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Psychosocial Intervention

versão On-line ISSN 2173-4712versão impressa ISSN 1132-0559

Psychosocial Intervention vol.21 no.2 Madrid Ago. 2012

http://dx.doi.org/10.5093/in2012a15 

Incredible Years® Parent, Teachers and Children's Series: Transportability to Portugal of Early Intervention Programs for Preventing Conduct Problems and Promoting Social and Emotional Competence

La Versión de Padres, Profesores y Niños del Incredible Years®: Adaptación a Portugal de Programas de Intervención Temprana para la Prevención de Problemas de Conducta y para la Promoción de la Competencia Social y Emocional

 

 

Carolyn Webster-Stratton1 , Maria Filomena Gaspar2 y Maria João Seabra-Santos2

1 University of Washington, USA
2 University of Coimbra, Portugal

Correspondence

 

 


ABSTRACT

Disruptive behavior disorders in children are on the increase. However, there is evidence that the younger a child is at the time of intervention, the more positive the behavioral effects on his/her adjustment at home and at school. Parental education might be an effective way of addressing early problems. The Incredible Years (IY) programs were designed to prevent and treat behavior problems when they first appear (in infancy-toddlerhood through middle childhood) and to intervene in multiple areas through parent, teacher, and child training. This paper summarizes the literature demonstrating the impact of the IY parent, teacher and child intervention programs, and describes in more detail the work done in Portugal so far to disseminate IY programs with fidelity, with particular emphasis on the IY Basic Preschool Parenting and Teacher Classroom Management programs.

Keywords: disruptive behavior disorders, Incredible Years, parental education, transportability.


RESUMEN

La frecuencia de trastornos de conducta en la infancia parece estar en aumento. Sin embargo, hay evidencias de que en la medida en que los niños y niñas son más jóvenes en el momento de la intervención, serán mejores los efectos en su ajuste comportamental tanto en el domicilio como en el colegio. La educación parental puede ser una forma efectiva de abordar los problemas de conducta en edades tempranas. El programa Incredible Years (IY) fue diseñado para prevenir y tratar los problemas de conducta tan pronto como aparezcan (desde la primera a la mediana infancia) y para intervenir en múltiples áreas a través del entrenamiento de los padres, los profesores y los niños. En este artículo se resumen las publicaciones que demuestran el impacto de este programa en sus versiones para padres, profesores y niños y se describe con mayor detalle el trabajo hecho en Portugal para diseminar el Programa IY con fidelidad al modelo original poniendo un particular énfasis en la versión del IY para padres y profesores de niños en edad pre-escolar.

Palabras clave: educación parental, Incredible Years, transportabilidad y adaptación, trastornos de conducta.


 

 

Behavioral and emotional problems are common in young children, with reports ranging from 6-15% of boys and girls aged 3-12 years having clinically significant emotional or behavioral problems (Egger & Angold, 2006; Sawyer et al., 2000) and as high as 35% reported for young children in economically-disadvantaged families (Webster-Stratton & Hammond, 1998). Young children with early-onset behavioral and emotional difficulties have been shown to have increased risk of developing severe adjustment difficulties, school drop out, violence and drug abuse in adolescence and adulthood (Costello, Foley, & Angold, 2006; Egger & Angold, 2006). Early intervention with evidence-based parent, teacher and child programs has been shown to prevent and reduce the development of conduct problems and in turn prevent secondary risk factors from developing (Kazdin & Weisz, 2010; Snyder, 2001).

Thirty years ago, Webster-Stratton (Webster-Stratton, 1981; Webster-Stratton, 1982) introduced the Incredible Years (IY) Parent Program as a new group-based performance-training method for supporting parents and improving parenting practices designed to reduce behavioral problems and promote children's social and emotional competence. IY was designed to overcome the limitations of existing parenting programs that relied on verbal training (e.g., didactic lectures) and one-on-one therapy methods, as well as to address the cost and feasibility problems associated with other performance-based methods such as individualized videotaped "bug-inthe ear"1 feedback. The IY Parent Program, and all subsequent programs, were based on cognitive social learning, self-efficacy and relationship-building theories and used video-based modeling methods delivered in group settings as the primary mode of intervention. Toward this end, a comprehensive video series of actual parent-child interaction vignettes illustrating positive and less effective parenting behaviors were developed for use as a tool for trained group leaders to facilitate parent groups involving group discussion, peer support, self-reflection and problem solving, practice exercises and collaborative learning. Families determined goals for themselves and their children informed by their cultural beliefs, self-managed their decisions regarding assigned home activities, participated in values exercises regarding their short- and long-term goals, and worked with group leaders to recognize and overcome their personal barriers. Since the 80s, the Incredible Years Training Series has been expanded to include three complementary curricula for parents, teachers, and children, all of which include similar training methods and therapeutic processes. These programs were designed to reduce the multiple risk factors associated with poor parenting practices, early-onset conduct problems and emotional difficulties.

The series has been the subject of extensive empirical evaluation. All three programs have been widely endorsed by various review groups as well-established evidence-based interventions for treating disruptive behavior disorders. Notably, during the past decade, several trials have also supported the preventive impact of these programs collectively and individually for use in schools to reduce children's risk for developing serious behavior problems by strengthening parenting and teacher classroom management skills and using classroom social and emotional curriculum to promote children's social, emotional and academic competencies.

The purpose of this article is to describe the conceptual grounding of the evidence-based IY programs including the program behavior-change methods and the risk and protective factors that are targeted by the programs. We summarize the literature demonstrating the impact of the parent, teacher and child interventions, and describe in more detail the approach taken in Portugal to disseminate the IY programs with fidelity, with a particular emphasis in the IY Basic Preschool Parent and the Teacher Classroom Management.

 

Need for Early Intervention

The IY Series was largely influenced by the burgeoning literature regarding the development of antisocial behaviors that emerged in the 1960s and 1970s and has continued to expand in more recent decades. Extensive research over the past forty years has consistently demonstrated the links between child, family, and school risk factors and the subsequent development of antisocial behaviors. Several prominent researchers (e.g., Dishion & Piehler, 2007; Dodge, 1993; Moffitt, 1993; Patterson, Reid, & Dishion, 1992; Patterson & Fisher, 2002) have helped coalesce this literature into strongly supported theories about the development of antisocial behaviors.

The extensive literature based on the development of antisocial behaviors highlights some obvious implications for interventions. First, early intervention timed to key developmental periods is critical. Treatment-outcome studies suggest that interventions for conduct disorders (CD) are of limited effect when offered in adolescence, after delinquent and aggressive behaviors are entrenched, and secondary risk factors such as academic failure, school absence, substance abuse and the formation of deviant peer groups have developed (Dishion & Piehler, 2007; Offord & Bennet, 1994). Second, effective interventions need to target multiple risk factors across various settings. The increased treatment resistance in older CD probands results in part from delinquent behaviors becoming embedded in a broader array of reinforcement systems, including those at the family, school, peer group, neighborhood, and community levels (Lynam et al., 2000). Significant advances in the conceptualization and practice of prevention science in mental health emphasize that interventions must target multiple risk- and protective factors and be tied to theoretical and life-course models.

For these reasons, the IY treatment programs were designed to prevent and treat behavior problems when they first begin (infancy-toddlerhood through middle childhood) and to intervene in multiple areas through parent, teacher, and child training. Early intervention across contexts can counteract risk factors and strengthen protective factors, thereby helping to prevent a developmental trajectory to increasingly aggressive and violent behaviors in later life.

Parent and Family Risk Factors

Parents and children develop coercive interactions that stem in part from a negative reinforcement pattern in which parents acquiesce to children's defiant requests and escalating demands (Patterson et al., 1992). In turn, the parent uses harsh or abusive discipline practices when the child escalates to severe misbehavior. Specific parent interpersonal characteristics put parents and children at risk for developing these maladaptive interactions including parent psychopathology, interparental conflict and divorce, depression and maternal insularity and lack of support (Knutson, DeGarmo, Koeppl, & Reid, 2005). Finally, low income is a significant risk factor for the early onset of conduct problems in young children. Poverty and its related aggregation of stressful risk factors (i.e., unemployment, crowded living conditions, high life stress, low education, illness, and high residential mobility) have deleterious effects on parenting, including the development of abusive disciplinary practices (Collins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000).

Child Biological and Developmental Risk Factors

In addition to the family and environmental factors described above, life course persistent antisocial behaviors are linked to early maladaptive development of the child's cognitive internal organization system. Children with conduct problems are more likely to have neurocognitive symptoms and certain temperamental characteristics such as inattentiveness, impulsivity, attention deficit/hyperactivity disorder, and high rates of aggressive responsiveness (Beauchaine, Hinshaw, & Pang, 2010). Other child factors have been implicated including deficits and delays in social-cognitive skills, social and emotional play skills, emotional regulation, and peer interactions (Dishion & Piehler, 2007). Children with conduct problems tend to define problems in hostile ways, seek less information, generate fewer alternative solutions to social problems, and anticipate fewer consequences for aggression. They may also distort social cues during peer interactions and make attributions of hostile intent to neutral interactions (Dodge & Price, 1994). Low academic achievement, learning disabilities and language delays often develop in these children during the elementary grades and continue through high school. Many children enter school with academic deficits and language delays, which increases the likelihood of behavior problems in the classroom (Malecki & Elliott, 2002). In turn, behavior problems reduce children's access to learning opportunities, which exacerbates any preexisting learning problems (Dodge & Pettit, 2003).,

 

Incredible Years® Parent, Teachers and Children's Series

Incredible Years Parent Programs

The BASIC parenting programs target four separate age groups: baby (6 weeks-1 year), toddler (1-2 1/2 years), preschool (3-5 years) and school age (6-12 years). Each of these recently updated programs includes age-appropriate examples of culturally diverse families and children with varying temperaments. The baby program is a minimum of 8-9 weekly, 2-hour sessions with parents and babies present. It uses the Incredible Babies book which includes journaling and developmental and safety checklists. The BASIC toddler parent program is completed in a minimum of 12-weekly, 2-hour sessions and has its own Incredible Toddlers book. The preschool and school age programs are offered in 18-20 or more weekly sessions and a reduced 14-week version protocol of the preschool program is available for low-risk prevention populations. The foundation of the program is video vignettes of modeled parenting skills (over 300 vignettes, each lasting approximately 1-3 minutes) shown by two trained group leaders to groups of 8-12 parents. The videos demonstrate social learning and child development principles and serve as the stimulus for focused discussions, self-reflection, problem solving, and collaborative learning. The programs are also designed to help parents understand typical child developmental milestones and varying temperaments, child safety-proofing and monitoring as well as age- appropriate parenting responses.

Goals of the programs are tailored specifically to each targeted age group and developmental stage and include: (a) promoting parent competencies and strengthening families by increasing positive parenting, parent-child attachment, and self-confidence about parenting; (b) increasing parents' ability to use child-directed play interactions to coach children's social-emotional, academic, verbal, and persistence skills; (c) reducing critical and physically violent discipline and increasing positive discipline strategies such as ignoring and redirecting, logical consequences, time-out, and problem-solving; (d) increasing family support networks; and (e) strengthening home-school bonding and parents' involvement in school related activities.

In addition to the BASIC parenting programs there are also two supplemental or adjunct parenting programs to be used with particular populations. The ADVANCE parenting program offered after completion of the BASIC preschool or school-age programs was designed for selective high-risk and indicated populations and focuses on parents' interpersonal risk factors such as depression, marital discord, poor communication, self-control and anger issues, problem-solving and ways to give and get support. The School Readiness Program for children ages 3-5 years is a 4-6 session prevention program designed to teach parents academic, social, and emotional coaching and ways to promote children's preliteracy and interactive reading skills. The content of both the BASIC and ADVANCE programs is also provided in the text that parents use for the preschool and school-age programs, titled The Incredible Years: A Troubleshooting Guide for Parents (Webster-Stratton, 2005).

Incredible Years Child Programs (Dinosaur Curricula)

There are two versions of the IY child program. In the universal prevention classroom version teachers deliver 60+ social-emotional lessons and small group activities twice a week, with separate lesson plans for preschool (Level One: 3-5 years), kindergarten (Level Two: 5-6 years), Grade 1 and 2 classrooms (Level Three: 7-8 years). The second is a small group therapeutic Dinosaur school where accredited IY group leaders work with groups of 4-6 children in 2- hour weekly or biweekly therapy sessions. The program can also be offered as an after school or "pull out" therapy program twice a week in schools, or can be offered in 2-hour sessions while the parents participate in the parent group. This 22-week program consists of a series of DVD programs (over 180 vignettes) that teach children problem-solving, social skills and emotional self-regulation skills. Organized to dovetail with the content of the parent training program, the program consists of seven main components: (1) Introduction and Rules; (2) Empathy and Emotion; (3) Problem-Solving; (4) Anger Control; (5) Friendship Skills; (6) Communication Skills; and (7) School Skills. More information about the child programs can be found in other reviews (Webster-Stratton & Reid, 2003, 2004).

Incredible Years Teacher Classroom Management Program

In 1995 (revised 2003) Webster-Stratton developed a 6-day (42-hour) Incredible Years Teacher Classroom Management (IY-TCM) training program with the goal of promoting teacher competencies and strengthening home-school connections by doing the following: (a) improving teachers' classroom management skills, including proactive teaching approaches and effective discipline; (b) increasing teachers' use of academic, persistence, social, and emotional coaching with students; (c) strengthening teacher-student bonding; (d) increasing teachers' ability to teach social skills, anger management, and problem-solving skills in the classroom and (e) improving home-school collaboration, behavior planning and parent-teacher bonding. A complete and recently updated description of the content included in this curriculum is described in the book that teachers use for the course, titled Incredible Teachers (Webster-Stratton, 2012a).

 

Behavior Change Methods

Cognitive social learning theory, modeling, self-efficacy, attachment and child development theories underlie the delivery method for all the IY series. Video- based modeling is based on social learning and modeling theory (Bandura, 1977), which contends that observation of a model on video can support the learning of new skills. In the IY series, video-based modeling involves showing participants vignettes of parents or teachers using social and emotional coaching, or positive discipline strategies, or children managing conflict with appropriate solutions. One advantage to using video-based modeling is that it provides a flexible method for intervention because vignettes can portray a variety of models representing different cultural back- grounds in different settings and situations with different child age groups and developmental issues that are difficult to recreate over and over again for live sessions. Additionally, the vignettes can be viewed individually or in group settings. When delivered in groups, video-based modeling has the added benefit of facilitating group discussion, collaborative learning and emotional support. Further, participants identify key "principles" from the vignettes, apply them to their personal goals by practising what they have learned with their personal problem situation and then receive direct feedback on their performance from the group leader and group members. Previous research indicates that parents and teachers tend to implement interventions with greater integrity when they are coached and given feedback on their use of the intervention (Noell et al., 2005; Stormont, Lewis, & Smith, 2007). Additional research has shown the value of having children observe, practice, and receive feedback about targeted social skills.

Observing models that represent a variety of cultures and situations increases the likelihood participants will learn to apply the methods in their own home situations. Additionally, participants are given opportunities to role play or practise these strategies in group settings and receive feedback until they achieve a sense of competence on targeted skills. The training sessions are spaced for parents, teachers and children once a week so that participants can practice the skills in their settings during the week and return in subsequent sessions for additional coaching and feedback.

An added benefit of the group format is that it helps reduce resistance to the intervention through motivational interviewing principles (Miller & Rollnick, 2002). Rather than receiving information solely from an expert, participants are given the opportunity to interact with each other. When participants express beliefs counter to effective practices, the group leader draws on others to express other viewpoints. Through this discourse, the group leader is able to elicit change talk from the participants themselves that makes it more likely they will follow through on intended changes. On the one hand, when group leaders position themselves in the "expert model" arguing for change it makes it more likely to cement the attitudes of participants who are resistant to the intervention (see Miller & Rollnick, 2002).

On the other hand, video vignettes allow group leaders to elicit behavioral principles from the parents' insights and serve as the stimulus for collaborative learning and practice exercises. After each vignette, the group leader solicits ideas from the group and involves them in the process of self-reflection, problem solving, sharing, and discussing ideas and reactions. The group leader's role is to support group members by teaching, leading, reframing, predicting, and role playing, always within a collaborative context. The collaborative context is designed to ensure that the intervention is sensitive to individual cultural differences and personal values. The program is "tailored" to each parent, teacher or child's individual needs and personal goals as well as to each child's personality, developmental ability and behavior problems.

The IY parent and child program also implies a commitment to group members' self-management. This approach empowers participants in that it gives back dignity, respect, and self-control to parents and teachers who may be seeking help at time of low self- confidence and feelings of self-blame. The group format is more cost-effective than individual intervention and also addresses an important risk factor for children with conduct problems including the family's isolation and stigmatization, teacher's sense of frustration and blame, and children's feelings of loneliness or rejection. The groups provide that support and become a model for support networks and friendships. The collaborative therapy process is also provided in a text for group leaders, titled Collaborating with Parents to Reduce Children's Behavior Problems: A Book for Therapists Using the Incredible Years Programs (2012). The child groups also provide children who have conduct problems some of their first positive social experiences with other children. Moreover, it is theorized that the group approach provides more social and emotional support and decreases feelings of isolation for teachers as well as parents and children.

 

Evidence Supporting the Incredible Years Programs

Evidence Supporting the Incredible Years Parent Programs

Treatment Populations: The efficacy2 of the IY BASIC parent treatment program for children (ages 2- 8 years) diagnosed with ODD/CD has been demonstrated in eight published randomized control group trials (RCTs) by the program developer (Reid, Webster-Stratton, & Hammond, 2007; Webster- Stratton, 1981, 1982, 1984, 1990a, 1992, 1994, 1998; Webster-Stratton & Hammond, 1997; Webster- Stratton, Hollinsworth, & Kolpacoff, 1989; Webster- Stratton, Kolpacoff, & Hollinsworth, 1988; Webster- Stratton, Reid, & Beauchaine, 2011; Webster-Stratton, Reid, & Hammond, 2004). In all of these studies, the BASIC program has been shown to improve parental attitudes and parent-child interactions and reduce harsh discipline and child conduct problems compared to wait-list control groups. The results were consistent for early childhood and school age versions of the programs. Treatment component analyses indicated that the combination of group discussion, a trained group leader, and video modeling produced the most lasting results in comparison to treatment that involved only one of the three training components (Webster-Stratton et al., 1989; Webster-Stratton et al., 1988). One earlier study (Webster-Stratton, 1994), indicated the additive benefits of the ADVANCE program on children's prosocial solution generation and parents' marital interactions. Consequently a 20-24 week program that combined BASIC plus ADVANCE became the core treatment for parents of children diagnosed with ODD and/or ADHD and was used for the majority of the treatment studies. Several studies have also shown that IY treatment effects are durable 1-3 years post treatment (Webster-Stratton, 1990b). Perhaps, most notable, a recent 8- to 12-year follow-up of families treated because of their children's conduct problems indicated that 75% of the teenagers were typically adjusted with minimal behavioral and emotional problems (Webster-Stratton, Rinaldi, & Reid, 2010).

In addition, the BASIC program has been replicated with treatment populations in five research projects by independent investigators in mental health clinics, or doctor's offices with families of children diagnosed with conduct problems (Drugli & Larsson, 2006; Gardner, Burton, & Klimes, 2006; Lavigne et al., 2008; Scott, Knapp, Henderson, & Maughan, 2001; Spaccarelli, Cotler, & Penman, 1992; Taylor, Schmidt, Pepler, & Hodgins, 1998).

Prevention Populations: Additionally, 4 RCTs have been conducted by the developer with multiethnic, socioeconomically disadvantaged families in schools (Reid, Webster-Stratton, & Beauchaine, 2001; Webster-Stratton, 1998; Webster-Stratton, Reid, & Hammond, 2001). A recent study with elementary school children evaluated the effects of the parent intervention delivered in schools with an indicated, culturally diverse population. Children who received the intervention showed fewer externalizing problems, better emotion regulation, and stronger parent-child bonding than control children. Mothers in the intervention group showed more supportive and less coercive parenting than control mothers (Reid et al., 2007).

Another 6 RCTs by independent investigators with high risk prevention populations have found that the BASIC parenting program increases parents' use of positive attention with their children (praise, coaching, descriptive commenting) and positive discipline strategies, and reduces harsh, critical, and coercive discipline strategies (see review by Webster-Stratton & Reid, 2010). These replications were "effectiveness" trials in applied mental health settings, not a university research clinic, and the IY group leaders were existing staff (nurses, social workers and psychologists) at the centers or doctor's offices. The program has also been found to be effective with diverse populations including those representing Latino, Asian, African American, and Caucasian background in the United States (Reid et al., 2001), and in other countries such as the United Kingdom, Ireland, Norway, Sweden, Holland, New Zealand, Wales, and Russia (Gardner et al., 2006; Hutchings et al., 2007; Larsson et al., 2009; Raaijmakers et al., 2008; Scott, Spender, Doolan, Jacobs, & Aspland, 2001; Scott et al., 2010). These illustrate the transportability of the BASIC parenting program to other cultures and countries.

Evidence Supporting the Incredible Years Child Programs

Treatment: To date, the developer has conducted three RCTs evaluating the effectiveness of the small- group child-training (CT) program for reducing conduct problems and promoting social and emotional competence in children diagnosed with ODD/CD (Webster- Stratton & Hammond, 1997; Webster-Stratton et al., 2004). Results indicated that children who received the child-training condition showed enhanced improvements in problem solving, and conflict management skills with peers compared to those in the parent training (PT) only condition. On measures of parent and child behavior at home, the PT condition resulted in more positive parent-child behavioral interactions in comparison to interaction in the CT only condition. One-year follow-up assessments indicated that all the changes noted immediately post-treatment were maintained over time. Moreover, child conduct problems at home had decreased over time. Analyses of the clinical significance of the results suggested that the combined CT + PT condition produced the most improvements in child behavior at 1-year follow-up. For this reason the CT program was combined with the PT program in a recent study for children diagnosed with ADHD. Results replicated the earlier studies with children with ODD (Webster-Stratton et al., 2011). There has been one RCT by an independent investigator of the child treatment program (Drugli & Larsson, 2006).

Prevention: One RCT using the classroom prevention version of the child program with Head Start families and primary grade classrooms have indicated significant improvements in school readiness, emotional regulation and social skills and reductions in behavior problems in the classroom (Webster-Stratton, Reid, & Stoolmiller, 2008).

Evidence Supporting Incredible Years Teacher Program

The IY-TCM program has been evaluated by the developer in one treatment (Webster-Stratton et al., 2004) and two prevention RCTs Webster-Stratton et al., 2001; Webster-Stratton et al., 2008) and five RCTs by independent investigators (see review Webster-Stratton, 2012b). Research findings have shown that teachers who participated in the training used more proactive classroom management strategies, praised their students more, used fewer coercive or critical discipline strategies, and placed more focus on helping students to problem solve. Intervention classrooms were rated as having a more positive classroom atmosphere, increases in child social competence and school readiness skills, and lower levels of aggressive behavior.

 

Implementation with fidelity

An important aspect of a program's efficacy is fidelity in implementation. Indeed, if the programme is not rigorously followed (for example, if components are added or dispensed with, if the leaders do not receive the necessary training or if the desirable resources are not available), then the absence of effects may be attributed not to the inefficacy of the programme but to a lack of fidelity in its implementation (Hutchings, Bywater, Eames, & Martin, 2008). Recent research with the Incredible Years parenting program shows that implementation with a high degree of fidelity not only preserves the anticipated behavior modification mechanisms but is predictive of behavioral changes in parents, which in turn are predictive of behavioral changes in the child as a result of the treatment (Eams et al., 2009).

One important aspect that facilitates the application of a program with fidelity is the standardization of intervention content, structure and materials. In Incredible Years, all components relating to the implementation of the programs are described in detail in DVDs and manuals, which also lay out the basic theoretical and empirical elements of each part of the program. For Weisz (2004), one of the main advantages of the Incredible Years programs, from the point of view of clinical practice, is precisely the program's accessibility for clinical use, along with its appealing nature and low abandonment rates.

In the context of implementation with fidelity, the training and supervision of group facilitators warrants great attention (Webster-Stratton, 2004). Consequently, facilitators receive 3 days of structured training by accredited mentors before leading their first group of parents and are then subject to supervision, through video recordings of their sessions as well as ongoing expert coaching and consultation. Considerable emphasis is also placed on peer coaching through the joint viewing of the video recordings, using inventories of desired behaviors and skills to be filled in by the individual involved and by the peer (Webster-Stratton, 2004). The process of facilitator accreditation is demanding, involving the leadership of at least two groups, and supervision and a positive final video group assessment by an accredited mentor or trainer as well as satisfactory completion of facilitator group session protocols and weekly parent evaluations. The whole process of coaching, consultation and accreditation of new facilitators is carried out by a network of national and international accredited IY mentors and trainers. A recent RCT has shown that providing facilitators with ongoing consultation and coaching following the 3-day workshop leads to increased facilitator proficiency, treatment adherence and delivery fidelity (Webster-Stratton, Hurlburt, Reid, Marsenich, in submission).

 

Implementation of the Incredible Years Training Series in Portugal

In Portugal, in recent years, there has been increased interest in family intervention methods known as parental training/education, as a way of increasing positive parenting, thereby promoting mental health in childhood and throughout life. This interest has been manifested politically (XVIII Governo Constitucional, 2009; Abreu-Lima et al. 2010), socially (Sampaio, Cruz, & Carvalho, 2011), in research (Almeida & Fernandes, 2011; Gaspar, 2003) and public opinion, reflecting European structures with key positions in the design of social policy (cf. Council of Europe, 2006). However, evidence-based interventions (EBIs) have not attracted much interest or recognition, and have not been considered a priority politically, socially or (as far as we can see) in research, in the public, private and volunteer sectors, or at central and local government levels. Ironically, authors such as Shernoff & Kratochwill (2007), have claimed: "There has never been a time in the history of education and psychology when there has been a stronger emphasis on the use of evidence-based interventions in mental health and educational settings" (p. 450).

This systemic EBI response, applicable in the different life contexts of the child (school and family) and to the child itself, with the potential to be implemented by professionals in different spheres (psychology, education, health, etc.) and on different levels of intervention (universal, selective and indicated), is found in the Incredible Years programs. What follows is a description of the first steps taken to transport to Portugal an EBI-technique developed elsewhere, taking as model the experience of other countries and teams that have used it with efficacy and effectiveness before us. Particular emphasis is given to the work of Judy Hutchings, who championed the transportability of the Incredible Years programs to Wales (Hutchings et al. 2007; Hutchings et al., 2008).

Training

The first training for facilitators of the Incredible Years Basic Parenting Program took place in October 2003, with the organization of a workshop at the Faculty of Psychology and Education, University of Coimbra (the institution to which the two last-named authors of this article - also the national coordinators of IY Series in Portugal - are affiliated). Since then, three basic training workshops have been organized within the same program, involving a total of 80 trainees3. Some of these facilitators continued their training in subsequent years, and there are presently four certified group facilitators, two of whom are already certified peer coaches, qualified to supervise non-accredited leaders (the other two are concluding their peer coach certification). The first two are also beginning the process that will enable them to become mentors of the Incredible Years programme in Portugal, after which they will be able to train new facilitators in Portuguese.

Research

Basic Parenting Program

Between 2004 and 2007, prior to the launch of the program, the respective materials (including the manual, leaflets to accompany each session and a book aimed at parents) were translated and adapted to the Portuguese context (Webster-Stratton, 2005/2010), and the scenes in DVD were subtitled. Thus, the version of the Basic program used in Portugal is the original version prior to the version updated in 2008.

The first Incredible Years parenting groups were implemented in 2007 and 2008, mostly in kinder- gartens, involving parents of children without any identified risk factors. At this stage, there were 5 groups, which enabled the facilitators to practise their recently-acquired skills and make small adjustments to the translations of the materials. The contents of the program proved adequate to the needs and cultural references of the Portuguese parents that took part. This initial phase of developing and launching the program in Portugal was carried out in close collaboration with the Incredible Years team in Wales4.

In 2008, the Incredible Years Basic Parenting Program was also used in a research project that aimed amongst other things to assess the efficacy of the program when implemented in a community of socioeconomically-disadvantaged families. This project, which ended in July 2009 and had the support of the Drug Dependency Institute (Instituto da Droga e da Toxicodependência or IDT)5, involved 11 groups of Incredible Years parents. Account was taken of evidence-based recommendations for the sensitization and recruitment of parents and other parental figures (contacted personally and by specialised technicians) and their maintenance in the program (transport, rewards, support groups for children, training and supervision of parental trainers). The results indicate a statistically significant change in different variables associated with the exercise of positive parenting, such as a reduction in the stress associated to the evaluation of parental competence (assessed using the Parenting Stress Index; Abidin, 2004) and an increase in the empathy and availability of the parental figure with regards to the child's needs (assessed with the Adult- Adolescent Parenting Inventory-2; Bavolek & Keene, 1999). It was found that these gains were maintained 6 months after the post-intervention assessment. Although no statistically significant changes were found in the parents' perceptions of their children's behavior, the difficulties faced or pro-social behaviors (as assessed with the Strengths and Difficulties Questionnaire - SDQ; Goodman, 1997), participants nevertheless indicated a marked change in themselves and also in their children the final Satisfaction and Efficacy Assessment (e.g., "I think my children have changed for the better as regards the way they talk and behave at home") (Cabral et al., 2009/2010).

Still in the context of the application of the program to modify the behavior of children from vulnerable families, a doctorate project is at present under way by Isabel Simões Silva, supported by the Foundation of Science and Technology (FCT), which aims to assess the efficacy of the Incredible Years programme applied not with groups of parents but with professionals from residential care institutions (Centros de Acolhimento Temporário).

Another project (Jerónimo, Sequeira, & Gaspar, 2010) sought to analyse the changes in the narratives of parents that participated in one of the groups throughout the sessions of the program using the Therapeutic Process Analysis Grid (Sequeira, 2003). The results obtained indicate that intervention permitted the emergence of exceptional moments in the parental narratives over the course of the program, pointing to the emergence of new meanings and perspectives that helped "dissolve" the problem narrative and reduce the significance of the symptom. As regards these parental narratives, parents tended at first to present themselves as passive and/or incompetent, but generally changed over the course of the program, describing themselves as more active and competent in the final sessions. This narrative change seems to have been strongly influenced by the group dynamic (which effectively amplified the emergence of new narratives), home assignments, models of interaction shown in the filmed scenes, and dramatizations. The results obtained suggest that there are similarities between the change processes found and those observed in "classic" systemic therapies (such as family and couple therapy).

Since 2009, a study has been under way to assess the efficacy of the Incredible Years programs for parents and kindergarten teachers for the prevention/early intervention of behavior problems. The target is a treatment population and the main objectives are to assess the efficacy of the IY basic parenting treatment program for preschool children (ages 3-6 years) with externalizing behavior problems, using a randomized control group trial (RCT). This project, funded by the FCT from October 20106, has till now implemented the parenting program with 15 groups (of which 10 are experimental and 5 are control). Two doctorate dissertations are being prepared under this research project, supported by the FCT. One of these (by Andreia Fernandes Azevedo) assesses the effects of the behavior program on children with symptoms of hyperactivity and attention deficit disorder, while the other (by Tatiana Carvalho Homem) is concerned with problems of defiance/opposition.

Although this project is still ongoing, preliminary results suggest that the parental program is effective in reducing externalized behavior problems in pre-school children (Azevedo, Seabra-Santos, Gaspar, Homem, & Marques, 2010; Azevedo, Seabra-Santos, Gaspar, Homem, & Leitão, 2011), and that the level of adhesion and satisfaction amongst parents is high (Seabra- Santos, Gaspar, Azevedo, Homem, & Pimentel, 2011).

In a second phase of this project, begun in the last quarter of 2011, parental intervention was combined with an intervention aimed at kindergarten teachers through the IY program for kindergarten teachers (TCM). The aim was to gauge if performance in both systems (family and school) translates into added gains with regard to the modification of the child's behavior. To date (July 2012), courses have been organized for three groups of parents of children with symptoms of externalizing behavior problems, while the respective kindergarten teachers received simultaneous training in the IY program for teachers (IY-TCM). We shall return later to this intervention with teachers.

Incredible Years Program - First steps (Toddlers)

Two doctoral projects, begun in 2011, aim to assess the efficacy of the Incredible Years program for the parents of children of 1-2 years of age (toddlers' version). These studies will involve risk families that are being monitored by the child protection services for having shown signs of parental maltreatment, implemented in the sphere of doctoral projects by Inês Coutinho and Isabel Fidalgo. These will analyse changes to child behavior and development rate, parental skills and parent/child interactions.

Incredible Years Teacher Training Program - TCM

The transportability of the TCM to Portugal was studied at two moments. The first took place in 2009 immediately after the handouts had been translated into Portuguese. The program was applied to a group of kindergarten teachers from the public sector in urban and rural areas. The research was carried out in the context of a research doctorate in Educational Psychology at the Faculty of Psychology and Education, University of Coimbra (Vale, 2011). Five weekly workshops were held over the course of two months, involving 25 hours of face-to-face group training. The DVDs were shown in English without Portuguese subtitling, and the book (Webster-Stratton, 2008) was also given in English (the kindergarten teachers had sufficient mastery of this language). The intervention group consisted of eight kindergarten teachers (who participated in the TCM training from March and April 2009), with a control group made up of another eight kindergarten teachers that was comparable to the intervention group but had not had any additional in-service training (in 2012 that control group was offered free training in TCM). This was an exploratory study involving a preliminary assessment (February 2009), post-intervention assessment (July 2009) and follow-up (February 2010, one year after the preliminary assessment). The results suggest that, after exposure to the program, preschool teachers assessed their children as displaying greater social competence and fewer conduct and behavior problems compared to the preliminary assessment by SDQ (Goodman, 1997) filled by themselves. Preschool teachers in the control group did not change their perceptions about the children's behavior and social competence. Additionally, observations by blind coders, using the Portuguese version of the Best Practices Inventory (The Incredible Years Project, University of Washington), showed that positive classroom practices improved in the intervention group, while remaining unchanged in the control group. The results remained unaltered seven months after the end of the program. Satisfaction with the program was very high. These findings provide the first support that this program is effective in enhancing school protective factors and reducing child risk factors in a sample community in Portugal.

At a second moment, the TCM is being used in the context of a broader research project that has already been mentioned ("Early prevention/intervention in disruptive behavior disorders: efficacy of parents and teachers programmes (PTDC/PSI-PED/102556/2008). Fourteen weekly sessions for parenting groups were offered at preschool centers. Using the research funding, all the DVD were subtitled in Portuguese and the book supporting the program was translated (Webster- Stratton, 2008).

In 2012, a new doctorate project was begun by Isabel Cristina Neves Borges, with the aim of assessing the efficacy of the TCM program in the primary school context (school-age children, with and without special needs).

 

Conclusion

At a time when the efficient management of human and economic resources is crucial, the availability of evidence-based programs in the Portuguese context should form part of the university's mission.

The Incredible Years programs have been classified in the main directories of evidence-based interventions in the USA: The California Evidence-Based Clearinghouse for Child Welfare (CEBC)7; Center for the Study of Prevention of Violence: Blueprints for Violence Prevention (Blueprints)8; Helping America's Youth (HAY)9; Office of Juvenile Justice and Delinquency Prevention Model Programs Guide (OJJDP)10; Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices (SAMH- SA)11. The main function of these directories is to serve as a guide for professionals in the selection of the most effective intervention for existing families, contexts and resources, increasing the guarantee of evidence-based practice that is simultaneously a combination of best evidence based on empirical research, with the practice most consistent with the values of the family/client (cf. http://www.cebc4cw.org).

The Incredible Years programs have been successfully transposed to other countries, particularly in Europe (e.g., United Kingdom, Ireland, Norway, Denmark, Finland, Holland), where they have maintained their efficacy and effectiveness. The results of the first research carried out in Portugal12, with both the basic preschool parenting program (prevention and treatment), and the TCM program for kindergarten teachers, are encouraging, motivating us to continue this assessment and dissemination, extending it to other types of families, children and education professionals, and other programmes of the Incredible Years series for parents and children.

 

1 Bug-in-the-ear (BITE) technology is an intervention technique that provides immediate feedback to the adult (mother, father or other carer) that is interacting with the child via an earphone placed in the ear. The feedback, given by an experienced professional that receives images of the interaction in another room through a recording device, is designed to reinforce and increase desired behaviors (Arhin, 2005).

2 Efficacy studies take place in controlled environments such as laboratories or clinics, while effectiveness studies occur in real contexts in order to assess results in daily practice (according to Division 12 of the APA, cf. Diniz-Neto & Feres-Carneiro, 2005).

3 The training sessions were run by the following trainers from the Incredible Years program: Dr Ted Taylor, psychologist and researcher at the Oregon Research Institute (2003); Dr Caroline White, clinical psychologist at Manchester University Children's Hospital (2008); Prof. Judy Hutchings, coordinator of the Incredible Years team in Wales and professor at the University of Bangor (2010 and 2011).

4 This initial phase was supported by the University of Coimbra Centro de Psicopedagogia (FCT research unit), British Council and Council of Rectors of Portuguese Universities. The funding provided by the last two bodies occurred under the Treaty of Windsor Anglo-Portuguese Joint Research Programme and enabled two members of the Portuguese team to travel to Wales and two researchers connected with the Incredible Years team in Wales to come to Portugal (Project: "Applicability of the Incredible Years Program in Portugal: Comparison with Wales").
5 Support was provided by the Drug Dependency Institute of the Ministry of Health (Grant PIF - A/84) for the project "An Adventure in the World of the Family: A prevention/intervention project for families at risk", implemented by the Aprender em Festa Group (IPSS Gouveia) in the context of which a study was carried out with the Incredible Years program.

6 Research and Technological Development Project entitled "Early prevention/intervention in disruptive behaviour disorders: efficacy of parents' and teachers' programmes", with the following reference PTDC/PSI-PED/102556/2008 funded by the programme COMPETE in is component FEDER and by the Foundation for Science and Technology (FCT).

7 http://www.cebc4cw.org

8 http://www.colorado.edu/cspv/blueprints/index.html

9 http://guide.helpingamericasyouth.gov/programtool.cfm

10 http://www.dsgonline.com/mpg_index.htm

11 http://nrepp.samhsa.gov/

12 The research with the Incredible Years parenting program in Portugal can be accompanied at http://projectopaismaesincriveis.blogspot.com/

 

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Correspondence:
María Filomena Gaspar
Department of Psychology. University of Coimbra
Coimbra, Portugal.
E-mail: ninigaspar@fpce.uc.pt

Manuscript received: 27/01/2012
Review received: 02/05/2012
Accepted: 04/05/2012

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