the rational positive parenting program for child externalizing behavior

Articles Section Journal of Evidence-Based Psychotherapies, Vol. 14, No. 1, March 2014, 21-38.

THE RATIONAL POSITIVE PARENTING PROGRAM FOR CHILD EXTERNALIZING BEHAVIOR: MECHANISMS OF CHANGE ANALYSIS Oana Alexandra DAVID*

Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania Abstract Cognitive-behavioral parenting programs are recommended treatments for child externalizing disorders, their efficacy being well established. Currently efforts are directed towards overcoming the barriers of medium/small effect sizes after the programs, low effects in terms of gain maintenance and high attrition rates reported by investigators of such programs. The Rational Positive Parenting program is an Enhanced parenting program strongly focused on the parental and child emotionregulation component, while maintaining at the same time the standard behavioral focus. On the basis of data collected in a randomized clinical trial comparing the efficacy of the Enhanced program with a Standard program and a wait-list, the present article investigates the theory of change advanced by each of the programs in the treatment of child externalizing disorders. Measures included to test the two theories of change assess: (a) parenting, (b) parental distress, and (3) dysfunctional attitudes, and irrational beliefs. Results obtained indicate that improved parenting mediates the effect of the Standard program on the outcomes, while in the case of the Enhanced program there are multiple predictors of change, with reduced parental distress partially mediating its effects. Keywords: enhanced cognitive-behavioral parenting programs, rational positive parenting program, mechanisms of change.

Cognitive behavioral parenting programs are currently considered treatment of choice for child disruptive disorders (see NICE, 2008; 2013). Cognitive-behavioral group-based parenting programs typically involve an interactive, collaborative, learning format in which program facilitators teach key behavioral principles and parenting skills (e.g. play, praise, rewards, discipline) to *

Correspondence concerning this article should be addressed to: E-mail: [email protected]

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parents/caregivers who then practice the skills that they have learned. Although there are common components to all the programs, there is also heterogeneity in targeting different discrete (e.g., marital conflict, parental depression) or multicomponent parental risk variables. Reviews on cognitive behavioral parenting programs have shown they are effective for treating behavior problems of children, with small to moderate effect sizes (Bradley & Mandell, 2005; Kaminski, Valle, Filene, & Boyle, 2008; Maughan, Christianse, Jenson, Olympia, & Clark, 2005; Lundahl, Risser, & Lovejoy, 2005; Nixon, 2002; Serketich, & Dumas, 1996) immediately following programs, while follow-up effects are small in magnitude. Thus, the most well researched parenting programs have sought to address parental distress and cognitions in order to maximize gains. It was suggested (Gavita & Joyce, 2008) that although comparable treatment gains may be achieved from standard and enhanced parenting programs, augmented programs, addressing parental affective and cognitive risk factors (Lovejoy, Graczyk, O’Hare, & Neuman, 2000), can obtain maximize changes and longer maintenance of child and family outcomes when designed coherently. The Rational Positive Parenting (RPP) program was developed (Gavita, 2011, Gavita, DiGiuseppe, & David, 2013) based on a theoretically coherent enhanced curricula (Gavita, Joyce, & David, 2011), incorporating the REBT approach to emotional disturbance, and the most recent advances in the emotionregulation field. The RPP program is adjunctively first focusing on building emotion-regulation capabilities in parents and children as a crucial target of the intervention (Gavita & Calin, 2013), and helping them reduce parental distress for improving implementation (learned in a second phase) of the behavioral techniques. We tested the efficacy of the RPP program in treating child externalizing behavior, compared with a standard parenting program and a control group (Gavita, David, & Dobrean, under review). Our results showed that the RPP program brings slightly greater magnitude changes in child outcomes and more generalized maintenance of these gains at one month follow-up. This study is a mechanisms of change analysis based on the original outcome data and aims at documenting the mechanisms of change involved in each of the two parenting programs and responsible for the changes obtained in child outcomes. Mechanisms/theory of change in the parenting programs While positive parenting practices are protective factors (McCord, 1991), poor parenting practices have been consistently related to disruptive behaviors (e.g., Frick et al., 1992; Haapasalo & Tremblay, 1994). The growing understanding of how parents contribute to their children’s adaptive and maladaptive behaviors lead to a change in addressing children’s psychopathology, from child therapy to interventions focused on improving parents’ practices 22

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towards children (Kaminski et al., 2008). In the parenting programs model, a double change model is postulated, since the parents act as active agents of change in their children’s behavior change. These programs are anchored in behavioral models of operant learning and social learning theories (see Bandura, 1977). Thus, in the standard cognitive-behavioral parenting programs (WebsterStratton, 1994), parents learn mainly techniques of positive and negative reinforcement (by praising and rewarding the desired behavior), while modeling positive behaviors.Despite the variations in terms of the components of the parenting programs, little research has been devoted towards investigating the variables associated with more or less effective programs. Although many parenting trials measure potential mediators, they rarely utilize these to test mediating mechanisms (Weersing & Weisz, 2002). Secondary analyses of randomized trials report changes in positive parenting skills to be an important predictor of changes in child outcome (Dishion et al., 2008; Forgatch & DeGarmo, 1999; Gardner et al., 2006; 2007; Gardner et al., 2010; Reid, WebsterStratton, & Baydar, 2004). Indeed, it was documented that much of the changes in the child outcomes of parenting programs can be explained by parenting (Dishion et al., 2008, Gardner, Burton, & Klimer, 2006; 2007; 2010; Nock et al., 2007). It was suggested that poor parenting behaviors should be seen in concert with parental psychopathology (e.g., distress). Some authors proposed (Burke et al., 2002) that while both contribute to child psychopathology, parental psychopathology may be a stronger determinant of disruptive behavior disorders in children than parenting behavior. Parents’ distress and psychopathology were found to be tightly linked to actual parenting practices (Hoza et al., 2000), and thus parenting programs, and especially the enhanced ones, have promoted changes in parenting cognitions in order to address parental’s affectivity. During the parenting programs, it is considered (Ben-Porath, 2010) that parents’ negative feelings can interfere with the generalization of traditional behavior management skills taught in standard parenting training programs to natural environments.However, parental distress was considered only scarcely in a model of change analysis (Hutchings et al., 2012) and results showed that improvement in maternal depression can mediate changes obtained in child outcomes. However, the work in the area of relating parent emotions and cognitions to parental treatment outcomes for externalizing disordered children is currently quite limited. Since parent self-efficacy and parent attributions for child problem behavior were the best documented (Hoza et al., 2000; Hoza et al., 2006) as being potentially relevant to parent treatment behavior and parent-child interactions, they were addressed within the parenting programs (Gavita et al., 2012). Only recently, the role of the reappraisal strategies (Gross, 2002), in the form of rational cognitions (specifically targeted by the Rational Emotive Behavioral Therapy, REBT; Ellis, Wolfe, & Moseley 1964) in reducing parental distress gained empirical support (Gavita, 2011; Gavita, David, & DiGiuseppe, 2014). The Rational Positive Parenting Program: Mechanisms of Change

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Based on the REBT model (DiGiuseppe et al., 1988), the intermediary goal for changing the child’s problematic behavior is to change parents’ irrational cognitions and emotional disturbance so they would be able to adopt more effective parenting skills. Our goal was the deepening of the understanding of the mechanisms of change involved in two types of cognitive-behavioral parenting programs (enhanced and standard) for the child outcomes. Based on the literature reviewed, we are proposing that improvements in parenting and distress will be functioning as intervention mechanisms in the enhanced program, while parenting will account for changes in children’s’ externalizing symptoms in the standard program. Method Since methodological details of this clinical trial have already been described elsewhere (Gavita, David, & Dobrean, under review), only the most important aspects will be briefly presented here. Participants Participants were 212 parents and their children recruited from Romania, Cluj county. 130 of them were included in the study for presenting externalizing syndromes (based on the ASEBA system, percentile 93 of the Child Behavior Checklist (CBCL) or the Carer-Teacher Report Form (C-TRF)/ Teacher Report Form (TRF); Achenbach, 1991). Children included were aged between 4 and 12 (M = 6.20, SD = 2.04), and 116 of their parents were mothers and 14 were fathers of the children (67 boys and 63 girls). Measures Outcome measures. The Child Behavior Checklist and Carer-Teacher Report Form/ Teacher Report Form (ASEBA, Achenbach System of Empirically Based Assessment; Achenbach, 1991) were used for measuring children externalizing behavior – primary outcome of the study. CBCL was collected at the same time as the CTRF/ TRF and measures the same constructs. The CBCL/1½-5/ CBCL 6-18 and C-TRF/ TRF were scored based on the empirically based externalizing syndromes and profile of DSM oriented scales. Hypothesized mediator variables. Parental variables hypothesized for mechanisms of change for both parental intervention groups were assessed by measures that focused on parenting, parent psychopathology and stress, and respectively general and specific cognitive variables. The Parenting Scale (PS; Arnold, O’Leary, Wolff, & Acker, 1993).The PS is a 30-item questionnaire measuring three dysfunctional discipline styles: laxness 24

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(permissive discipline), over reactivity (authoritarian discipline, displays of anger and irritability), and verbosity (long reprimands or reliance on talking). The scale has adequate internal consistency for the total score ( = .84), Laxness ( = .83) and Over reactivity Scales ( = .82), and modest internal consistency for the Verbosity Scale ( = .63). It has good test-retest reliability and discriminates between parents of children referred to clinic settings and children in the general population. The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbarugh, 1961). The BDI is a 21-item questionnaire that assesses symptoms of depression in adults. It has been extensively used and shown to have good internal consistency (alpha Cronbach =.81 for non psychiatric samples), moderate to high test-retest reliability (ranging from r=.60 to r=.90 for non psychiatric populations), as well as satisfactory discriminant validity between psychiatric and non psychiatric populations (Beck, Steer, Ball, & Ranieri, 1996; David, 2007). The Parental Stress Scale (PSS; Berry & Jones, 1995). PSS is a selfreport scale with 18 items representing both positive themes of parenthood (emotional benefits, self-enrichment, and personal development) and negative components (demands on resources, opportunity costs, and restrictions). Parents are rating each item on a five-point scale rating their typical relationship with their child or children, from strongly disagree to strongly agree. Higher scores on the scale indicate greater stress. The scale is intended to be used for the assessment of parental stress for both mothers and fathers and for parents of children with and without clinical problems. The Parental Stress Scale demonstrated satisfactory levels of internal reliability (.83), and test-retest reliability (.81). The Parenting Sense of Competence Scale (PSOC; Gibaud-Wallston & Wandersman, 1978). The PSCS is a 16-item measure assessing the degree to which a parent feels competent and confident in handling child problems. The PSOC has two subscales: satisfaction with parenting role (reflecting the extent of parental frustration, anxiety, and motivation); and feelings of efficacy as a parent (reflecting competence, problem-solving ability, and capability in the parenting role). Low efficacy scores were correlated with reports of child behavior problems (Johnston & Mash, 1989; Rodrigue, Geffken, Clark, Hunt, & Fisbel, 1994). The total score, satisfaction score, and efficacy score show a satisfactory level of internal consistency ( = .79, .75, and .76 respectively; Johnston & Mash, 1989). General Attitudes and Beliefs Scale–Short Form (GABS-SF; Lindner et al., 2007). The GABS is a 26-item self report measure for irrational cognitive processes (e.g., demandingness, awfulizing, global evaluation, low frustration tolerance). Items are cognitively worded, referring to cognitive processes such as "I must be treated fairly by people and I will not accept unfairness"; "It is awful and terrible to be treated unfairly by people in my life") and additionally include sets of irrational and rational items. Adequate psychometric properties have been The Rational Positive Parenting Program: Mechanisms of Change

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reported in the literature (DiGiuseppe et al., 1988; Lindner et al., 2007; David, 2007). The Parent Rational and Irrational Beliefs Scale (P-RIBS; Gavita, DiGiuseppe, David & DelVecchio, 2011). The P-RIBS is a 24 items measure reflecting rational and irrational processes. The scale was developed based on the RIBS General Format (David, 2008), reflecting evaluative processes in the child behavior and parent-role. The items are reflecting the four irrational (DEM, AWF, LFT, and GE/SD) and four rational [(preferences and flexibility rather than demandingness (PRE); negative evaluations rather than awfulizing (BAD); frustration tolerance [(FT); Non-GE/SD)] processes as measured by the general irrational cognition scales. The P-RIBS includes a guided imagery instruction, as a way to access parents’ evaluative beliefs. Each of the item is assembled in a 5point Likert format, ranging from strongly disagree (1) to strongly agree (5). Factor analysis yielded three factors for the scale: Irrational Beliefs Subscale, Rational Beliefs Subscale and Global Evaluations Subscale. The total score on the scale was obtained by summing up the items, with rational items reverse scored and for each of the three subscales separately. The scale has good psychometric properties (alpha=.73), and a satisfactory level of internal consistency and testretest reliability (r=.78). Procedure Parents were randomly allocated to the three conditions: Standard program (N=47), Enhanced program (N=45), wait-list (N=38), with a drop-out rate of 18.40% of the parents at the post-test and another 5.66% at the follow-up phase. Parents allocated to both condition participated in 10 weekly group sessions (about 15 hours of intervention) with a two group co-leaders. Parents were assessed before beginning the interventions, after completing the intervention, and re-assessed 1-mont after program completion. Families allocated to the Control condition received no treatment and filled the pre, post and followup assessments. The Parenting Programs The Standard Cognitive Behavioral Parenting Program (Standard program). Parents allocated to this condition attended 10 sessions of group intervention focused on teaching parents child and self-management strategies (Clark, 1996; Gavita et al., 2012) designed to promote positive parenting (i.e., attending to the child, social rewards, parents as role models, encouragement, quality time, communication with children; giving effective commands and instructions; and behavior charts), and other strategies are designed to help parents manage misbehavior (i.e., setting rules; common discipline mistakes; active ignoring; consequences). Each family received handouts and monitoring forms. 26

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The Rational Parenting Program (RPP/Enhanced program). Parents in the Enhanced program first learned efficient emotionregulation strategies, and afterwards the intensive behavioral parent training component as described previously for the Standard program (i.e., the child management strategies; Gavita, DiGiuseppe, & David, 2013; Gavita et al., 2012). Parents received the same length of intervention as in the Standard program, 10 sessions of intervention completed over a 10-week period. The adjunctive curricula covered the content of the first two sessions (session 2 and 3), following the CBT/REBT theory based on the ABC model (DiGiuseppe & Kelter, 2006; Ellis, 1994; Joyce, 1995). Data analysis Several steps should be considered in exploring the mechanisms of change involved in this clinical trial (see also Weersing & Weisz, 2002; Kazdin & Nock, 2003). First, it is necessary to determine whether the intervention or treatment is efficacious. Second, the influence of the intervention on the hypothesized mechanisms of change needs to be analyzed. Third, it is necessary to look at how hypothesized mechanisms of change influence the outcomes. Finally, the question must be answered of whether intervention effects can be accounted for by the hypothesized mechanisms of change. We focused on each of these aspects. Results The research question addressed by analyzing the data was if the parent emotional, cognitive, and behavioral variables are working and mechanisms of change in the parent programs for child disruptive symptoms. 1. Efficacy test. The treatment or intervention (A) must be related to therapeutic change or treatment outcome (C). The main child outcomes of the randomized clinical trial were presented by Gavita, David, & Dobrean (under review). Significant differences were found in terms of externalizing syndromes at post-test between each experimental group (i.e., RPP and standard) and the control condition at post-treatment and follow-up, but no significant differences between the two parental interventions. There are also significant differences between pretreatment and post-treatment scores in each study condition. Changes in child disruptive behavior from post-treatment to follow-up were not significant. 2. Intervention test. The treatment (A) has the specific effect intended, which it must be related to the proposed mediator (B). We looked at the impact of each treatment condition on the processes it was expected to impact, as well as those outside its domain. Thus, we examined the degree to which each condition resulted in decreased dysfunctional parenting style, parental stress and depression, parental efficacy and irrational beliefs. The Rational Positive Parenting Program: Mechanisms of Change

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Parental outcomes at Mid-treatment. Table 1 presents the results in case of parental outcomes. Table 1. One way analysis of variance comparisons across treatment conditions on parent outcomes and mean differences at mid-treatment (Tukey HSD). Conditions VARIABLES

3 group ANOVA

PS BDI PSS PSOC GABS (RB) GABS (IB) P-RIBS (RB) P-RIBS (IB)

F(2,103) = 8.59, p < .01 F(2,103) = 7.74, p < .05 F(2,103) = 18.55, p < .01 F(2,103) = 35.54 p < .01 F(2,103) = 5.25, p < .05 F(2,103) = 50.53, p < .01 F(2,103) = 14.31, p < .01 F(2,103) = 24.27, p < .01

Standard vs. Control 14.21* 2.70 -.81 -12.38* .04 -3.02 1.23 1.80

Enhanced vs. Control 10.88* 2.65 8.45* -14.53* -1.22 11.44* -3.93* 8.69*

Enhanced vs. Standard -3.32 5.35** 9.26* -2.15 -1.63* 14.47* -5.17* 6.89*

Note. * The mean difference is significant at the 0.05 level; NS: p > .05. SCBPP = Standard Cognitive Behavioral Parent Program; ECBPP = Enhanced Cognitive Behavioral Parent Program; PS = Parenting Scale; BDI = Beck Depression Inventory; PSS = Parental Stress Inventory; PSOC = Parental Sense of Competence Scale; GABS = General Attitudes and Beliefs Scale; P-RIBS = Parental Rational and Irrational Beliefs Scale.

Parent Outcomes at Post-treatment. As seen in Table 2, continuous data analyses show significant differences among study conditions (except for the BDI) in the case of parent relevant outcomes. The same analysis conducted on all variables of the Enhanced condition, from pre-treatment to post-treatment, showed a decrease in child disruptive behavior (CBCL) [F(1,36) = 57.12, p < .01, ε2= .56]; parent depressive symptoms, [F(1,36) = 38.48, p < .01, ε2= .51]; dysfunctional parenting, [F(1,36) = 90.50, p < .01, ε2=.71]; parent irrational cognitions, [F(1,36) = 70.46, p < .01, ε2= .65]; irrational general attitudes and beliefs, [F(1,36) = 86.98, p < .05, ε2= .70]; as well as parental distress, [F(1,36) = 10.26, p < .05, ε2= .21]; also an increase of parent competency (i.e., parent self-efficacy and satisfaction) was found [F(1,36) = 145.80, p < .01, ε2= .79]. In contrast, the Control group did not differ significantly from pre-treatment to post-treatment (all ps > .05).

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Articles Section Table 2. One way analysis of variance comparisons across treatment conditions on parent outcomes and mean differences at post-treatment (Tukey HSD). Conditions VARIABLES

3 group ANOVA F(2,103) = 30.64, p < .01 F(2,103) = 3.78, p >.05 F(2,103) = 4.73, p < .05 F(2,103) = 34.00, p < .01 F(2,103) = 4.70, p < .05 F(2,103) = 50.53, p < .01 F(2,103) = 17.14, p < .01

Standard vs. Control 19.54* .20 3.36 -12.85* .04 .90 -.004

Enhanced vs. Control 22.71* 3.13 5.66* -14.90* -1.36 19.99* -4.70*

Standard vs. Enhanced 3.17 2.92 2.30 -2.05 -1.40* 19.08* -4.69*

PS BDI PSS PSOC GABS (RB) GABS (IB) P-RIBS (RB) P-RIBS (IB)

F(2,103) = 53.48, p < .01

.35

9.30*

8.94*

Note. * The mean difference is significant at the p < .05 level; NS: p > .05. PS = Parenting Scale; BDI = Beck Depression Inventory; PSS = Parental Stress Inventory; PSOC = Parental Sense of Competence Scale; GABS = General Attitudes and Beliefs Scale; P-RIBS = Parental Rational and Irrational Beliefs Scale; RB = Rational Beliefs; IB = Irrational Beliefs.

Parental Outcomes at 1-Month Follow-Up. As seen in Table 3, continuous data analyses show significant differences among study conditions in case of parent relevant outcomes. Table 3. One way analysis of variance comparisons across treatment conditions on parent outcomes and mean differences at follow-up (Tukey HSD). Conditions VARIABLES

3 group ANOVA

PS BDI SSP PSOC GABS (RB) GABS (IB) P-RIBS (RB) P-RIBS (IB)

F(2,97) = 23.27, p < .01 F(2,97) = 11.16, p < .01 F(2,97) = 6.60, p < .05 F(2,97) = 29.18, p < .01 F(2,97) = 4.45, p < .05 F(2,97) = 16.44, p < .01 F(2,97) = 7.61, p < .05 F(2,97) = 26.60, p < .01

Standard vs. Control 19.58* -1.27 .80 -14.35* -.22 1.35 .008 1.85

Enhanced vs. Control 16.79* 4.65* 5.59* -14.22* -1.37* 13.95* -3.47* 8.41*

Enhanced vs. Standard -2.79 5.92* 4.78* .13 -1.15* 12.60* -3.48* 6.55*

Note. * The mean difference is significant at the .05 level; NS: p > .05. PS = Parenting Scale; BDI = Beck Depression Inventory; PSS = Parental Stress Inventory; PSOC = Parental Sense of Competence Scale; GABS = General Attitudes and Beliefs Scale; P-RIBS = Parental Rational and Irrational Beliefs Scale; RB = Rational Beliefs; IB = Irrational Beliefs.


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3. Mediator and change test. In order to test if the proposed mediator is related to change in symptoms (or outcome domains), the mediator (B) must be related to therapeutic change (C). We calculated residual change scores from pretreatment to post-treatment (Treatment change) and from post-treatment to follow-up (Follow-up change) for (a) child externalizing symptoms (CBCL) and (b) each mediating variable. Table 4 presents the correlations between treatment change in the hypothesized mediating variables and post-treatment change in child externalizing behavior in each study condition. Table 4. Treatment change analyses: correlations between primary outcome (CBCL) and hypothesized mechanism of change). Mechanism PS PSS BDI GABS R GABS IR P-RIBS R P-RIBS IR PSOC

Post-Interventions externalizing symptoms change (pre-post) Standard Enhanced Control .35* .34* -.05 -.04 .34** .08 .39** .33* -.11 .18 .16 .05 .06 .38* .23 .12 .42* -.10 .22 -.04 .02 .14 .19 .07

Note. PS = Parenting Scale; BDI = Beck Depression Inventory; PSS = Parental Stress Inventory; PSOC = Parental Sense of Competence Scale; GABS = General Attitudes and Beliefs Scale; PRIBS = Parental Rational and Irrational Beliefs Scale.

We further conducted a Fisher’s Z test of the differences between the correlations found for parenting in both treatment conditions and we found that correlations are not significantly different (z = .04, p > .05). 4. Mediation, intervention, and change test. The relation between the intervention (A) and therapeutic change (C) must be reduced after statistically controlling for the proposed mediator (B). We formulated conclusions regarding the mechanisms of change based on the three steps described above. Treatment status (Standard and Enhanced experimental conditions vs. Control reference condition) was “dummy” coded as an independent variable (see Treadwell & Kendall, 1996). Residual differences pre-posttest on child externalizing score, measured by the externalizing subscale of the CBCL, was the primary outcome variable. Results on the outcomes of Standard condition met the first requirement allowing testing for mediation since significant correlations were found between two supposed mediators (PS and BDI) and the dependent variables (child behavior) following treatment. The mediating variable was parenting style (PS) 30

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treatment change (pre-treatment to post-treatment) in the Standard program. Summary of Multiple Regression analysis for Parental Discipline predicting Externalizing syndromes (with the Group factor) is presented in Table 5. Table 5. Summary of Multiple Regression analysis for Parental discipline predicting Externalizing syndromes (with the Group factor). Variable

B

SE B

β

Group

5.58

1.01

31**

Parenting

.21

.84

.55**

Group Parenting

6.35 .14

1.37 .05

.38* .28**

Step 1 Step 2 Step 3 Note. R2 = .38 for Step 1; ∆R2 = .50 for Step 2. *p < .05, **p < .01. in comparison with the reference condition (Control).

Regression analysis showed that, when controlling for the group variable, the standard coefficient of the parenting variable for predicting the outcome variable was significant, = .28, p < .05. In the same equation, the group variable was lower but still significant ( = .38, p < .01). We further operated the Sobel test for the mediation analysis in order to check whether the whether the indirect effect of the group variable on the child externalizing syndromes through the parenting variable was significant. We obtained a Sobel test value of z = 2.23, p < .01, which showed mediation was significant for parenting. Our data did not met the requirements for mediation when using parental depression (BDI) as mediating variable (p < .05) for the effects of the Standard intervention on child externalizing symptoms. The data obtained on the Enhanced program met the first requirement in order to allow testing for mediation, since significant correlations were found between the five hypothesized mediators (PS, BDI, PSS, irrational P-RIBS) and the dependent variable (child externalizing syndromes) after the treatment. When parenting (PS) and treatment status were both included in the regression equation, the standardized coefficient for treatment group was reduced from .62 (p < .01) in the second equation to .44 (p > .05) in the third equation with parenting remaining significant ( = .26, p < .05). The Sobel test did not support tough the mediation of the PS on the effects of the intervention on reducing child externalizing syndromes (z = 1.51, p < .05; see Table 6). We further tested the mediating effect of parental distress for the impact of Enhanced program compared to the Control condition on child externalizing symptoms. When parental stress and group condition were both included in the regression equation, the standardized coefficient for parental distress was no longer significant ( = .20, p > .05). The Rational Positive Parenting Program: Mechanisms of Change

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Articles Section Table 6. Summary of Multiple Regression analysis for Parental discipline predicting Externalizing syndromes (with the Group factor). Variable

B

SE B

β

Parenting

.22

.04

.57**

Group

3.43

.53

.62**

Group Parenting

2.43 .10

.72 .05

.44** .26*

Step 1 Step 2 Step 3 Note. R2 = .31 for Step 1; ∆R2 = .43 for Step 2. *p = .05, **p < .01

We further tested the mediation effect of parental distress on the child outcomes measured by the DSM derived subscales of the CBCL meeting the previously mentioned conditions (see Table 7). Table 7. Summary of Multiple Regression analysis for Parental Distress predicting Conduct Problems (with the Group factor). Variable

B

SE B

β

Group

3.85

.78

.54**

Parental distress

.44

.09

.50**

Group Parental distress

2.81 .29

.82 .10

.39** .33**

Step 1 Step 2 Step 3

Note. R2 = .24 for Step 1; ∆R2 = .36 for Step 2 (ps < .01). *p < .05, **p < .01.

For the child conduct problems as outcome, when the parental distress was entered in the equation, the coefficient for the group variable was reduced from .44 (p < .01) to .39 (p < .011, while the parent distress was = .33 (p < .01). The Sobel test supported mediation of parent distress for the effect of treatment on child outcomes (z = 2.33, p < .01). We tested the parental depression (BDI) as mediating variable for the effects of the Enhanced program on child externalizing syndromes. For the child externalizing syndromes as outcome, when the parents’ depression was entered in the equation, together with the independent variable (group, the coefficient for the group variable was reduced from = .62 (p < .01) to = .54 (p < .01). However, the Sobel test did not support mediation (z = .79, p > .05). The mediating role of parents’ general irrational cognitions on the effect of the Enhanced intervention on child externalizing symptoms was also tested. No 32

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mediation effect was found for general irrational beliefs as mediator for the impact of treatment on child externalizing syndromes. Discussion In this study, we examined the role of hypothesized mediators for child outcomes in two cognitive-behavioral parenting programs (enhanced versus standard) compared a wait-list condition. Significant decreases in parent-rated child externalizing behavior following treatment in both intervention conditions were reported elsewhere (Gavita, David, & Dobrean, under review). High effect sizes were registered for both intervention conditions at post-test, and at follow up – with the enhanced condition bringing slightly (but not significant) higher gains. No gains were evidenced in terms of teacher rated child externalizing syndromes after the treatment or at 1 month follow-up. However, significant decreases in child Oppositional Defiant Disorder symptoms for the Enhanced intervention compared to the Control condition were evidenced by teacher ratings at follow-up. This is the first study to our knowledge that examined whether focusing on parental distress and irrational cognitions at the beginning of the parental intervention enhances clinical level outcomes reported by either parent or teacher. As concerning the mechanisms of change, a mixed picture emerged from our analyses. We had predicted that for the Enhanced program (RPP), parental practices, distress, and cognitions would mediate the effect of the intervention on children' s level of externalizing behavior at post-treatment, while for the Standard program parenting will mediate these outcomes. Our expectations were partially confirmed, in that we found that parenting was a mechanism for the Standard program and also predicted, but not significantly mediated, changes in the Enhanced program; parental distress however was found to mediate the impact of the Enhanced intervention on child outcomes. Although results showed that parental depression was a predictor of change in the Enhanced condition, we failed to show that parent depression had mediating effect of this intervention for child disruptive symptoms. However, this result could be due to the fact that the initial level in parent depression was in the low range (see means and SD in Table 2) and it could be that this could explain the lack of statistical significant mediations. The mediator analyses replicated and extended earlier studies, which tested mediators within parenting intervention trials conducted in more specialized research settings (see Forgatch & DeGarmo, 1999; Gardner et al., 2006; 2007; 2010). The findings showed that improvement in the parenting style represents a key factor mediating change in child problem behavior in the standard parenting programs which focus on this component. In addition to previous studies addressing mechanisms of change variables in parent programs for child disruptive behavior, we conducted mediational analysis to test if changes The Rational Positive Parenting Program: Mechanisms of Change

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in child behavior could be attributable besides to parenting, to parental emotion regulation variables. Results obtained showed how reducing parental stress, depression and irrational cognitions influenced favorably changes in child behavior, which is in line with the REBT/CBT theory (i.e., the ABC model in CBT/REBT). This study had several strengths. The trial addresses issues which were identified as being of key importance for the field: the need to establish if the right integration of parent stress module in parent programs brings contributions for child outcomes and the lack of variables mediating such intervention. Furthermore, we were able to show specificity of mediation effects, by parental stress but not by other parental variables. Thus, a theoretically informed cognitive package, incorporating focus on both intermediate but also evaluative core beliefs of parents is needed before addressing child management strategies for better long-lasting outcomes. This study is not without limitations. The absence of observational data on children externalizing behavior is a weak point in our assessment scheme. Second, although the trial was initially powered for the main efficacy analysis, the sample size is relatively small for mediator analyses. Recommendation for future research refer to continuing to investigate the efficacy and effectiveness of enhanced cognitive-behavioral parent programs for child disruptive behavior and exploring further the theory of change of parent regulation factors for child outcomes. Determining which components appear to be essential across a variety of programs has important implications for practice. When selecting among programs to implement, such information could be used to select programs containing components associated with greater program effectiveness. With the changes introduced in the content and sequence of delivery in enhanced parent programs, we propose to bring more benefits for the cognitive-behavioral parent programs by incorporating the recent data in cognitive sciences. Existing programs could increase their effectiveness by integrating at the right sequence specific components reliably associated with greater effectiveness, rather than experiencing the higher costs, extensive time for staff retraining, and other barriers associated with adopting and implementing an entirely different packaged program. Acknowledgements The study is part of the Ph.D. dissertation of Gavita (David) Oana Alexandra, awarded by the Babes-Bolyai University Cluj-Napoca. Part of this work was supported from a grant awarded to Oana Alexandra David by the Babes-Bolyai University, project number GTC_34060/2013.

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