ks

)

grade

control, engager

treatment, engager

control, non-engager

treatment, non-engager

Preventive Effects on Growth in Alcohol Use by

Intervention Engagement (50% Engaged)

From Van Ryzin, Stormshak & Dishion, 2012 41

Preventive Effects on Growth in Marijuana Use by

Intervention Engagement – Transition to High school

0

1

2

3

4

5

6

Time 1 Time 2 Time 3

Pa

st

mo

nth

ma

riju

an

a u

se

Noncomplier,Intervention

Complier,Control

Complier,Intervention

-1.38 (.28), p <

.05.

Stormshak, Connell et al., 2011 42

Randomized

FCU in

Middle

School

Improved

Parent

Monitoring

(observed)

Reductions

in Early

Adolescent

Drug Use

6th grade 7th to 9th grade

Mediation of Reductions in Substance Use for

Highest Risk Young Adolescents (adapted from Dishion, Nelson & Kavanagh, 2004)

43

Police Documented Arrests from Age 11 through 17

as a Function of FCU Engagement.

(Connell, Dishion et al, 2007).

11 12 13 14 15 16 17

E

Ec

Ei

N N

N=Non-engaged

E=Engaged

Age in Years

100

80

60

40

20

10

Pe

rce

nta

ge

of

Arr

es

ts a

t E

ac

h A

ge

44

Randomized

FCU in

Middle

School

Reduced

Growth

Family

Conflict

12-15

Reduced

Antisocial

Behavior

19

6th grade Middle to Late Adolescence

Mediated Effects on Antisocial Behavior (adapted from Van Ryzin & Dishion, 2012)

45

Summary Promising Effects

Reductions in problem behavior associated with improvements in parenting and reductions in maternal depression in early childhood (Dishion et al, 2008; Shaw et al, 2006, 2009)

Reductions in the development of comorbid emotional distress and problem behavior in early childhood (Connell et al, 2009)

Reductions in problem behavior in adolescence mediated by improved monitoring and reduced family conflict (Dishion et al, 2002; Connell et al, 2007; Dishion et al in preparation; Stormshak et al, 2010; Van Ryzin et al 2012)

Reductions in depression from middle school through early adulthood (Connell et al, 2006), and in one study, changes mediated by reductions in family conflict (Fosco et al in preparation)

46

Embedding Family Check-up

Into School Wide Positive Behavior

Intervention Support (PBIS):

Positive Family

Support Model

47

PBIS & PFS PFS Core Components

Universal • School expectations

• Positive reinforcement

Selected • Specialized support

• Check-In/Check-Out

School-Based Supports

Individualized • Individualized supports

• FBA

• WEB based Family Check-up •Parent management training

•Parent support of intervention

• Behavior change plan

• Check in/ Check out

• Email and Text messages

• Family Resource Center

• Enhance school-family

relationships

• Parent screener

• Parenting resources

• (brochures/videos)

48

Three Key Features of this Model

Follows a Response to Intervention Approach

Designed as a school-wide SYSTEM

Adapted & tailored to the unique ecology of each school

49

Brochures, TV/DVD, Supplies Meeting Table, Computer, Coffee/Danishes on counter

Universal Family Support: The Family Resource Center

50

Parenting Resources: Brochures

51

Proactive Screening that is Respectful to Parents”

Revised Multiple Gating Approach

Parent

Readiness

Screener

(school entry)

Teacher &

Staff

Readiness

Screener

(fall-spring)

Family

Check Up

School-

Parent

PBS plan

Tailored

Student &

Family

Support

52

53

The Parent Readiness

Screener Begin the School Year with Parents Expressing THEIR Needs

• Use Parent Readiness Screen

to place students in the triangle

• Use their data to guide your

approach to contact parents

54

Sixth Grade Parent Responses to the

School Readiness Screener (N=3 schools)

Item

Description

Doing Great Some

Concern

Serious

Concern

Asking for

Support

Completing

Homework

assignments

59% 30% 8.9% 11%

Needing

Structure and

Supervision

65% 28% 6% 9%

Getting easily

distracted by

other kids

51% 40% 10% 11%

Focusing and

staying on

task at school

60% 33% 7% 9%

Depressed

or anxious

69% 25% 6% 7%

55

Invite Parents to Join CI/CO

Use Home Incentives Plan

Check-In/ Check-Out

For teachers &

family resource

specialists

For parents and students

(with teacher & family

resource specialist help)

For teachers and parents

Selected-Level: Behavior Change Plans

56

Video Support for Families

Following the Family Check Up

57

Concluding Comments.

1 Embedding family interventions within agencies such as public schools and WIC is feasible and efficient (3 to 6 hours yearly);

2 The families that are the most at risk are the most likely to engage in the FCU (single parents, teen mothers, low education, low income);

3 Although effect sizes are small, they are enduring overtime, and positive involvement and monitoring are mediating effects;

4 The model and findings are consistent with a public health approach to promoting behavioral health with periodic, brief support over time increasing effect sizes.

58

Acknowledgments Thanks to:

NIDA Support!

Key Research Colleagues:

Frances Gardner

Kate Kavanagh

Daniel Shaw

Beth Stormshak

Melvin Wilson

and:

Early Steps & Project Alliance

Families& Staff

59

Username: Pubs

password: CFCpublication

For more information:

dishion@asu.edu

http://cfc.uoregon.edu

Dishion, T. & Stormshak, E. (2007).

Intervening in Children’s Lives: An Ecological,

Family-centered Approach. APA: Washington DC

Dishion, T. , Stormshak, E., and Kavanagh, K (2011)

Everyday Parenting: A Professional Guide for Changing

Parenting Practices. Research Press. New York, New York

60

http://cfc.uoregon.edu