PARENT MANAGEMENT TRAINING (PMTO) Program implementation and research in Norway

Terje Ogden ”The Behavior Center – Unirand”

Norwegian Center for Studies of Conduct Problems and Innovative Practice,

Unirand, University of Oslo

The Behavior CenterAdministration

National Implementation

Team for childrenResearch Unit

NationalImplementationTeam for youth

Program director4 National consultants

6 Regional coordinators

Research director Research consultant

Data manager7 Researchers

Program director6 National consultants

The logistics team

Programdevelopment

Dissemination

Adoption

Fidelity/Adherence

Adaptation

Out-comes

Implementation

Readiness Context

Factors influencing program outcomes

Implementation of Parent Management Training in Norway

A national top-down implementation project initiated by the Ministry of Child and Family Affairs in cooperation with 3 other ministries (Education, Health and Social affairs, Justice)

Adoption and implementation of PMTO at a) the regional and b) municipal level

Training 3 generations of PMTO therapists (1999-2006)

Therapist training program

Training the trainers: the first generation of PMTO specialists A 2 year extensive PMTO training program in Norway based on the

principles of social interaction learning theory (SIL) (Patterson, 1982;2002) and PMTO procedures (Forgatch, 1994).

Training, supervision and certification by senior therapists from Oregon Social Learning Center (OSLC)

Training the second and third generation of PMTO therapists: A PMT-O National Implementation Team with a program director, 4

national consultants and 6 regional coordinators, responsible for the training

The first generation of PMTO specialists working as trainers and supervisors of new candidates

The PMTO training program

Training program based on the principles of social interaction learning theory (SIL) (Patterson, 1982;1996) and PMTO procedures (Forgatch, 1994).

Didactic instruction, videotaped examples, and role play demonstrating the procedures.

All sessions were video-taped and about 20% were transcribed, translated into English and subject to feedback from experienced clinicians at the OSLC.

Training three generations of PMTO therapists/specialists (1999-2006)

The 1st generation recruited from Child and Adolescent Mental Health Services and from the Child Welfare Services in all regions of Norway (G1: N=33, 1999-2001)

The 2nd generation also recruited from the specialist child and youth services in a 1.5 year training program (G2: N=84, 2001-2003)

Pre-assessment of 19 agencies (sites), negotiating administrative support, adequate working conditions and necessary equipment for the candidates

The 3rd generation recruited from various municipal child and youth services (G3: N=70, 2004-2006)

The 4th generation starting 2006

PMTO – clinical outcome study

A clinical trial with 100 families randomly distributed to PMTO and treatment as usual

Measuring changes in child behavior at home and at school using multi-informant behavioral assessment, parent reports, observations and background information

Children aged 12 years or younger with physical and verbal aggression, excessive noncompliance, delinquent behaviors, frequent escalating conflict between parent and child and out-of-control behavior

Intervention: training in the core PMTO elements 1) encouragement, 2) discipline, 3) monitoring, 4) problem solving and 5) positive involvement

Intake battery

Child’s mood Describe your friends Adaptation to school

Child Behavior Checklist (CBCL) parents Parent information about the child’s development and functioning Family economy and parents health Mutual adaptation in partner relationship Parents social support Cohesion and adaptation in the family (FACES) Parent Daily Report (PDR) Parent satisfaction with the treatment

Social skills – parent and teacher ratings (SSRS) Teacher Report Form (TRF) Teacher ratings of parent monitoring

Video recording and coding of structured family interaction tasks

Structured family interaction tasks are video recorded before and after treatment (playing/planning, problem solving/hot topics, waiting and evaluating)

Reliable coding with Family and Peer Process Code (FPPC) Real time coding of:

Activity, Withdrawal Contents

Affect is registered for each content code

Total Aversive Behavior score (TAB) Coders Impression Scale

Studying implementation and fidelity drift of PMTO

A collaborative research project on implementation, outcome effectiveness and fidelity drift between OSLC and the Behavior Center

Marion Forgatch (PI), Dave DeGarmo and Gerald Patterson, Oregon

Social Learning Center (OSLC) Richard Price, University of Michigan Terje Ogden (PI) and Kristine Amlund Hagen, The Behavior Center,

Unirand, University of Oslo The logistics team: Eyvind Elgesem, Carl Ivar Holmen, John Kjøbli,

Kristin Nordahl

The studies are sponsored by the National Institute of Drug Abuse (NIDA) and the Norwegian Ministry of Child and Family affairs

Aims of the study

A Norwegian RCT (N=100), a non-randomised replication study, and the study of fidelity drift over time and across successive generations of PMTO therapists

To study the fidelity to PMTO core components as practiced during the effectiveness trial and examine if fidelity and variation in delivery of PMTO affect parenting outcomes.

To analyze PMTO fidelity changes within specialists over time and as a function of training successive generations of Norwegian PMTO therapists.

FIDELITY WITHIN THE SIL FIDELITY WITHIN THE SIL MODELMODEL

Agency Characteristi

cs

Interventionist

Characteristics

Family Characteristi

cs

FidelityChange

ParentingChange Child

Behavior

Assessment of treatment fidelity

Treatment fidelity or adherence is measured by rating competent adherence to the intervention protocol and scored by Fidelity of Implementation Rating System (FIMP) (Forgatch & Rains)

Hypothesis: High scores on the PMTO treatment fidelity measure (FIMP) will increase the quality of the parenting

Year 2Fidelity

Year 3Fidelity

Year 4Fidelity

Year 1

Fidelity

Agency Characteristics

Interventionist Characteristics

Family Characteristics

Agency Characteristics

Interventionist Characteristics

Family Characteristics

Agency Characteristics

Interventionist Characteristics

Family Characteristics

Agency Characteristics

Interventionist Characteristics

Family Characteristics

Repeated measurements of treatment Repeated measurements of treatment fidelity over 4 yearsfidelity over 4 years

AgencyCharacteristics

G1Fidelityn = 33

G2Fidelityn = 84

InterventionistCharacteristics

FamilyCharacteristics

TrainingQuality of G2

G3Fidelityn = 70

TrainingQuality of G3

AgencyCharacteristics

InterventionistCharacteristics

FamilyCharacteristics

AgencyCharacteristics

InterventionistCharacteristics

FamilyCharacteristics

The study ofThe study of

therapist therapist

intergenerational intergenerational

fidelity driftfidelity drift

Obstacles and challenges

Characteristics of a structured treatment program: Short term intervention with predefined core components, Measuring behavioral change and monitoring treatment

fidelity A general limited faith in parents’ abilities to care for their

children and change problem behavior Program myths:

Works only in family with resources Too little flexibility Superficial behavior change Too litle focus on the child

Bringing research into the implementation:

Adding research to the implementation increased the work-load and challenges for the project

Introducing randomized controlled trials and quantitative group designs in clinical research

The recruitment of therapist (intervention + control) and the randomization procedure slowed down the referral process

New and challenging procedures: Video recordings of family interaction (FPPC) and therapy sessions (FIMP)

Overcoming obstacles at the program level

Long term planning and implementation

Continued and consistent support from the program developers Marion Forgatch, Gerald Patterson and their colleagues at OSLC

Establishing PMTO therapist networks and continued supervision

Developing training programs, handbooks and material in Norwegian

Negotiating training programs and the scope and contents of interventions with the municipalities

Facilitators at the national level

Increased professional demand for effective and empirically based methods to treat and prevent behavior problems in children

‘Champion advocates’ at the national, regional and local level generating interest, motivation, enthusiasm and effort

A genuine interest and commitment at the political and administrative level - consistent funding

Establishing a national implementation and research center and a national training program

Positive feedback from families and from the media

That was all!

Thank you!