Foreldrenes status og rolle i familie- og nærmiljøbaserte intervensjoner for barn med atferdsvansker

Abstract

During the last two decades, there has been a marked change in the public services for children with conduct problems in Norway, both at the primary and specialist level. Norwegian authorities have taken an initiative to fund the importation and implementation of well-documented treatment programs from abroad (mainly the US) and the programs has been culturally and socially adapted to ordinary clinical settings in Norway. The programs are variants of Parent Management Training (PMT), and share a common theoretical basis. The programs emphasize an ecological, family and community perspective, both in their understanding of how conduct problems are developed and maintained, and in their choice of interventions. Negative parent-child interaction and lack of parental skills is considered the proximal risk factor for developing conduct problems, later fine-tuned and diversified through the children’s peer relations. The interventions are directed at parents and aimed at developing parent skills and change negative parent child interaction. To achieve this goal, parents are systematically taught a variety of operant and social learning techniques which are practiced in roleplay and various home assignments. These techniques are imbedded in a general understanding of attachment and communication theory. Parents and parental skills play a central role in these intervention programs, but there is little empirical information about the characteristics of the parents in Norway, for example how these characteristics may influence the parents participating in the programs. Building on central elements and components of the implemented treatment programs (PMTO), a new Norwegian programs has been developed for the municipality level and aimed more at early prevention and interventions (Norwegian acronym TIBIR). Paper I describes the development of the program, Early Initiatives for Risk (TIBIR), its theoretical rationale, intervention modules and practical considerations. The development of the program was a response to the authorities request to make evidence-based knowledge and PMTO available in various setting and arenas in the municipality-based services for children. The program was designed to identify children with conduct problems as early as possible and to offer tailored interventions as a part of the ordinary primary services for children in the municipalities. The paper discusses some of the challenges concerning the programs ability to reach various risk groups as well as challenges with quality assurance and fidelity maintenance. The implementation of empirically supported treatment (EST) is recommended as a way to transfer knowledge from research to clinical practice. The aim is to improve service quality. Critics and supporters alike have been concerned with client representativeness in such studies, i.e. to what degree participation in EST studies resemble the target group in usual care settings. Paper II explores and describes central family and parent characteristics of Norwegian families with conduct disorder children. The families (N = 376) were recruited from ordinary clinical practice in connection with two evaluation studies of PMTO in Norway, one randomized control study and one large-scale implementation study in routine practice. Data indicated that there were few differences between the two samples and thus that the parent at family characteristics found in the RCT were considered representative of help-seeking families with conduct disorders children in Norway. The Norwegian families had a low problem levels and their problem profile differed from the problem profile of participants in studies published in the US. Given this, one could perhaps expect even better outcome results. One area where the parents showed increased problems was parenting stress. Parents rated lower on scales measuring perception of global health and wellbeing, and higher on indications on acute and long-lasting stress. These results applied only to the mothers, not the fathers. In Paper III, we investigated possible changes in mothers’ perception of distress and well-being over the course of treatment of child conduct problems. Several measures of well-being and distress showed significant change over the period from intake to post treatment. The changes were significantly related to perceived changes in children’s conduct problems, but this only predicted a small part of the variance. The results also indicated that mother’s involvement in the treatment of their child conduct problems resulted in beneficial effect on mother’s perception of well-being and distress, regardless of treatment condition. In the thesis, I argue that patient characteristics, culture and preferences also should include parent and family characteristics when the patient is a child. In my opinion, knowledge of parent and family characteristics will be decisive in the further development of PMT for families with children with conduct disorders. I also argue that these characteristics are important even if they do not directly relate to child conduct problems. Meeting parents’ need and problems could reduce parent stress and improve their function in areas that are important to them, thus making parents with more confidence and energy. This is important for parents with the task of raising children with conduct problems. Active participation from parents are decisive for securing children with conduct problems high quality service. Programs that has been developed (PMT) specify central topics and tasks where parents should improve to a certain standard. However, what roles parents should have in these programs and what expectation they are met with from the therapists are poorly defined. A better understanding of role expectations may make the therapist more confident and make it easier to motivate parents. The realization that parents have a central role in both in the development and intervention of conduct problems in children is built on solid research and clinical knowledge, but this could result in an understanding that stigmatize parents and individualizes the responsibility for prevention and treatment. It is important that public services continue to look for and develop effective interventions that can support parents in a demanding and challenging situation.