Parenting Skills Training

jcap_014.fm Page 45 Wednesday, June 1, 2005 6:15 PM

Parenting Skills Training: An Effective
Intervention for Internalizing Symptoms in
Younger Children?
Parenting
ORIGINAL
2
18 if 2005
© know UK
1073-6077 Nursecom, Inc.
Journal 2005 ARTICLE
JCAP by Skills Training:
Oxford, of Child and Adolescent Psychiatric Nursing
Blackwell Publishing, Ltd. An Effective Intervention for Internalizing Symptoms in Younger Children?

Sam Cartwright-Hatton, D Phil, Clin PsyD, Deborah McNally, RMN, RGN, Clin PsyD, Caroline White,
Clin PsyD, and Chrissie Verduyn, Msc, PhD
PROBLEM:

A number of interventions are effective

in treating older children with internalizing symptoms. However, little is known about the efficacy of psychological interventions in treating younger children. This study examined the impact on internalizing symptoms of a parenting skills training program.
METHODS: Forty-three parents took part in a parenting skills training program. Externalizing and internalizing behaviors were measured before and after treatment and after a 6-month period.
FINDINGS: Externalizing symptoms fell after treatment. Interestingly, internalizing scores fell to an approximately equivalent degree.
CONCLUSIONS:

An intervention targeted towards

parenting may be efficacious in the treatment of children’s internalizing symptoms.
Search terms: Anxiety, childhood, depression,

parenting

Journal of Child and Adolescent Psychiatric Nursing, Volume 18,
Number 2, pp. 4 5 – 52
JCAPN Volume 18, Number 2, April-June, 2005

Sam Cartwright, Department of Child and Adolescent
Psychiatry, University of Manchester. Deborah McNally,
RMN, RGN, and Chrissie Verduyn MSc, PhD,
Department of Clinical Psychology, Royal Manchester
Children’s Hospital. Carolyn White, Clin PsyD,
Department of Clinical Psychology, Booth Hall Children’s
Hospital, Manchester, UK.

Introduction
In the past decade, there has been an increasing interest in children’s internalizing symptoms. Until recently, children were not thought to experience
“true” depression, and if they experienced anxiety, they were expected to grow out of it. We now know that this is not always the case.
Recent research has reported 1-year prevalence rates of depressive disorder in adolescents that are as high as 10% (Angold, Costello, & Worthman, 1998). We also know that the symptoms of depression can manifest in very young children (Rutter, 1991), and there is evidence that depressive disorders in the young may be increasing (Fombonne, 1995). Moreover, it is clear that children do not simply grow out of depression.
Harrington, Fudge, Rutter, Pickles, & Hill (1990) followed a group of depressed children and a matched sample of control children over an 18-year period. The sample who were depressed as children were more likely to be depressed as adults than those in the control group.
The picture is similar for anxiety. Anxiety disorders are a very common form of psychological disturbance in childhood, and it is estimated that up to 17% of young people will meet criteria for an anxiety disorder
(Costello & Angold, 1995). Again, these symptoms can manifest in very young children. Moreover, both anxiety and depression can lead to other serious problems.
Children with depressive disorders are at an elevated risk of suicide and self-harm (Lewinsohn, Rohde, &
Seeley, 1994). Children with anxiety disorders often go on to develop depression (Kovacs, Gatsonis, Paulauskas,
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Parenting Skills Training: An Effective Intervention for Internalizing Symptoms in
Younger Children?

& Richards, 1989), and, if they attempt self-medication, may be at an increased risk of substance misuse
(Kushner, Sher, & Beitman, 1990).
With these concerns in mind, new treatments for childhood anxiety and depression have developed.
In particular, cognitive behavior therapy (CBT) has been shown to be a promising intervention for both depression (Harrington, Whittaker, & Shoebridge, 1998), and anxiety (e.g., Barrett, 1998; Flannery-Schroeder &
Kendall, 2000). The efficacy of CBT, however, is known only for older children. It is not thought to be as effective for children under the age of about 8 years.
In a search of the literature to find interventions for internalizing disorders of younger children, the authors found very little empirical evidence for any treatment. Barrett (2000) also highlights this lacuna in her review of the anxiety literature.
In fact, there is very little in the way of empirically validated treatments for any of the psychological disorders of early childhood. There is, however, one exception: in the past 20 years, a large body of literature has developed chronicling the success of behavioral parent skills training (BPST) for families of children with externalizing disorders (Scott, Spender, Doolan,
Jacobs, & Aspland, 2001; Webster-Stratton, 1990). This approach teaches parents behavioral skills, which they then use to manage their children’s difficult behaviors.
Broadly, the aim of this approach is to help parents to play more effectively with their children, praise and reward desirable behaviors more effectively, set effective and reasonable limits, and handle misbehavior using ignoring and mild negative consequences.
Parents are taught to apply these procedures consistently and to interact more calmly with their children.
These programs are also thought to improve family relationships and increase parent–child warmth.
It is now widely accepted that BPST is an effective intervention for externalizing symptoms in young children. However, over the course of running many sessions of parent-training programs themselves, the authors often received informal reports from parents, suggesting that their children were improving not just
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in terms of their behavior, but also in terms of their confidence and self-esteem. Upon reflection, this comes as no surprise, as a number of researchers have reported a relationship between children’s internalizing disorders and parenting style (e.g., Wood, McLeod,
Sigman, Hwang, & Chu, 2003). In a review of the literature, Krohne (1990) showed that lower use of praise, higher use of blame and punishment, and inconsistent use of child management techniques have all been associated with internalizing disorders. It is these aspects of parenting that are targeted by behavioral parent skills training programs. Similarly, there is evidence that early attachment difficulties may be associated with later anxiety disorders (Bowlby, 1973;
Cassidy, 1995). Parenting skills programs are thought to enhance infant–parent attachment.
Despite the strong relationship that appears to exist between certain parenting behaviors and internalizing disorders, the extant studies are mainly correlational designs. The authors are aware of no studies that have attempted to manipulate parenting and examine the effect upon anxiety and depression symptoms in young children. For older children, there is some evidence that providing a partly parent-focused intervention does have an impact upon internalizing symptoms, and a number of groups now include a parental component in their CBT package for anxious older children (e.g.,
Flannery-Schroeder & Kendall, 2000; Cobham, Dadds,
& Spence, 1998). Barrett, Dadds, & Rapee (1996) compared a basic individual CBT package with a package including CBT and family anxiety management therapy (FAM) for the treatment of anxiety in 7- to 14year-olds. The FAM component consisted (in addition to CBT) of 12 sessions covering rewarding courageous behavior with praise or small privileges; extinguishing anxious behavior and complaining by ignoring it; dealing with parents own “emotional upsets”; and family communication and problem solving. The study showed that the children who received both the individual CBT and FAM were more likely to be free of an anxiety diagnosis (based on clinical parent and
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child interview) at the end of treatment (84%) than the children who received CBT alone (57%) or those on a waiting list (26%).
It seems likely, therefore, that teaching families good parenting skills may have a positive impact on their child’s internalizing symptoms. This study aims to investigate whether manipulating parenting skills produces change in children’s internalizing behaviors as well as the expected changes; it also aims to investigate whether these changes are maintained over time.
Method

All parents who took part in the study were experiencing moderate or severe difficulties with their preschool child’s behavior, and were living in an area that experiences a high level of social and economic deprivation.

Participants
The participants were composed of 43 parents attending a community-based Child and Adolescent
Mental Health Service in the northwest of England.
Thirty of the target children were male, and 13 were female. The ages of the children ranged from 24–56 months, mean age was 33 months (SD 10.8). Twentyeight of the children were under 3 years of age, 15 were 3 years or older. The parents were either referred for help with their preschool children’s externalizing behaviors by family doctors or by health visitors, or were self-referred. Self-referred parents were recruited through a community outreach program. The outreach program involved mental health professionals visiting preschool centers in communities with known high levels of need, and encouraging parents to join the parenting programs (for further details, see White,
Agnew, & Verduyn, 2002). All parents who took part in the study were experiencing moderate or severe difficulties with their preschool child’s behavior, and were living in an area that experiences a high level of social and economic deprivation (Salford & Trafford
Health Authority, 1998). Although both parents were invited to participate in the program, only one parent per family attended. Parents were excluded if they lacked adequate English to complete the course. Families who were excluded were referred for individual help. JCAPN Volume 18, Number 2, April-June, 2005

Procedure
Upon recruitment, parents met with a research assistant who performed the inclusion assessment and asked parents to complete either the child behavior checklist—preschool version or the 4–18 years version, whichever was appropriate (CBCL—Achenbach,
1992a,b). These two versions of the instrument were designed to be used side by side, and raw scores on both versions may be converted to a “T score,” which takes into account a child’s age and allows outcomes across a wide age range of children to be compared.
The CBCL measures a wide range of common, difficult, child behaviors. It can be used to provide a total problem score, several subscale scores, or scores on the two higher dimensions of “internalizing” and “externalizing.” Internalizing consists of anxiety, depression, withdrawal, and somatic symptoms. Externalizing consists of delinquent and aggressive behavior. It is these two dimensions that were of interest in this study. The
CBCL had good psychometric properties of reliability and validity, and was widely used as a measure of internalizing and externalizing symptoms in this age group. Although scores on the internalizing and externalizing subscales of the CBCL were known to be correlated, they had also been clearly shown to measure separate phenomena (e.g., McConaughy,
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Parenting Skills Training: An Effective Intervention for Internalizing Symptoms in
Younger Children?

Table 1. Mean CBCL externalizing and internalizing t scores pre-intervention, postintervention, and 6 months postintervention N
Externalizing
Internalizing

CBCL pre (SD)

CBCL post (SD)

CBCL 6 months (SD)

43
43

63.47 (10.55)
60.42 (10.00)

54.35 (9.72)
51.44 (8.25)

54.37 (10.22)
52.60 (9.11)

Achenbach, & Gent, 1988). Davis and Spurr (1999) report that clinical caseness is indicated on the CBCL by a T score of 64 or above. However, Lang, Field,
Pickens, Martinez, Bendell, Yando, and Routh (1996) describe scores of 60 on the total, externalizing and internalizing scores as “clinically moderate to severe.”
Parents were then invited to attend the “parent survival course” (PSC). The PSC is an eight-session program, with groups of six to eight parents meeting weekly for 90 minutes. The material covered in the
PSC was based on the program developed by WebsterStratton, which has been shown to be highly effective in the reduction of behavior problems in children of this age (e.g., Webster-Stratton, 1990). Material covered included learning to give children positive attention through play; learning to increase good behavior by paying it increased attention by using “specific labelled praise” and frequent small rewards; learning to give commands in a manner that is most acceptable to children; learning to withdraw attention for inappropriate behavior; & learning to use “time out” for dangerous
& destructive behaviors. Interested readers are referred to
White, Agnew & Verduyn (2002) and White, McNally, &
Cartwright-Hatton (2003) for a more detailed description of the program. Group leaders were mental health professionals with a nursing/clinical psychology background who were blind to the hypothesis of the study.
No changes were made to the program specifically to improve outcomes for internalizing difficulties.
Parents were asked to complete the CBCL on two other occasions, immediately after completion of the program, and again 6 months later.

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Results
It was hypothesized that parental reports of both internalizing and externalizing behaviors would fall after attendance at the behavioral parenting skills training program. The mean internalizing and externalizing scores pre-, post-, and 6 months post-therapy are presented in Table 1 and Fig. 1. In order to test this hypothesis, repeated measures analyses of variance were computed comparing reports of (a) externalizing scores and (b) internalizing scores, pre- and immediately postintervention. The results of these analyses showed that both externalizing (F(1,42) = 56.2, p