AN EXAMINATION OF GROUP PARENT TRAINING WITH CONTEXTUALIZED
COACHING ON POSITIVE PARENTING PRACTICES
by
DANA COHEN
A THESIS
Presented to the Department of Special Education
and Clinical Sciences
and the Graduate School of the University of Oregon
in partial fulfillment of the requirements
for the degree of
Master of Science
June 2010
"An Examination of Group Parent Training with Contextualized Coaching on Positive
Parenting Practices," a thesis prepared by Dana Cohen in partial fulfillment of the
requirements for the Master of Science degree in the Department of Special Education
and Clinical Sciences. This thesis has been approved and accepted by:
~---
n, Chair of the Examining Committee
ii
Committee in Charge:
Accepted by:
Dr. Erin Barton, Chair
Dr. Jane Squires
Gerry Morgan
Dean of the Graduate School
© 2010 Dana Cohen
iii
IV
An Abstract of the Thesis of
Dana Cohen for the degree of Master of Science
in the Department of Special Education and Clinical Sciences
to be taken
Title: AN EXAMINATION OF GROUP PARENT TRAINING WITH
June 2010
CONTEXTUALIZED COACHING ON POSITIVE PARENTING PRACTICES
Approved: _:c-'-'_'(_'~_/G_~/------,.,L-/Jc_.;_,2(_/\../"L__·-----,f,---·_·-"_···_"-~ _
/' Dr. Erin Barton
There is some evidence to support the use of parent training with families with
young children with developmental disabilities exhibiting challenging behaviors.
However, not all caregivers respond to group parent training. The purpose of this paper is
to describe a study examining the use of contextualized coaching with a group parent
training with two high risk families. Maternal caregivers from both families participated
in a group based parent training using a modified version of the Incredible Years
curriculum provided by the local early intervention agency. A multiple baseline across
behaviors research design was used to examine the relation between contextualized
coaching and positive parenting practices. Contextualized coaching consisted of
individualized, performance-based feedback, live modeling, and material support. Results
indicate contextualized coaching was functionally related to increases in positive care-
giving practices. Results are discussed in terms of applications for practice and future
research in parent training.
v
CURRICULUM VITAE
NAME OF AUTHOR: Dana Cohen
PLACE OF BIRTH: Israel
DATE OF BIRTH: 12/11/1980
GRADUATE AND UNDERGRADUATE SCHOOLS ATTENDED:
University of Oregon, Eugene, OR, USA.
Hakibutzim College, Tel-Aviv, Israel.
DEGREES AWARDED:
Master of Science, June 2010, University of Oregon.
Bachelor of Education, June 2007, Hakibutzim College, Israel.
AREAS OF SPECIAL INTEREST:
Special Education and Family Guidance.
PROFESSIONAL EXPERIENCE:
Practicum intern, Early Childhood Cares, Eugene, Oregon, 2008-2010.
Research Assistant, Department of Special Education and Clinical Sciences,
University of Oregon, Eugene, 2010.
Leading preschool teacher for children with developmental delays, Ministry of
Education, Tel-Aviv, Israel, 2006-2008.
GRANTS, AWARDS AND HONORS:
Maalot Scholarship, Hakibutzim College, Tel-Aviv, Israel, 2002-2006.
VI
vii
ACKNOWLEDGMENTS
I wish to express sincere appreciation to Professor Barton for her assistance in the
preparation of this manuscript. I also thank the members of the committee members for
their valuable input. In addition, special thanks are due to Mr. Morgan whose familiarity
with the needs and ideas of the community was helpful during the early programming
phase of this study.
To my supporting husband who always believes in me.
viii
IX
TABLE OF CONTENTS
Chapter Page
I. INTRODUCTION.... 1
Prevalence.............................................................................................................. 1
Conceptual Framework for Parent Training.......................................................... 3
Transactional Approach 3
Applied Behavior Analysis 3
Family Determined Interventions 6
Parent Training Interventions................................................................................ 7
Group Parent Training 8
The Incredible Years Curriculum 16
Current Project 29
II. METHODS. 31
Participants............................................................................................................. 31
Adults............................................................................................................... 31
Children... 32
Settings................................................................................................................... 32
Group Caregiver Training 32
Baseline and Contextualized Coaching 33
Chapter Page
x
Research Design..................................................................................................... 34
Depended Measures 35
Group Caregiver Training................................................................................ 37
Baseline............................................................................................................ 38
Contextualized Coaching................................................................................. 38
Data Collection 40
Interobserver Agreement....................................................................................... 40
Treatment Integrity 41
III. RESlTLTS 42
Target Behaviors.... 42
Responsive Play 42
Labeled Praise 45
Limit Setting 45
Handling Challenging Behaviors..................................................................... 45
Follow-Up 45
PSOC 46
ASQ:SE............................................................................................................ 47
SEAM 47
Caregiver Attendance....................................................................................... 47
Social Validity................................................................................................. 47
Chapter
Xl
Page
IV. DISCUSSION 50
Limitations............................................................................................................. 53
Applications for Practice 55
Future Research..................................................................................................... 56
REFERENCES 58
xii
LIST OF FIGURES
Figure Page
1. Graphic Depiction of the Transactional Model 4
2. Prevention Pyramid............................................................................................... 9
3. Daily Feedback Form............................................................................................. 39
4. Brenda's Target Behaviors 43
5. Marcy's Target Behaviors...................................................................................... 44
xiii
LIST OF TABLES
Table Page
1. Caregiver Demographic Information..................................................................... 32
2. Child Demographic Information............................................................................ 33
3. Child Assessment Information................. 34
4. Operational Definitions of Parent Behaviors 36
5. Interobserver Agreement 40
6. Group Fidelity Checklist........................................................................................ 41
7. Percentage of Intervals with Target Behaviors at Baseline and Intervention........ 46
8. Percentage of Intervals with Target Behaviors at Follow-Up 46
9. Assessment Information......................................................................................... 48
10. Caregiver Concerns on the SEAM......................................................................... 49
11. Social Validity 49
1CHAPTER I
INTRODUCTION
Prevalence
The estimated rates of children with challenging behaviors and conduct disorders in
the general population vary widely across research studies. For example, Qi and Kaiser
(2003) estimated between three percent and six percent of children in the general
population exhibit challenging behaviors before kindergarten and about 30% of children
are from low income families. Hutchings et al. (2007) estimated between five percent and
ten percent of children between the age five and 15 years old met the criteria of conduct
disorder. As with Qi and Kaiser, they noted higher rates among single parent families and
financially disadvantaged families. Gross, Fogg, Garvey, Julion, Webster-Stratton, &
Grady (2003) reported that conduct disorder affects between seven percent and 35% of
preschoolers, again, with higher rates among children from financially disadvantaged
families.
Research consistently points to a higher prevalence rate for children with
developmental disabilities than children with typical development (Erbas, 2010);
however, the exact prevalence rates also vary (Emerson, 2003). Many children with
disabilities exhibit problem behaviors as a primary or secondary condition to a
developmental disability (Jolivette, Gallagher, Morrier, & Lambert, 2008). Emerson
(2003) estimated that children with disabilities are seven times more likely to meet the
criteria of conduct disorder. Roberts, Mazzucchelli, Studman, & Sanders (2006) reported
2between 41 % and 64% of preschool children with disabilities display severe problem
behaviors. Gavidia-Payne and Hudson (2002) reported similar rates. These variations
may be due to sampling procedures or diagnosis criteria (McIntyre, 2008). However, over
time and across studies, prevalence rates consistently point to higher rates among
children with disabilities.
This high prevalence has influenced both research and policy making. In the past
decade, several studies examined what types of interventions are most effective
preventing and reducing severe problem behaviors (Dunlap et aI., 2006). The primary
means of prevention is early identification (e.g., Ages and Stages Questionnaire: Social-
Emotional-ASQ:SE; Squires, Bricker & Twombly, 2002; Squires & Bricker, 2007).
When young children with or at risk for developing challenging behaviors are not .
identified early and given the appropriate intervention, their problems are more likely to
become severe and persist over time. Furthermore, children with challenging behaviors
are at a higher risk for academic failure and poor outcomes (Dunlap et aI., 2006; Erbas,
2010). Although systems (e.g., Child Find) and tools (e.g., ASQ:SE; Squires et aI., 2002)
for early identification are widely available, the identification and provision of
specialized services to address challenging behaviors remains inadequate (Dunlap et aI.
2006).
Recommended practices promote the use of early screening measures and the
provision of services as early as possible for children with challenging behaviors (DEC,
2007; Dunlap et aI., 2006; Squires & Bricker, 2007). This approach is consistent with the
universal prevention model (Brotman, Gouley, Chesir-Teran, Dennis, Klein, & Shrout,
32005) and stresses the importance of working with young children and their families
(Sharry, Guerin, Griffin, & Drumm, 2005; Squires & Bricker, 2007; Vaughn, Dunlap,
Fox, Clarke, & Bucy, 1997). Research consistently demonstrates a strong, direct relation
between parenting communication styles, healthy development, and prevention of
disruptive behaviors. Thus, the effects of a high quality early environment and early
intervention to prevent and reduce problem behaviors are essential (Brotman et al., 2005).
Conceptual Framework for Parent Training
Transactional approach. The transactional approach views development as a result
of interactions between the child and her environment. This model of development
stresses the reciprocal nature of early experiences, particularly the child's early social
environment, which is largely facilitated through the child's primary caregivers. This
approach considers the child's impact on her social environment and the reverse (i.e., the
environmental impact on the child), as primary factors in early development (Sameroff &
Fiese, 2000).As such, family context and positive experiences within the child's
immediate environment and the child's reactions to the context and early social
experiences become crucial for typical development (McIntyre & Phaneuf, 2008).The
cyclic nature of the transactional model is often depicted with two arrows pointing
towards each other (See Figure 1).
Applied behavior analysis. Recent parent training research indicates that parent
knowledge of applied behavioral principles is the most important factor associated with
positive outcomes over time (Joseph & Strain, 2003; Lucyshyn, Dunlap, & Albin, 2002;
Matson, Mahan, & LoVullo, 2009). Applied behavior analysis (ABA) is one of three
4Figure 1. Graphic depiction of the transactional model.
of behavior analysis. In general, behavior analysis uses scientific principles to examine
behavior. However, with applied behavior analysis, the focus is on examining socially
important behaviors of concern to caregivers in natural settings (Cooper, Heron, &
Heward, 2007). ABA uses scientific principles to increase socially important behaviors
and decrease maladaptive behaviors. Furthermore, the focus is on using strategies or
intervention practices in natural settings by primary caregivers (e.g., parents or teachers).
Specific strategies based on the principles of ABA include: a functional approach to
challenging behaviors, shaping, prompt fading, token economies, differential
reinforcement, planned ignoring, teaching generative skills, and programming common
stimuli. For example, a functional approach to challenging behaviors teaches parents and
caregivers to use direct and indirect assessments to determine the function (i.e., what the
child is attempting to communicate) of the challenging behavior (i.e., obtain or avoid)
and develop interventions to teach functional communication skills to replace the
challenging behavior (Cooper, Heron, & Heward, 2007).
Evidence-based parent training curricula emphasize ABA principles and stress the
importance of positive parent- child interactions and generalization of skills across
settings. Research indicates that maintenance of positive parenting practices over time is
5more likely when the basic principles of applied behavior analysis are verbally taught,
modeled, and rehearsed in role play (Harvey, Boer, Meyer, & Evans, 2009; Kaminsky,
Valle, Filene & Boyle, 2008; Matson et al., 2009). The three most commonly used
evidence-based parent-training curricula focus on principles of applied behavior analysis
(Matson et al., 2009). These are Parent Plus Program, The Stepping Stones Triple P
Program (SSTP), and Incredible Years. Parent Plus Program is a group-based training
that was adapted in 2007 for preschool age children with disabilities. Parents who
participated in the Parent Plus Program improved their use of positive parenting practices
and showed maintenance at a ten month follow-up. SSTP is a behaviorally oriented
program with an emphasis on social skills learning. Parents' use of positive parenting
practices maintained for one year after participating in the SSTP. The Incredible Years
program teaches parents child-directed play, praise, limit setting, reinforcement, and
replacement skills. The purpose of teaching these strategies is to increase positive
interactions between parents and children and provide parents with tools to reduce
challenging behaviors (Matson et al., 2009, Webster-Stratton, 2008)
Harvey et al. (2009) conducted a meta-analysis for treatment validity and
standards for practice within intervention research addressing challenging behaviors.
They identified 142 articles published between 1998 and 2006 with three hundred
participants involved in the identified studies. Interventions in this study were analyzed to
examine different aspects of change using an effect size algorithm. Data from this
comprehensive analysis support the growing research and practice of interventions based
on applied behavior analysis (Dunlap et al., 2006). Evaluation of patterns of interventions
6indicated that antecedent based changes (e.g., using visual prompts or verbal cues) were
most effective with disruptive and self-injurious behaviors. Contingency management
(e.g., systems of reinforcement or token economies) resulted in a reduction of
inappropriate social behaviors. Skill replacement (e.g., teaching replacement behaviors)
was the most effective with all categories of behaviors (i.e., self injury, stereotypic
behaviors, disruptive and inappropriate behavior). Furthermore, the authors found that
interventions based on function based assessments produced larger effects. This suggests
that programs that address or prevent challenging behaviors should include principles of
applied behavior analysis (i.e., a functional approach) with an emphasis on teaching
children socially important replacement skills (Harvey et al., 2009).
Family determined interventions. Caregivers spend the largest amount of time
with children and are the primary model for social interactions (Bruder, 2000). Current
research stresses parent-child interactions are a primary predictor for developing behavior
problems (Reid, Webster-Stratton, & Baydar, 2004; Webster-Stratton, Reid & Hammond,
2004). The complex nature of these relationships and the importance of parent wellbeing
should be considered when designing and implementing prevention programs (Matson et
al., 2009). Caregivers provide the greatest influence on child development. The primary
goal of early intervention is to enhance the families' sense of confidence, ability to parent
their children, and competency in supporting their development (Bruder, 2000;
Gallagher, Rhodes and Darling, 2004). In fact, parental stress is often associated with
negative outcomes (Erbas, 201O).Interventions with young children should actively
involve and support caregivers to enhance child development across domains.
7"Caring for a child with a developmental disability can be a daunting and
challenging experience for parents. These parents spend more time involved in direct
care-giving tasks with their children than parents of typically developing children" (Plant
& Sanders, 2007, p.362). Families with children with developmental delays experience
more stress and dysfunction (Baker, Blacher, Crnic, & Edelbrock, 2002; McIntyre, 2008).
One possible factor exacerbating stress and dysfunction is the presence of challenging or
maladaptive behaviors. As previously mentioned, prevalence estimates indicate that
children with disabilities demonstrate higher rates of challenging behaviors than typical
peers (e.g., Baker et aI., 2002). Furthermore, delays in motor planning, cognitive skills,
and communication abilities may impair communication and social skill development.
These impairments increase the likelihood of challenging behaviors, and have negative
effects on parent-child interactions and the whole family system.
Parent Training Interventions
For the past 30 years, the field of early intervention has examined the role of
parental styles and practices on children inappropriate behaviors and outcomes (Kazdin,
1997). Negative parent-child interactions, coercive parenting, harsh discipline, criticism,
and ineffective limit setting have been shown to have a deleterious impact on the
development and persistence of children's conduct problems (Kazdin, 1997; Nicols,
2009; Scott, Sylva, Doolan, Price, lacbos, Crook, & Landau, 2010; Sharry et aI., 2005).
Successful interventions focus on facilitating positive parent-child interactions to
improve child adaptive functioning. Effective programs teach caregivers appropriate
strategies for changing their own behaviors and in turn improve child behaviors (Gross et
8al., 2003; Erbas, 2010; Reid et al., 2004; Roberts et al., 2006). Intervention delivery
models include individual parent-child training (Beauchaine, Webster-Stratton, Reid &
Hammond, 2004; Lundhal, Risser, & Lovejoy, 2006; Webster-Stratton, 1984), group
parent training (Brotman et al., 2005; Nicols, 2009; Plant & Sanders, 2007; Roberts et al.,
2006), combined parent-child training, and teacher training (Powell, Dunlap & Fox,
2006; Webster-Stratton et al., 2004; Webster-Stratton & Hammond, 1997). Parent
training programs have been implemented for both prevention and treatment (McIntyre &
Phaneuf, 2008). The next section provides an overview of group parent training
programs.
Group parent training. Numerous programs have been developed to prevent and
reduce challenging behaviors in young children. Educational systems have adopted the
model of prevention and intervention from the public health sector. The model is
represented by a pyramid and provides a hierarchical framework for prevention and
intervention activities (Powell et al., 2006). The model includes four levels (See Figure
2). The first two levels are universal and address support needed by all children, building
positive relationships and prevention activities in home and classrooms settings. These
levels address children's need for developing positive relationships to build their social
emotional competence. They include strategies to promote secure attachment and positive
relationships. The third level targets young children at risk for developing behavior
problems. This level addresses individualized strategies for implementation within
natural contexts to enable teachers and caregivers to increase positive interactions and
teach appropriate social skills. This level also includes strategies for caregivers such as
9group training and individual coaching for parents across settings. The focus is to provide
parents with an opportunity to obtain contextual feedback, practice skills, and problem
solve in natural situations.
The top level of the pyramid addresses the needs of children with persistent
challenges or families with several risk factors who might need more intensive,
individualized intervention. Interventions at this level often include multiple components.
One example of a multiple component intervention is the Incredible Years parent and
teacher series and child focus intervention (Powell et al., 2006; Webster-Stratton et al.,
2004).
Intensive
individual
intervention
Social emotional coaching for
children at risk
Preventative activities to all children across settings
and routines
Building positive relationships for all children.
Figure 2. Prevention pyramid (adapted from Powell, et al., 2006).
10
The increased prevalence of young children exhibiting problem behaviors has
influenced national policy. No Child Left Behind (NCLB) and Part C of the Individuals
with Disabilities Education Act (IDEA) stress the need to translate research findings to
practice in natural settings (Dunlap et al., 2006). Over the past decade researchers have
examined a wide range of interventions to implement in natural settings. Syntheses of
these interventions indicate that evidence-based interventions are based on principles of
applied behavior analysis and social learning theory (Conroy, Dunlap, Clarke, & Alter,
2005; Lundhal et al., 2006). For example, Conroy et al. (2005) conducted a critical
review of positive behavior interventions with children age six or younger. They
examined experimental studies with at least one participant younger than six years of age.
Seventy-three articles were identified as meeting the inclusion criteria. The authors found
that 79% (n=58) of the studies included young children with disabilities, which supports
current data on higher incidence among this population (Emerson, 2003; Hutchings et al.,
2007).Sixty-six percent (n=48) of studies implemented instructional interventions (i.e.,
teaching children replacement skills) including: functional communication skills,
problem solving skills, and alternative adaptive behaviors. More than two thirds (n=29)
of studies were conducted in community school settings, 26% (n: 19) at children's
homes, and 22% (n= 16) in special educations settings. The authors concluded that this
literature was limited by a lack of systematic programming and measurement for
generalization and maintenance and insufficient measurement of social validity (Conroy
et al., 2005).
11
Kaminski et aI. (2008) used meta-analysis methods to synthesize results from 77
evaluations of parent training programs designed to reduce challenging behaviors in
children younger than seven years of age. The study indicated a significant positive
impact on changing parental behaviors and preventing the development of disruptive
behaviors across parent training programs. Parent training that included teaching parents
strategies for increasing positive parent-child interactions and required practice of new
skills were related to a significantly stronger positive impact on child and parent
outcomes. Also, a focus on consistency in discipline practices was related to a reduction
in challenging behaviors. Their analysis also suggested that parent's engagement and
active learning (e.g. modeling, role play and home work practicing new strategies) were
better predictors for positive outcomes then the mere use of standard manuals(Kaminski
et aI., 2008).
Lundhal et al. (2006) also conducted a meta-analysis of parent training on
reducing challenging behaviors in young children. They included 63 studies in their
review (i.e., 36 group training and 18 individual training). The purpose of their analysis
was to compare the effect of behavioral parent training and non-behavioral programs on
disruptive child behaviors and parental behavior. They examined two child outcomes,
(i.e., child behavior and child adjustment) and three main parent outcomes (i.e., parent
behavior, parents' perception of parenting, and general adjustment). The authors found
that single parent families demonstrated less positive outcomes compared with two
caregiver households. Results indicated that family adversity often presents a barrier for
positive changes in parental behavior. These findings suggest that for financially
12
disadvantaged families, individual parent training was significantly related to better
outcomes (for both parent and child behaviors) than group training. Individually
delivered intervention can be better tailored to the unique conditions of a given family.
They reported that only four studies of the non-behavioral training included follow up
data; thus, more information is needed to conclude superior effectiveness of behavioral
training. The authors emphasized that there should be greater focus on generalization and
maintenance in future research and practices (Lundhal et al., 2006).
Conversely, DeRosier and Gilliom (2007) found no differences between single
group training (e.g., parent training) and combined training (e.g., parent combined with
child training). They conducted a randomized trial of 42 families randomly assigned to
one of three conditions: parent training, parent and child training and a control group.
Parent training followed the Parent Guide for Social Skills curriculum. The model was
based on cognitive-behavior theory. Their data suggested that outcomes were similar for
conditions, parent training and parent training combined with child group. They reported
moderate to large effect sizes for both parent and child outcomes over time.
Plant and Sanders (2007) utilized an adapted version of the Stepping Stones Triple
P- parenting program. Seventy-four families were randomly assigned to one of three
conditions: Standard Stepping Stones Triple P group (SSTP-S), Stepping Stones Triple P-
Enhanced (SSTP-E), and a waiting list. The enhanced program (SSTP-E) included
additional training designed to support parents in caring for a young child with
disabilities. The training focused on minimizing family risk factors, coping with stress,
collaborating with professionals, time management, and enhancing social supports. Both
13
treatment groups showed significant progress in child behavior based on parent report.
Sixty-seven percent of children in the SSTP-S and 77% in the SSTP-E demonstrated a
30% reduction in negative behavior. Children in both training groups no longer met
clinical criteria for behaviors disorders. At a one-year follow-up, there was no evidence
for superiority of the SSTP-E over the standard group. These findings support current
knowledge that group-based parent trainings using a behavioral framework are effective
(Harvey et aI., 2009 & Plant & Sanders, 2007).
Niccols (2009) examined short-term outcomes of a parent group called COPEING
with Toddler Behavior. The purpose of this study was to examine the COPEING
effectiveness as a preventive program with non-clinical, at-risk toddlers. Parents in this
program identified errors and assessed their own responses using program video clips.
COPEING with Toddler Behavior is based on active learning approach adopted from the
Coping Modeling Problem Solving Approach. Similar to the Incredible Years BASIC
program (Webster-Stratton, 2008) this model focuses on parenting styles and strategies to
prevent the development of disruptive behaviors in toddlers. In a randomized controlled
study the author examined the effect of the COPEING program on child and parent
behaviors. Findings from this study are consistent with previous data that supports group-
based training (Plant & Sanders, 2007). Results from this pilot investigation indicated
significantly lower scores on the Eyberg Child Behavior Inventory Problem Scale
(Eyberg & Pincus, 1999) and a significant improvement in parent-child interactions. The
author suggested that COPEING with Toddlers Behavior parent group is consistent with
14
prevention programs for families with children at risk for severe behavior problems
(Niccols, 2009).
A recent study conducted by Scott et al. (2010) in the United Kingdom examined
the effect of the SPOKES project. The project targets four risk factors: hostile parenting
style, symptoms of conduct disorder, attention deficit hyperactivity disorder (ADHD)
symptoms, and poor reading skills. This group project was adapted from the Incredible
Years school age program (i.e., video modeling with a focus on child cooperation, praise
and rewards, handling misbehavior, natural consequences, and time out). They also
included a child literacy component (i.e., relating the text in books to children's daily
experiences by mutual parent- child discussion). Participants were randomly assigned to
the SPOKE project or to a control group. After the intervention, parents reported they
spent more time engaging in play with their children. Direct observations of parents in
the intervention group showed higher parental responsiveness, higher rates of positive
attention communicated through praise, and less hostility. Antisocial behaviors dropped
from the 81 st to 61stpercentile. Parents reported improvement of ADHD symptoms with a
moderate effect size, diagnosis of oppositional disorder dropped from 60% to 31 %, and
reading skills increased from the 40th percentile to the 75th in average. These results
suggest that manipulating important aspects of a child's environment can have
measurable effects on challenging behaviors. The primary limitation this study was
attrition and attendance. Only 40% of parents with children identified as at risk took part
in the study. Parents reported that the delivery model (one morning a week) and the
distant location limited accessibility and effectiveness. Also, a quarter of the parents did
15
not complete the follow-up measures. Hence, despite the evidence of efficacy, group
models of parent training are often limited by attendance and accessibility (Scott et al.,
2010).
Although the plethora of research on parent trainings provides sound evidence for
their usefulness with parents of young children with challenging behaviors, not all
families respond and benefit from these programs (McIntyre & Phaneuf, 2008). Scott and
Dadds (2009) reported that between a quarter and a third of the families and their
children do not benefit from evidence-based group training programs. Many parent
factors (e.g., education level, mental health, marital, socioeconomic status and stress),
child factors (e.g., age, severity and duration of behaviors and developmental
disabilities), and treatment delivery models (Beauchaine et al., 2005; Lundhal et al.,
2006; Roberts et al. 2006) influence treatment outcomes. McIntyre and Phaneuf (2008)
suggested a three-tier problem solving approach to balance program intensity with family
specific characteristics and needs. The first tier utilizes self-administrated programs. This
type of program includes manuals or audiovisual materials, to promote accessibility for
as many families as possible. The second tier utilizes group-based training, it offers more
intensive support. This delivery model provides feedback from therapist and other parents
to increase parental self-competency. The third tier utilizes individual programs offering
one-on-one direct feedback. Individual sessions provide parents with an opportunity to
problem solve with the therapist within their unique context while also participating in
the group training. Research suggests that families experiencing poverty or low
socioeconomic status benefit more from individual than group-based intervention
16
(Lundhal et al., 2006). The model suggested by McIntyre and Phaneuf (2008) offers an
approach to support families who do not benefit from traditional parent training programs
(Scott & Dads, 2009).
"Family involvement in the planning and implementation of interventions
facilitates durable reductions in challenging behaviors of young children" (Dunlap et al.
2006, p. 38). Interventions that provide parents with opportunities to practice behavioral
strategies (e.g., positive reinforcement, praise, and following natural consequences) are
more likely to be effective (Conroy et al., 2005; Kaminski et al., 2008). Research
suggests that parent training can result in positive change for both parent and child
(Taylor, Schmidt, Pepler, & Hodgins, 1998). Randomized trials (Brotman, Klien,
Kamboukos, Brown, Coard, & Sosinsky, 2003; Hutchings et al., 2007; Reid et al., 2004),
follow up studies (Beauchaine et al., 2005;Gardner, Burton, & Klimes, 2006) and
comprehensive meta-analysis (Harvey et al., 2009; Lundhal et al.2006) suggest that group
parent trainings are effective for reducing and preventing child challenging behaviors.
One of the most researched parent training programs is the Incredible Years curriculum
series developed by Carolyn Webster-Stratton (1982, revised in 2001 and 2008) at the
University of Washington. The next section provides a literature review of the Incredible
Years series and the research to support it.
The Incredible Years Curriculum
The Incredible Years series was first developed by Webster-Stratton in 1982 and
revised in 2001 and 2008. The series includes parent, teacher, and child programs. Parent
training curricula include the Baby program, Toddler program, BASIC Early Childhood
17
program, and the school readiness program. Teacher training includes five programs that
address classroom management. The Dina Dinosaur training offers a comprehensive class
based curriculum to support children's social- emotional development. All training
programs can be used as prevention or intervention programs (Webster-Stratton, 2008).
The Incredible Years BASIC is a parent training curriculum designed to prevent
and reduce challenging behaviors in young children The curriculum targets several
populations: parents with children ages three to six, parents of children with conduct
behavior problems and attention deficit disorder between ages three to six, parents at risk
for abuse or neglect, foster and adoptive parents, teenagers participating in family life
courses, and professionals who work with children (e.g., social workers, therapists,
teachers, nurses, physicians, child protective providers and daycare providers; Webster-
Stratton, 2008).
The Incredible Years addresses each level of intervention according to the risk
pyramid. The first three levels of the pyramid are universal and are designed to prevent
challenging behaviors and the development of behavior disorders in young children. The
two highest levels address intervention for parents whose children demonstrate symptoms
of or are diagnosed with behavior disorders (Incredible Years Programs, 2009).
Based on socialleaming theory and principles of applied behavior analysis,
Webster-Stratton carefully designed video vignettes that address communication and
behavior principles to promote positive parent-child interactions. The vignettes follow the
five-level prevention pyramid. The first level focuses on child-directed play. This level
addresses children's need for positive attention during play. Parents are taught to follow
18
their child's lead in play to promote language and social interactions (Webster-Stratton,
2008). Child-directed play is the universal level. It is viewed as the preventative tier, as
child-directed play occasions more positive social and communicative interactions
between children and their caregivers. Also, child-directed play has practical value; play
is a practical alternative to maladaptive behaviors (Barton & Wolery, 2008).
The second level teaches parents to use differential praise as a celebration of
expected behavior. The first two levels lay the foundation for positive interactions.
"These programs show parents ways to play with children and to use praise and rewards
to encourage cooperation, foster creativity, build self esteem, and strengthen pro-social
behaviors" (Webster-Stratton, 2008, p.l?). Teaching replacement skills are emphasized
throughout the training phases. Parents are given several opportunities to practice
phrasing negative behaviors positively.
The third level emphasizes the importance of effective limit setting; this part of
the curricula explains the importance of clear expectations (e.g., house rules) and
consistent follow through to decrease the likelihood of challenging behaviors. The fourth
and fifth levels offer parents strategies for delivering effective consequences when
challenging behaviors occur. These strategies are based on two main principles. The first
principle focuses on ignoring undesired behavior. Group leaders present the role attention
has on decreasing undesired behaviors and increasing positive ones. Parents have
opportunities to discuss the importance of consistent consequences. The second principle
focuses on using natural consequences to teach children replacement skills The program
19
provides parents strategies for using time out to help children calm down rather than as a
punishment (Cooper et al., 2007; Webster- Stratton, 2008).
The Incredible Years curriculum content is delivered via several different
methods. The primary teaching method is video modeling, which is used to increase
attention and accessibility. Also, social modeling theories suggest that parents are more
likely to alter their behaviors to promote positive parent-child interactions after watching
examples of such interactions (Sharry et al., 2005; Webster- Stratton, 1981, 1982). The
video vignettes incorporate parents and children of different ages, sex, background,
ethnicity, socioeconomic status, and family structure and display a range of everyday
situations and routines. The purpose of the vignettes is to provide parents with the
opportunity to identify their own responses in similar situations and to reflect on their
child's responses. Thus, the video vignettes lead to a group discussion and problem
solving (Webster-Stratton, 1981, 1982,2008).
The second component of the curriculum is defined by the author as a
collaborative process. In this model, the leader is not the expert. Instead, the group leader
and parents have a reciprocal relationship. They share experiences, discuss self-
reflections, reframe video vignettes to their own lives, and engage in role playing
exercises. The group leader refers to parents as the primary experts in relation to their
own children to encourage internalization of the core concepts and maintain them over
time (Webster-Stratton, 2008). Parents are offered weekly homework practice activities
to promote maintenance of skills. Homework includes reading materials, watching CDs
20
observational (e.g., observing child behaviors across daily routines) and reflection
activities (Webster-Stratton, 2008). These activities provide opportunities for parents to
discuss which strategies are easier to implement and identify generalization components.
The Incredible Years series has been substantially studied since it was first
published. Two randomized control studies conducted by Webster-Stratton in 1981 and
1982 examined the effects of the training on parenting practices. Results indicated that
video modeling procedure was significantly related to improvements in specific parenting
behaviors. These results supported the assumption that group training using video
modeling is cost effective, because it can be used to increase accessibility, particularly for
families with children with challenging behaviors. However, the participants were all
Caucasian, middle-upper class, and parents reported at least four years of college
education. Nonetheless, this sample was considered representative of nonclinical, self-
seeking parents. Subsequent studies have found the Incredible Year program was
effective for families from a range of racial and economic backgrounds (Webster-
Stratton, 1981, 1982,2008).
Over the years, research has shown higher prevalence of risk factors among low-
income families (Gardner et al., 2006; Gross et al., 2003; Hutchings et al., 2007; Powell
et al., 2006). Children from low socioeconomic backgrounds are more likely to exhibit
problem behaviors at preschool age (Qi & Kaiser, 2003). Qi and Kaiser identified risk
factors related to the development of behavior problems in preschool children from
financial disadvantaged families. Their results are framed within a transactional model of
child development. For example, infants classified with disorganized attachment are less
21
likely to experience positive interactions with parents and subsequently at high risk for
developing severe behavior problems by the age five. Temperament and prematurity were
also found as a predictor for later challenges. For example, the study showed that
"parents of preterm children reported more hyperactivity by their children than did
parents of full-term children" (p. 193). The authors found that children from low-income
families have an overall lower IQ level which associates with higher rates of behavioral
problems. Studies also indicated that children from low-income families present with less
sophisticated social skills. The authors identify the connection between higher Child
Behavior Check List (CBCL; Achenbach, 1991a) total scores and lower social skills (Qi
& Kaiser, 2003).
The alarming increasing rates of young children who meet the diagnostic criteria
for conduct disorder shifted national focus from intervention to prevention (Dunlap et al.,
2006). Effective prevention programs identify and minimize risk factors associated with
aggressive behaviors. Harsh parenting, high stress, and negative interactions are
indicators of high risk for developing behavior disorders. In repeated randomized trials,
the Incredible Years has been shown to be a cost effective prevention approach that
addresses risk factors associated with low-income. Compared with clinical-based
individual therapy and combined parent training with child and teacher training, parents
assigned to the Incredible Years group-based training showed significant improvement
immediately after treatment and maintained these improvements at six month and one-
year (Taylor et al., 1998; Webster-Stratton et al., 2004).
22
In the past decade researchers have evaluated the Incredible Years curriculum as a
prevention program with families experiencing poverty and other risk factors. Webster-
Stratton and her colleagues examined the parent program training as a prevention
program for multiethnic, emolled in Head Start programs. In their study Reid et al.
(2004) included 14 centers (n=882 families) in the experiment group between 1993 and
1997. Mothers and children were classified as indicated if mothers made more than ten
correction statements during home observation and if the child scored more than one
standard deviation above the mean on the Child Behavior Checklist Teacher Report Form
(Achenbach, 19991b). Results suggested that the Incredible Years can be used as a
prevention program for conduct behaviors by improving parent and child behaviors. Date
showed a correlation between mother's attendance and their use of critical statements.
Forty percent of mothers in this experiment were defined as non-attendees, meaning that
they attended less than three sessions. The authors suggested that future research should
examine barriers for attendance and attrition (Reid et al., 2004).
Gross et al. (2003) examined the curriculum efficiency with parents of toddlers in
a low-income, urban community. Eleven day-care centers were randomly assigned to one
of four conditions: parent training, parent and teacher training, teacher training, and
control group. Parent behaviors measured in this study included: praise, positive parent
behavior, affect, use of indirect and direct commands, critical statements, and negative
physical behavior. Children's rate and severity of behaviors were measured by parent and
teacher report, and direct observation. All parents who received parent training showed a
significant increase and maintenance of positive strategies at post-intervention and at a
23
one-year follow-up. Immediately at post-intervention, over 40% of children categorized
as high risk at baseline improved to the low risk category and close to 70% of the
children demonstrated improvement at a one year follow-up. Children whose parents
received parent training only demonstrated significant improvement in classroom
behavior suggesting that parent training alone may promote generalization of child
behaviors. The authors reported a dropout rate of 30%, which is similar to previous
studies (Gross et al., 2003; Reid et al., 2004; Scott et al., 2010). They also stressed that
future research should focus on strategies for improving parent attrition.
Brotman et al. (2003) provided further support for the Incredible Years as a
preventative intervention for families with multiple risk factors. The authors used
Webster-Stratton's curriculum with low-income preschoolers with a family history of
antisocial behaviors. Parents in the experimental group received home visits to help
generalize skills taught in the group. Home visits provided an opportunity for parents to
practice positive discipline and child-directed play within the family context in order to
increase parents' competencies. Parents in the experimental group showed increased
responsiveness and child externalizing behaviors decreased over time.
Brotman et al. (2005) examined the use of the Incredible Years as a prevention
program with low-income, preschool siblings of children with conduct or behavior
disorders. This study targeted population with multiple risk factors: familial risk factors
for antisocial behavior and financial disadvantage. Ninety-nine children and their families
were randomly assigned to a control or experiment group. The experiment group
provided parents with multilevel group intervention for parents and children following
24
the Incredible Years curriculum once a week (two hours) over 22 weeks with ten
biweekly 90 minutes home visits. Low cost activities were used to facilitate parent-child
interactions at the end of each group session. These activities provided parents an
opportunity to practice skills with direct feedback and reinforcement by the group
leaders. Home visits were designed to help parents apply strategies discussed in the
curriculum to fit their environment and needs. Data showed high parental satisfaction
with this model which resulted in high attendance rates (e.g., all participants attended
more than half of group sessions and all home visits). Parents and children demonstrated
clinical benefits reducing negative parenting and increase in children's social
competence. These outcomes provide evidence that this model can result in long-term
preventative effects. Future research should investigate which added component had the
most influence (i.e., child group, direct feedback at the end of each session, or home
visits) to better understand the essential components (Brotman et al., .2005).
Hutchings et al. (2007) conducted a randomized trial to evaluate the
implementation of the Incredible Years parent curriculum with low-income families
receiving Sure Start services in Wales, United Kingdom. Results indicated reduced
criticism among participants and a significant reduction in child deviance for families in
the experiment group. Parents reported lower level of stress and depression, and higher
competence level. These findings support previous research (e.g. Gross et al., 2003).
Although few studies have investigated the prevalence of conduct disorder among
children with disabilities, findings suggest that children with development delays are
more likely to develop severe behavioral disorders than typically developing children
25
(Emerson, 2003). Parent support and training become crucial for families of children with
disabilities because the child's disabilities may impose an additional stressor that may
impact the family structure (McIntyre, 2008). Research has continually emphasized the
high association between inappropriate or negative parent-child interactions and the
development of challenging behaviors and severe behavior disorders (e.g., Jones, Daley,
Hutchings, Bywater & Rames, 2007; Reid et al., 2004). Previous research on the
Incredible Years curriculum concluded that this program is efficient in reducing child
behavior problems by increasing parent positive discipline strategies, primarily for low-
income families with typical developing children.
In the last several years McIntyre (2008) has examined the efficiency of the
Incredible Years for families with young children with disabilities. Although very little
research was done on the utility of the Incredible Years with parents of children with
special needs, McIntyre hypothesized the behavior principles underlying the curriculum
would be appropriate with slight modifications for this population. The primary
modification she found was to include a discussion about the adaptations for children's
developmental level, needs, and interests. Results from her study suggest that the
Incredible Years program yields similar results to previous findings with low-income
families. Focusing on improving parenting practices led to an increase in positive parent-
child interactions and positive child outcomes over time. Parents reported that the
adaptations to the curriculum during weekly group sessions were helpful. These results
support past research suggesting group-based parent training is a successful intervention
as well as cost effective (Plant & Sanders, 2007).
26
Additionally, McIntyre (2008) conducted the first randomized control trial
evaluating the Incredible Years as a training program for parents of children with
developmental delays. Twenty-one families with preschool children eligible for special
education services in New York State were randomly assigned to a control or
experimental group (i.e., receiving a 12-week parent training using the Incredible Years
program). Preliminary findings indicated that early intervention using the Incredible
Years program can have a positive impact on parent practices for families with children
with developmental disability. Further replications are needed to confirm these findings
and broaden the use of this program by special education agencies.
Jones et al. (2007) examined the efficacy of the Incredible Years curriculum with
families with children exhibiting externalized behaviors and hyperactivity symptoms.
Seventy-nine families with children that exhibited scores above cutoff on the Eyberg
Child Behavior Inventory (Eyberg, & Pincus, 1999) were randomly assigned to a waiting
list or a treatment group. Post-treatment results showed that 58% of children in the
experiment group were below clinical concern regarding hyperactivity symptoms. These
results support previous findings that parent training and specifically the Incredible Years
program are related to positive child and family outcomes (McIntyre, 2008).
Lees and Ronan (2008) conducted a study with four single mother families with
children diagnosed with ADHD in New Zealand. The authors used a multiple baseline
design to examine the effects of the Incredible Years parent training curriculum on the
behaviors of parents of children with ADHD. The training involved two-hour weekly
sessions over 20 weeks with a booster session at two month post-treatment and a four
27
month follow-up. In the effort to keep mothers engaged, the group leader helped mothers
set individual weekly goals and provided feedback accordingly. Therapists conducted a
weekly phone call to problem solve individual barriers. The therapists also conducted
home visits during baseline condition to provide an opportunity to observe the families at
home. All four mothers completed the program with high attendance rate (attendance at
more than sixteen sessions). Mothers monitored child behaviors daily and reported both
positive and negative behaviors. Results indicated all four children exhibited increased
rates of positive behaviors. Further, two children demonstrated a steady decrease in
negative behaviors over time. Mothers exhibited improvement in their interactions with
their children on both self-report questionnaires and direct observation. Future research
should examine the impact of this training with single mothers and families with
additional risk factors (e.g., children diagnosed with other disabling conditions; Lee &
Ronan, 2008).
The Incredible Years was designed for typical developing children and their
parents. In an effort to prevent maladaptive patterns of parent-child interactions, Phaneuf
. and McIntyre (2007) used a multiple baseline design to evaluate the extent to which
individualized video feedback enhanced the implementation of skills discussed at group
for twelve families of young children with disabilities. Parents attended a group training
for two and a half hours, once per week, over 11 weeks and received weekly video based
feedback. Data were collected during weekly 15-minute videotaped observations that
included ten minutes of play, two minutes of clean up and three minutes of a structured
activity. The content of the feedback sessions followed the parent group curriculum (Le.,
28
child-directed play, praise and reward, limit setting, and handling misbehavior). Parents'
inappropriate behaviors significantly decreased after treatment; thus, the treatment was
functionally related to decreases in maladaptive parenting practices. Phaneuf and
McIntyre (2007) provided preliminary evidence for adapting this curriculum for mothers
of children with developmental delays. Furthermore, their results suggest the combination
of group training with individualized-based video feedback could be used as an early
prevention program for parents of children with disabilities who are at risk for developing
persistent behavior problems.
In summary the Incredible Years appears to be an effective parent training
program. The Incredible Years curriculum has extensive evidence for use with families
with a variety of risk factors. However, research on the Incredible Years is limited in
several ways. First, few studies have examined increases in positive parental practices,
most studies has examined decreases in negative parent behaviors. Further, none of the
studies examined an increase in positive parenting practices with parents of children with
disabilities. Second, few studies have examined adding individualized components to the
group training. McIntyre and Phaneuf (2007) found that video feedback is effective with
families with children with disabilities. However, this type of feedback might be costly
and less accessible to practitioners. Third, current research studies on professional
development in early childhood indicates that group trainings are more effective with
follow-up coaching including feedback and practice (e.g., Casey & McWilliam, 2008;
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). However, few studies have
systematically examined the use of individualized, focused coaching during home visits
29
with families of children with disabilities. These families are likely to already receive
coordinated special education services including weekly or biweekly horne visits by early
intervention practitioners or special education teachers. Thus, training early
interventionist practitioners and special education teachers to conduct coaching with
parents participating in group training might promote generalization, maintenance, higher
rates of attendance, and a reduction in attrition. Finally, few studies have examined the
social validity of group trainings for caregivers. Social validity measures are essential for
understanding if primary caregivers can implement interventions in natural settings and if
the interventions produced therapeutic changes in the behaviors of concern for the child
and their primary caregivers (Kennedy, 2005).
Current Project
The current project addressed limitations in the literature by examining the effects
of horne visiting with contextualized coaching (individualized performance based
feedback, modeling, role play, and discussion) on positive parenting practices of parents
attending a group training using the Incredible Years curriculum and measuring social .
validity after the training. The objectives of this project were to examine the relation
between the group-based parent training and contextualized coaching and positive
parenting practices in parents of young children with disabilities. It was hypothesized that
the horne visiting component would decrease the likelihood of attrition and would
increase the likelihood of success for parents with multiple risk factors. The target
parenting practices were: responsive play, praise, appropriate limit setting, and handling
misbehaviors. A multiple baseline design across behaviors across caregivers was used to
30
examine the effectiveness of contextualized coaching during horne visits. The
intervention focused on teaching parents to be their child's play and communicative
partners and to prevent challenging behaviors.
Child challenging behaviors have been associated with negative interactions
between children with disabilities and their parents (Erbas, 2010). Thus, the outcomes of
this intervention were to increase positive parent-child interactions while decreasing
children challenging behaviors. Parents were taught to implement the targeted skills (i.e.,
responsive play, the use of praise and rewards, limit setting, and positive strategies to
handle misbehaviors) during structured group-based cULTiculum. Weekly horne visits
provided opportunities to discuss and practice the strategies in natural settings. Thus, the
content of the horne visits and performance-based feedback aligned with the group
curriculum.
31
CHAPTER II
METHODS
Participants
Inclusion criteria for caregivers were: (1) having a young child (ages 36 months-
60 months) with developmental delays and eligibility for special education services, (2)
planned enrollment in the group parent training program offered by the local early
intervention agency (i.e., based on the Incredible Years curriculum), (3) availability to
attend all weekly group training sessions based on caregiver report, (4) parental concerns
about the child's challenging behaviors at home, (5) consent to participate in the research,
(6) no current weekly home visits through the local early intervention agency, (7)
residence in the surrounding areas, and (8) English language proficiency. Two families
volunteered to participate in the study and each met the inclusion criteria. Both were
recruited through the local early intervention agency.
Adults. Both participating caregivers were mothers. Caregivers completed a
demographic questionnaire at the start of the study. Both mothers were Caucasian and
reported low-middle socioeconomic status. Caregiver demographic information is
described in Table 1. Brenda directed a childcare center at her home during the day.
Marcy was employed part time as home care provider for the elderly; she was a single
caregiver.
32
Table 1. Caregiver Demographic Information
Primary Race Age
Caregiver
Number
of
children
Income Health
Information
---------Parent Risk factors
Sense of
Efficacy
(PSOC)
.-..~.~_.__.--.----~.----
Pre Post
Brenda
Marcy
Caucasian 30
Caucasian 38
4
2
Between Experiencing 3.88 5 Depression
40,000 depression
and 50,00 for 4 years
Less than 3.82 4.05 Single
20,000 caregiver
household,
low-income
Children. Two children participated in this study. Both children received services
from the local early intervention agency in community preschool classrooms. Child
demographic information is described in Table 2. Child eligibility diagnosis and behavior
concerns are described in Table.3.
Settings
Group caregiver training. A behavior specialist led the group from the local
early intervention agency in a town in the Pacific Northwest. The group was held in a
classroom at the local university one night per week for two hours, over 12 weeks.
Childcare and a light snack or dinner were provided to parents who attended the program.
The behavior specialist followed the Incredible Years parent curriculum (Webster-
Stratton, 2008). He adapted the program from 22 weeks to 12 weeks.
33
Table 2. Child Demographic Information
Race
~---Gender Age Age at
entry into
services
Challenging behaviors
(based on caregiver
concern)
Number of
siblings
Tom Caucasian Male
(Brenda's
son)
48 42 months
months
Oppositional
hyperactivity, non
compliance and
aggressive behaviors
(i.e., screaming, kicking
and hitting)
Three, ages:
nine, six and
one
Al
(Marcy's
daughter)
Caucasian Female 53 14 months Non compliance, One, age six
months screaming and
aggressive behaviors
(i.e. biting, hitting,
spitting and scratching)
Baseline and contextualized coaching. The researcher conducted baseline and
contextualized coaching sessions at each family's home twice per week over 13 weeks.
The primary measurement contexts were daily routines selected by the parent. Both
parents selected daily routines that were most difficult for their family. Brenda chose
morning routines (i.e., breakfast, getting dressed and morning play time). Marcy selected
bedtime routines (i.e., brushing teeth, washing face, reading books, and transition to bed
and afternoon free play). During weeks 13 and 17, the researcher faded contextualized
coaching and home visits were reduced to once per week. Follow-up observations were
conducted two weeks and six weeks after the end of the group training for Brenda and at
two weeks and ten weeks after group training for Marcy.
34
Table 3. Child Assessment Information
Battelle Assessment Child Conners Individual
Developmental Evaluation and Behavior Parent Rating Family Service
Inventory Program Checklist Scale- Family Plan
System (AEPS) Revised (IFSP)
Goals
Adaptive 1Sl -Tom Adaptive 36%, Externalizing Hyperactivity Child will
(Brenda's percentile, social 22% behavior- 90 th 58 th comply with
son) Personal social percentile, percentile teacher and
1st percentile overall (supports parent
behavior 87 th eligibility for direction.
percentile ADHD), Child will
Conners cooperatively
ADHDindex play with
63rd partners during
percentile child directed
(supports free play
eligibility for
ADHD)
AI Adaptive 5st cognitive 21 %, Child will
(Marcy's percentile, communication maintain
daughter) personal social 52% appropriate
1sl percentile physical
communication orientation.
5th percentile, Child will play
cognitive 1st appropriately
percentile with peers
Research Design
A single subject research design was used because it is ideal for examining the
effects of a systematic intervention in natural environments on the behavior of
individuals. In single subject design participants serve as their own control, allowing a
comparison of the individual progress over time. This design allowed for replications of
dependent variables (i.e., positive parenting practices) over the course of intervention
(Lees & Ronan, 2008). A multiple baseline design was used to examine the relation
35
between the intervention (i.e., contextualized coaching) and parent behaviors. A multiple
baseline design across caregiver behaviors was replicated across two caregiver child
dyads. This approach is adequate because it allows for the systematic examination of the
acquisition of caregiver behaviors (Kennedy, 2005), which would be difficult to detect
with a group design. Further, a withdrawal design was not used because the target
parenting behaviors were predicted to be irreversible. To establish experimental control,
introduction of the intervention was staggered across behaviors and participants (Gast,
2010).
Dependent Measures
Prior to baseline, caregivers were asked to complete the Ages and Stages
Questionnaire: Social Emotional (ASQ:SE; Squires et al., 2002); the Social Emotional
AssessmentlEvaluation Measure (SEAM; Squires and Bricker, 2007); and a caregiver
self efficacy questionnaire adapted from the Parent Sense of Competence (PSOC;
Gibaud-Wallston, 1977). The SEAM and ASQ:SE were used to provide information on
the child and assess parental concerns about the child's social emotional repertoire. The
PSOC was used to measure parental self-efficacy at the beginning and the end of this
study. Research indicates a correlation between perceived child challenging behaviors
and caregivers' sense of competence (Johnston and Mash, 1989).
The primary dependent variable was caregivers' use of responsive play, using
reinforcement, effective limit setting, and handling misbehaviors. These were selected
based on the content and focus of the Incredible Years curriculum. Operational
definitions and examples of the dependent variables are provided in Table 4.
36
The secondary dependent variable was child's challenging behaviors. These were
defined as maladaptive behaviors that impeded the child's ability to have positive
interactions with others or engagement in the environment. These were defined by each
caregiver for each child and are described in Table 2.
Table 4. Operational Definitions ofParent Behaviors
---Behavior Definition Examples Non-Examples
----
Promoting The parent imitates the A child picks a puzzle No, now we are playing
play child's play behaviors with piece shaped as a truck with the puzzle, put the
interaction the same / similar toys or and "drives" it; truck in its place.
engages in a related play
behavior Here let me help you--
that is too hard for you.
Praise and Praise- positive verbal I like it when you use Good job.
reinforcement reinforcement immediately your words. Thank you
after a desired behavior. for sitting down quietly.
Praise should be specific to
the child's action. Giving the child a sticker
Reinforcements- delivery of for following his picture Handing a cookie to a
an incentive (e.g. sticker, schedule independently. child after he threw a toy
candy, watching a movie
etc.) after a desired behavior
and follow through with
reinforcement system if
there is one in place.
Effective limit Positive and clearly stated We use spoon to eat our No, I said no cartoons
setting. commands and follow food. Use your soft voice before dinner.
through with commands. please. Ok, I will let watch
cartoons but just this
time.
Responding to Ignoring child's attention Ignore a child's If you keep screaming
challenging maintained negative humming at the dinner you will not have dessert
behaviors/hand behaviors, using natural table. again
-ling consequences and time out I see you are very upset,
misbehaviors to calm down I think you need some You are going to be in
time to relax so you can time out until I tell you
use your instead of your to get up
legs.
37
Group caregiver training. The caregiver training followed the Incredible Years
BASIC curriculum (Webster-Stratton, 2008) and included weekly two-hour sessions over
12 weeks. The first session included an introduction and overview of the program. Each
session started with a review of the homework activity and a problem solving discussion.
The group leader presented the targeted behaviors for the session, displayed the relevant
vignettes, and distributed handouts related to the target behaviors. The group leader
facilitated group discussions by asking caregivers to identify effective parental responses
and reflect on how they might react in similar situations. Each session ended with a
review of handouts and assigned home activities. The investigator completed a checklist
with six planned activities for each session to measure fidelity of implementation of the
Incredible Years curriculum (See Table 6).
The Incredible Years curriculum was separated into four sections. The first
section in the curriculum focused on appropriate caregiver play skills. Thus, the first set
of target behaviors was promoting play interactions. The second section focused on
appropriate use of praise and rewords. The second set of target behaviors included the use
of specific, contingent, and immediate praise for desirable behaviors. This section also
targeted inappropriate use of reinforcements, including follow through with
reinforcement systems and appropriate delivery (i.e., positive consequence for the child's
inappropriate behavior). The third section focused on effective limit setting skills. This
included a reduction of inappropriate commands (i.e., use positive stated commands and
clearly stated commands). In addition, this section targeted follow through with
commands. The final section of the curriculum focused on handling misbehaviors (i.e.,
38
ignoring inappropriate responses, use of logical consequences, and effective use of time
out to calm down).
Baseline. Baseline home visits were conducted in the family home twice per
week during the primary measurement context (i.e., daily play times) and commenced
immediately after the first group training. After establishing stable patterns of responding
in caregiver responsive play during baseline, the researcher introduced contextualized
coaching focused on the first target behavior (i.e., responsive play with Brenda and praise
with Marcy). Once patterns of responding stabilized with responsive play, the
contextualized coaching was introduced with the second target behavior (i.e., praise with
Brenda and setting appropriate limits with Marcy). This procedure was replicated with
each target behavior across caregiver (i.e., limit setting and handling challenging
behaviors).
Contextualized coaching. Home visits were conducted during the same routines
as the baseline home visits, except the researcher provided performance-based feedback,
modeling, discussion of needed supports and concerns, and a plan for follow-up focused
on target behaviors. These sessions were between 45 minutes to an hour. During the 12
weeks of the group training, home visits were conducted twice per week excluding weeks
that the family canceled due to illness, Contextualized coaching (i.e., performance- based
feedback, modeling, and follow up discussions) on the four target behaviors were
staggered across behaviors within each caregiver. The researcher provided performance-
based verbal and written feedback and modeled use of target behaviors (i.e., play, praise,
limit setting, or handling misbehaviors) during each home visit. Written feedback
39
included frequency count of the caregivers' use of target strategies, examples of their
appropriate use of the strategies, a contextually relevant summary of the observation, and
strategies for the caregiver to work on. The researcher provided specific examples and
strategies relevant to each caregiver's daily routines, individual child needs, and
interaction style. The researcher verbally reviewed the written feedback with the
caregiver at the conclusion of each home visit. Figure 3 provides an example of the
written feedback form.
Date Time _
Observer _
Family initials _
Condition (tier) _
Home Observation
Data
Things you are doing well
Things to work on
Next visit parent signature _
Figure 3. Daily Feedback Form
40
Data Collection
A partial interval observational recording system was used to collect data on all
four caregiver behaviors during each session. A paper and pencil data recording form was
designed for this study with each I5-minute observation divided into 20-s intervals (i.e.,
for total of 45 intervals per observation). The researcher recorded if any of the four
caregiver behaviors were observed at any time within the interval. All scored intervals
were divided by 45, which provided percentage of intervals that caregivers exhibited the
target behaviors (i.e., a duration estimate; Kennedy, 2005).
Interobserver Agreement
A second, trained observer independently collected data during 25% of sessions
across conditions, target behaviors, and participants. This observer was a doctoral student
in special education. Interobserver agreement (lOA) was calculated using interval by
interval agreement with percentage agreement. Overall lOA was 94% during baseline,
96% during intervention, and 94% at follow up across behaviors and participants (see
Table 5).
Table S. Interobserver Agreement
o/cAgreement
Brenda
Marci
Baseline
92
95
Intervention
95
97
Follow up
93
94
--------------- --- ---_._..._---_._--
41
Treatment Integrity
Two types of treatment integrity were measured in the study. First, treatment
integrity during the home visits was measured on the written feedback form (Figure 3)
during the intervention conditions. At the end of each home observation the caregiver
signed the feedback form indicating the research reviewed the form with her. Parents
signed the form after each home visits during the coaching condition, indicating
treatment integrity was 100% across participants. Second, treatment integrity also was
measured during the group training sessions. The research completed used a checklist to
assess implementation of six planned items during the Incredible Years group training.
These items were based on the Incredible Years curriculum (see Table 6) Results from
the checklists indicate the behavior specialist implemented all six components during
each of the 12 planned group sessions.
Table 6. Group Fidelity Checklist
1. Group leader discussed home work assignment, ref1ecting and
problem solving difficulties.
2. Group leader presented target behavior for current session.
3. Group leader displayed relevant vignettes.
4. Group leader facilitated group discussion about vignettes.
5. Group leader provided summary of the session
6. Group leader provided parents with handouts and explained
home work assignments.
42
CHAPTER III
RESULTS
Target Behaviors
Visual analysis was used to examine changes in parental responding with the
introduction of the contextualized coaching (Oast, 2010; Kennedy, 2005). The results
suggested a functional relation between the contextualized coaching and parents' use of
the positive parenting practices targeted. Target behaviors were low during baseline and
increased immediately afterthe introduction of the intervention, although remaining at
somewhat low levels throughout the study. This pattern was replicated across tiers and
participants. Results are presented in Table 7 .Visual presentations of the results are
displayed in Figures 4 and 5.
Responsive play. During baseline, Brenda demonstrated moderate variability in
responsive play with a mean of 38% (range 13% to 58%). Responsive play increased
immediately after introducing the contextualized coaching. With the exclusion of one
data point (i.e., a no school day with all 4 children and 2 day-care children were present)
the percentage of intervals of responsive play increased significantly with a mean of 56%
(range 42% to 91 %). Responsive play results demonstrated a moderate increasing trend
with some variability over the course of the study. Marcy's data demonstrated a stable,
high level of responsive play, so the first target behavior for her was labeled praise.
/----.I~
wi f"lay
I1renda
100
80
bO
40
:Hr
o
Baseline COl'1te;.:tlJ;aii~.edCoachir'lg
•
i Follow-upi..-----~! •
J"
.
JOO
80
60
Praise
d!1
10
u - ~ .0._- -------
""e:~ ~:oo
Handl~ng
Misbe haviors
Lim it Setti,ng
...
:2£
.
.,
,
I
:
I
:.ol
!
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1·'231.2::u:l!():L"H':L7
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..........~:-:--.-~-....------.~_ ... ...~.
II \) 10 11 ]:;, :L3 1-~ ~s. 1"
o
20
c"
60 -:
.:t(,.. ,-
bO
!lo·
80
::~._~-~..~~~~
loa
<;
~
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oC;
0..
Home Visits
Figure 4. Brenda's Target Behaviors
.j:::.
w
t-;larc\,
8 aso:>i1(1e Co ntl!!xtlJalizQd -Co'lchi"g Foilml.HJp
~[)~
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2 3. 5 ;; 8 9 l() 11 12 13 1~ 15 16 17 18 19 let 11 2.1 13 24 25
lio·me Ilisi ts
Figure 5. Marcy's Target Behaviors
+>-
+>-
------------- ._-------
45
Labeled praise. During baseline, both participants had low levels with a mean of
10% (range 2% to 18%) for Brenda and a mean of 5% (range 0% to 7%) for Marcy.
Following the introduction of contextualized coaching on labeled praise, both participants
showed a slight increase in levels of labeled praise. This increase maintained throughout
the study for both participants with the exclusion of one data point for Marcy.
Limit setting. The trend for limit setting demonstrated a moderate degree of
variability for both participants during baseline. Immediately following the introduction
of contextualized feedback focused on limit setting, both participants demonstrated a
slight increase in level. Brenda had an immediate increase in level, which maintained at a
level slightly higher than baseline over the course of the study.
Handling challenging behaviors. During baseline, both participants
demonstrated low levels of appropriate handling of challenging behaviors. Both
participants demonstrated an immediate increase in level with the introduction of
contextualized coaching that maintained over t1)e course of the study.
Follow-up. Target behaviors were measured at two and six weeks after
intervention for Brenda, and at two and ten weeks after intervention for Marcy during the
primary context. Both caregivers demonstrated maintenance of target behaviors at
follow-up (see Figures 4 & 5). Percentages of intervals are displayed in Table 8.
46
Table 7. Percentage ofIntervals with Target Behaviors at Baseline and Intervention
Baseline Intervention
Play Praise Limit Handling Play Praise Limit Handling
settings misbehavi setting misbehavior
or s
Brenda
Range 13% 2%- 16%- 3%-9% 42% 7%- 4- 13%-29%
-58% 18% 20% 49% %63%
91%
Mean 38% 10% 14% 4% 56% 35% 34% 19%
Marcy
Range 53%- 0%- 9%-29% 2%-16% 49% 2%- 9%- 11 %-22%
67% 7% 29% 40%
89%
Mean 49% 5% 18% 4% 73% 21% 32% 15%
Table 8. Percentage of Intervals with Target Behaviors at Follow-up
Play Praise Effective limit setting Handling misbehaviors
Brenda
Marcy
2 weeks
6 weeks
2 weeks
51%
58%
*
36%
38%
20%
20%
27%
33%
20%
22%
20%
10 weeks 55% 22% 30% 21%
*Mom requested observing during bedtime routine with no opportunities for
responsive play.
PSOc. Both participants demonstrated an increase in parenting self-competence
as measured by the PSOC. Brenda demonstrated a larger increase from baseline to post
treatment (see Table 1).
47
ASQ:SE. Both children scored well above the cut-off during baseline on the
ASQ:SE (see Table 9). These findings indicate the children should be referred for further
testing in the social emotional domain. At post-treatment, the scores decreased for both
children (in the positive direction). At baseline Brenda reported six items of concern
(e.g., high activity level, hurting peers, and destroying things on purpose). At post-
intervention Brenda reported only three items of concern including (i.e., destroying
things, friendship skills, and toileting). At baseline Marcy reported five items of concern
(i.e., safety with dangerous items and with strangers, long lasting tantrums, sleeping, and
property destruction). At post-intervention Marcy reported concerns of only two items of
concern (i.e., safety around dangerous items and strangers). However, their overall scores
remained above the cut-off. These children were currently receiving services from the
local early intervention agency, which included specialized instruction on social
emotional goals.
SEAM. During baseline, both children scored relatively high on the SEAM, and
caregivers had concerns about several items (see Table 9). At post-treatment the scores
decreased (moving in a positive direction) and caregivers expressed concerns about fewer
items (see Table 10).
Caregiver attendance. Brenda attended nine out of twelve sessions; Marcy
attended eight out of twelve sessions. Both families missed sessions due to family illness.
.Social validity. Social validity of the contextualized feedback and target
behaviors was measured at the end of the study. Caregivers anonymously completed the
social validity questionnaire (see Table 11) and returned via post to the researcher. Both
48
caregivers reported high satisfaction with the contextualized coaching. They repOlted the
contextualized coaching was effective for helping to applying the strategies introduced in
the group training into their daily routines. Both caregivers reported that they felt the
coaching helped them appropriately respond to their child's challenging behaviors and
found the strategies easy to implement across settings and over time. Also, both mothers
reported that they would recommend this intervention to other caregivers with children
with developmental disabilities attending the Incredible Years caregiver training offered
at the local agency.
Table 9. Assessment Information
Baseline Post intervention
Age and Stages Social Emotional
Questionnaire: AssessmentlEvaluati
Social Emotional on Measure
(ASQ:SE) (SEAM)
Age and Stages Social Emotional
Questionnaire: Social AssessmentlEvaluati
Emotional (ASQ:SE) on Measure
(SEAM)
Tom
AI
130 ( cut off 59) 215
150 (cutoff 70) 80
95( cutoff 70)
105
(cutoff70)
105
70
Table 10. Caregiver Concerns on the SEAM
Baseline Post intervention
Brenda • Child's responds to peers' and adults' • Social play skills,
soothing, • Demonstration of
• Child can calm down within 5 minutes, affection toward adults
• Child's response to others' feelings, and peers.
• Child shared attention. • Safety.
• Participation in group activities
• Child displays positive self image,
• Self-regulation skills.
• Safety.
Marcy • Self regulation skills • Safety.
• Sleeping habits.
• Safety.
Table 11. Social Validity
49
Question
1. Coaching was effective for implementing strategies discussed during
group.
2. Coaching was effective for improving parental practices for handing
challenging behaviors.
3. Suggested strategies were easy to implement.
4. The duration of the home visits was appropriate.
5. I was able to generalize the use of the strategies to other settings.
6. My use of the strategies maintained over time.
7. I recommend the suggested intervention to other parents.
A
5
5
6
6
6
5
6
B
6
6
6
6
6
6
6
Note. 1 = strongly disagree, 2=disagree, 3=sornewhat disagree, 4=sornewhat agree,
5~agree, 6= strongly agree
50
CHAPTER IV
DISCUSSION
The purpose of this study was to examine the relation between contextualized
coaching and increases in positive parenting practices for caregivers participating in
group training. The results of this study suggest a functional relation between
contextualized coaching and increase in positive parental behaviors. The target behaviors
remained low prior to introducing the contextualized coaching and slightly increased with
the contextualized coaching. Furthermore, the parents reported high satisfaction with the
contextualized coaching and child outcomes and less concerns about child challenging
behaviors after intervention. These findings suggest that contextualized coaching may
supplement community provided group-based parent training for parents of children with
special needs. Adding an individualized component to an evidence-based parent training
curriculum may increase positive interactions between caregivers and their children with
developmental delays. The results of this study suggest contextualized feedback based on
group training may be effective in supporting positive parenting practices in caregivers of
children with disabilities.
This study adds to the growing literature on the implementation of the Incredible
Years curriculum with caregivers of young children with developmental delays. The
current study used an evidence-based curriculum for families with children with typical
development and numerous risk factors. Results from this study support previous findings
on the use of the Incredible Years curriculum with parents of children with special needs
51
(McIntyre, 2008; Jones et al., 2007; Lees and Ronan, 2008). This study expands the
literature by examining the use of an individualized intervention (i.e., contextualized
coaching) focusing on positive parents practices with families with children with
developmental delays. Research indicates that children with developmental disabilities
are more likely to develop severe behavior disorders than their typical peers (Baker et al.
2002; Emerson, 2003; Roberts, Mazzucchelli, Taylor, & Reid, 2003). This study provides
support for the use of individualized, contextually relevant early intervention for families
of children with disabilities exhibiting challenging behaviors.
This study extends the parent training literature in three ways. First, this study
provides preliminary evidence of the effects of the Incredible Years curriculum and
positive parenting practices of caregivers with children with special needs. Most of the
research on the Incredible Years has focused on decreasing parental negative behaviors
such as: criticism, inappropriate play behavior and inappropriate use of consequences.
(Gross et al., 2003; McIntyre 2008; Phaneuf & McIntyre, 2007; Reid et al., 2004). This
study focused on increasing of positive parental behaviors including, responsive and
appropriate play behaviors, using labeled praise appropriately (i.e., delivery of tangible
reword or verbal praise in when the child engages in expected behavior), effective limit
setting (i.e., clearly, positively and short stated commands) and handling misbehaviors
appropriately (i.e., ignore misbehaviors, follow through with commands, use of time out
to calm down, use of natural consequences and reinforce compliance). This study
supports past research demonstrating that teaching replacement skills is related to better
short and long term outcomes for parents and children (Erbas, 2010; Harvey et al., 2009).
52
Second, this study suggests that individual contextualized coaching is functionally
related to increases in positive parenting practices in caregivers of children with special
needs, and a reduction in concerns about child behaviors. Coaching strategies included
observations, reflection with parents, modeling, active listening, problem solving with
parents, and material support related to the group training. Practitioners can implement
these strategies with little training, resources, or technical assistance. This might be a cost
effective means of service delivery for early intervention and special education agencies.
Furthermore, this component might be a necessary adjunct for caregivers with low
attendance rates at group training sessions. Both caregivers in this study missed several
group training sessions.
Third, pre and post measurement of parents' sense of efficacy using the PSOC
showed increases after intervention. These results support and extend the current
literature connecting the increase in parental self-efficacy with an increase in parental
positive behavior. An important focus of early intervention includes helping caregivers
increase their confidence in their ability to care for their children (Bruder, 2000;
Gallagher et al., 2004; Gross et al., 2003). Research has established that caregivers with
low sense of efficacy are more likely to use ineffective strategies in response to child
challenging behaviors (Kazdin, 1997). Results from this study support the use of
individualized, contextually relevant coaching with caregivers of children with special
needs displaying challenging behaviors (Johnston & Mash, 1989).
Finally, parents were highly satisfied with the intervention and the outcomes.
Parent involvement and satisfaction are essential for any effective intervention and
53
particularly for reducing challenging behaviors at home (DEC, 2007). Despite
widespread evidence for practice, one major limitation of parent training groups is
attrition. Social validity measures provide important information about the feasibility and
acceptability of interventions and outcomes. Applying this information to future group
trainings might prevent or preclude attrition.
Limitations
There are several limitations in this study worth noting. First, most of the target
parenting practices never reached high levels for either parent. There are several possible
explanations for this including: (a) the duration of the coaching, (b) the nature of the
behaviors, (c) the measurement system, or (d) the measurement context.
The parent training group and coaching occurred over the course of 12 weeks. For
both parents, the strategies were novel and constituted replacement behaviors for other
ineffective behaviors. Hence, it may take more time to unlearn old strategies and acquire
new parenting practices. The nature of the behaviors also may have contributed to the
low levels over the course of the study. For example, limit setting and handling
misbehaviors were contingent on child behaviors. Thus, as child challenging behaviors
decreased over the course of the study, parents might have fewer opportunities to use the
target behaviors.
A partial interval measurement system was used in this study. This measurement
system was selected because it provides an estimate of target behaviors that might be
occurring at a high rate and simultaneously. This may have underestimated the actual
frequency of target behaviors. Furthermore, the measurement contexts were selected by
54
parents. Although this ensures the contexts were important for the parents, they may not
have been ideal opportunities for observing changes in target behaviors.
Second, results from the child behavior measurements, the ASQ:SE and SEAM,
indicated both children had fewer problem behaviors at the end of the study, but
remained in the referral range. There are several possible reasons for this result. As
shown in previous studies (Gross et al., 2003; Webster-Stratton, 1998), parental
behaviors show significant changes within the initial phase of intervention, with a small
decrease in child negative behaviors. These data suggest that children's negative
behaviors are more resistance to change and may require more than 12 weeks to observe
notable changes.
Third, these tools were designed to screen and identify children who need further
assessment and develop goals for addressing social emotional development. These
measures might not be sensitive enough to detect change in children's behaviors over
time.
Fourth, most observations were conducted during the same routine. This may
limit the generality of the results. Even though each caregiver chose the daily routine,
ensuring ecological validity, observations during different times might provide
information related to generalization of strategies across routines and time of day.
Fifth, although the research design used for this study establishes experimental
control by staggering intervention across behaviors, the sample used in this study consists
of only two families participating in community-based group training. This reduces the
external validity of the study. An analysis of the individual contribution of the
55
contextualized coaching without the group parent training was outside the scope of this
study. Future research might examine the use of contextualized coaching with or without
the group training component.
Finally, due to the nature and the context of this training, parents chose to
participate in this training out of their own volition. Also, they volunteered to participate
in home visits in addition to the group training. This may have inflated the results
somewhat, since the caregivers chose to receive home visits. Future research might
examine the addition of contextualized coaching to group parent training using a tiered or
response to intervention approach (McIntyre & Phaneuf, 2008). In this manner,
caregivers would receive contextualized coaching based on their performance during
baseline.
Applications for Practice
The results from this study have several applications for practice. For example,
local agencies that utilize the Incredible Years curriculum group training might train all
service providers to be familiar with the content of the group training. Service providers
will then be able to use contextualized coaching during home visits and provide parents
with the support to implement evidence-based strategies discussed in the group training.
This approach might be cost effective and efficient. Practitioners will be able to use
contextualized coaching based on the content of the Incredible Years training during
standard, regular home visits.
This approach also might address issues of attrition with the group training. The
combination of individualized, contextual feedback with group training can be used with
56
families with a high risk of attrition from group trainings (Lees & Ronan, 2008). This
also applies to families with multiple risk factors who may need more intense
intervention. Further, this intervention may be appropriate for families who need also
individualized support (Powell et al., 2006). The individualized component may motivate
parents to complete the program and offer opportunities for families to problem solve
with the coach and practice positive practices.
Future Research
Future research might evaluate the individual contributions of each component of
the intervention (Le., group training, home visits, and contextualized coaching) to the
elements related to parental competency. For example, future study might examine child
behavior pre and post intervention using different measures such as the Eyberg Child
Behavior Inventory and the Child Behavior Checklist (Achenbach, 1991a. & Eyberg, &
Pincus, 1999). Follow-up at six months may validate the observed change in parental
behavior and the caregiver's report of child behavior. Future studies might also focus on
child outcomes. Possible research questions might examine whether child outcomes are
better when parents receive additional individual coaching. Also, more research is needed
to differentiate which parent strategies are associated with decreases in child maladaptive
behaviors.
Families caring for children with disabilities often experience higher levels of
stress (Roberts et al., 2003). Future investigation may examine the effectiveness of the
presented intervention on decreasing parental stress. For example, does contextualized
feedback helps reduce parental anxiety and stress? Is there a difference between parental
57
level of stress and family outcomes among parents who participate in the Incredible
Years training alone and parents who receive additional home visits implementing
contextual feedback?
In conclusion, families with young children with disabilities often experience
higher than average levels of stress. Higher stress levels are related to less frequent
positive parent child interactions and increased negativity (Baker et al., 2002). Group
parent with training with individualized, contextually relevant coaching might be a cost
effective-evidence based option for supporting parents and children with special needs.
Our education and social services agencies are experiencing dramatic cuts in funding and
resources. It is time for agencies to work together to examine evidence-based practices
that are cost effective and feasible in community settings. This study provides
preliminary evidence of a cost effective, evidence-based model of parent training,
implemented in a real life, community-based setting.
58
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