Matthew K. Nock and Alan E. Kazdin examined the effect of implementing a novel intervention on participation of parents in Parent Management Training (PMT). The intervention was designed to address the problem of treatment adherence and attendance of children. It has been studied that parent involvement is a major contributor to greater treatment adherence and attendance among children. The study asserts the necessity of randomized controlled trials (RCT) in the field of increasing attendance and adherence due to the lack thereof such studies.
One area proposed to improve treatment adherence and attendance is participant motivation. Nock and Kazdin’s study implicates that “greater efforts to increase parent motivation to treatment and to identify and remove potential barriers to treatment, would lead to higher rates of attendance and adherence at child therapy.” (Nock & Kazdin, 2005) It is important to note that participation of parents in PMT was assessed in the context of parents of children referred to mental health services for conduct problems including opposition, aggression, and antisocial behavior as PMT is well-established for this specific clinical population.
The study consisted of 76 participants (parents/legal guardians) randomly assigned to either an experimental or control group. The design was additive, thus the treatment for child conduct problems (PMT) was consistent across the groups and only the type of intervention to increase motivation in PMT was manipulated. The experimental group was assigned an intervention developed by Nock & Kazdin, the Participation Enhancement Intervention (PEI). The PEI was based off previous interventions and also included novel components including psychoeducation and motivational statements related to the importance of treatment adherence and attendance as well as guidance to identify and resolve barriers to treatment. The control group received treatment as usual (TAU). The duration of the study was 8-sessions and measures of parent motivation, treatment attendance, and treatment adherence were measured at baseline, session 1, session 5 and session 8. Parent motivation was broken down into three separate components: “desire for child to change, readiness to change, and perceived ability to change” (Nock and Kazdin, 2005).
The results showed that treatment adherence and attendance was only different between the two treatment conditions at session 7 and not prior to this. It was found that treatment condition significantly predicted attendance and therapist reported quantity of adherence (but not parent reported). Additionally, treatment condition significantly predicted two components of parent motivation (readiness to participate and perceived ability to participate). To determine if parent motivation was a factor influencing the difference, it was evaluated as a statistical mediator for treatment adherence and attendance. However, the two components of parent motivation shown to be predicted by treatment condition did not significantly predict the number of sessions attended or treatment adherence. Therefore, parent motivation did not explain participant attendance or participant adherence.
Although parent motivation as a mediator for treatment adherence and attendance between the PEI condition and TAU condition was not statistically significant, the study is still valuable. There are two key identifiable strengths in the design of the study. First, it is essential to note that this is a brief intervention and the PEI can be administered at the beginning of therapy sessions. This was identified as crucial for PMT by Nock and Kazdin as they predicted motivational training is important for adherence and attendance of parents. However, the strength in the design of their intervention is not only in its benefits for clients but more so for clinicians. There are often structural constraints including time limits for therapy sessions that clinicians must tackle. By creating an intervention that is brief (only 5-15minutes) that can be incorporated into PMT, Nock and Kazdin have developed an easily administrable program that will not take away from the limited time clinicians have with their participants but rather enhance their experience. Second, the study is internally valid. By controlling for the type of treatment children with conduct problems received, the researchers could direct the study around their dependent variables, treatment attendance and adherence of parents in the intervention. Extraneous variables were controlled for, thus manipulating the independent variable of treatment condition can be attributed to treatment outcomes of parents (adherence and attendance to intervention).
Nonetheless, there are also potential limitations of the study. The short nature of the intervention (8-sessions) was designed to prevent attrition. However, if the PEI was only 5-15 minutes across 6 sessions, then the maximum amount of support the parents could receive from this intervention was a total of 90 minutes. This could have been a factor influencing the result of parent motivation not being statistically mediational in treatment outcomes, as the sessions may not have covered as much breadth as the parents may have hoped for. This may be supported by the result that there was only a statistically significant difference in treatment attendance and adherence between the PEI and TAU groups after session 7. Additionally, the study is only internally valid to a certain extent. The results of the study found that only two components of parent motivation were crucial in treatment outcome, readiness to participate and ability to participate, but not desire for child to change. This is crucial as the study did not prepare the parents to take action. Desire for child to change is a critical measure of parent motivation because ultimately the goal of PMT is to facilitate parents to effectively manage with their children’s behaviors. However, since the parents were not motivated to change their children’s behaviors, this may implicate that they may not act on what they have been taught during the PEI intervention despite reporting greater readiness and perceived ability to participate. This impacts the internal validity because if the intervention was designed to enhance parental participation but parents have no desire to do so, then the intervention may not have been measuring or influencing the parents’ motivation but another measure, perhaps self-efficacy.
To address these limitations, the future directions of research could gear towards accurately identifying measures of motivation and effectively intervening in them among high risk parents. This could include having longer interventions both in duration at each session and in terms of the entire duration of the intervention. Since the components of motivation in the PMI, readiness to participate and perceived ability to participate, were statistically different across the two groups, it is important to keep these components in the intervention. They may be interpreted not as motivation from the parents but rather self-efficacy. Self-efficacy is the perceived ability to achieve a desired goal. Several hypotheses could then be tested: (I) if increasing self-efficacy will result in increased likelihood for positive outcomes (II) if the relationship between self-efficacy and desire to change behavior results in increased parental motivation and (III) if increased motivation results in desire to change the child’s behavior. Thus, the PEI could be modified to first improve self-efficacy among parents, and then to prepare them for a longer intervention that targets motivation validly. Additionally, in this study the children were not key participants. Therefore, it is unclear what interaction was happening between the parent and child outside the context of the study and this could have also impacted parental motivation. Applying an approach such as multisystemic therapy may address this, as family functioning has been shown to implicate children’s aggressive behavior. (Borduin et al, 1995.)
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