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Reducing Preschool Behavior Problems in Families Living in Urban Poverty: A Pragmatic Comparative Effectiveness Trial

Sat, March 23, 4:15 to 5:45pm, Hilton Baltimore, Floor: Level 2, Key 9

Integrative Statement

Introduction: Although parent management training (PMT) is the first line of treatment for preschoolers with behavior problems, current PMT models tend to be less effective for families in poverty. We compared the effectiveness and cost of two evidence-based PMT programs in a sample of low-income, predominantly African American families seeking mental health treatment for their preschool children’s behavior problems. Specifically, we compared a 12-session group-based PMT program (The Chicago Parent Program; CPP) versus a mastery-based parent-child coaching PMT program (Parent-Child Interaction Therapy; PCIT) on parent satisfaction, PMT completion rates, impact of psychosocial adversity, child externalizing behavior problems, and treatment costs.
Hypotheses: We hypothesized that CPP would not be inferior to PCIT for reducing behavior problems. We also hypothesized that CPP would take less time to complete, would have higher parent completion rates, cost less, and receive higher parent satisfaction ratings.
Study Population: Sample included 158 parents and their 2-5 year old children referred to mental health treatment for externalizing behavior problems. Approximately 58% were boys; mean age (SD) was 3.6 years (1.03); 98% were Medicaid insured. Primary diagnoses were ADHD, adjustment disorder, disruptive behavior disorder, and oppositional defiant disorder/conduct disorder. Most parents were the target child’s mother (76%), were African American (70%), had a high school diploma or less (58%), and reported annual incomes below $20,000 (73%).
Methods: This study used a randomized, pragmatic design. Parents of 2-5 year old children were recruited from an urban fee-for-service mental health clinic following intake and standard diagnostic assessments. Following consent, parents were randomized to CPP (n=79) or PCIT (n=79). The primary outcome measured at baseline and post-discharge follow-up was externalizing behavior problems using the preschool Child Behavior Checklist (CBCL). Psychosocial adversity was measured using the Center for Epidemiologic Studies Depression Scale-Revised (CESDR). Treatment duration, completion rates, and costs were captured from clinician and administrative billing records. All PMT sessions were conducted by licensed, graduate-prepared clinicians employed at the clinic who had been previously trained in CPP or PCIT.
Results: There were no differences in PMT initiation or completion rates by condition. Behavior problems improved in both conditions (Cohen’s d=0.57-0.50) and CPP was not inferior to PCIT (90% CI -2.46, 2.54), even after controlling for differences in treatment length (90% CI -1.79, 5.00). However, CPP took less time to complete (87 days vs 406 days) and per participant treatment cost was lower for CPP (M=$1,413) than PCIT (M=$2,151) (95% CI $-1,304, $-170). Parents with higher psychosocial adversity were less likely to drop out of CPP (p<.01). Parents randomized to CPP were more likely to be “very satisfied” with treatment than PCIT (p<.05).
Conclusion: Results suggest that among parents of young children living in urban poverty seeking treatment for externalizing behavior problems, group-based CPP is not inferior to PCIT for reducing child behavior problems. Moreover, CPP may require less time to complete, be more likely to retain parents with high psychosocial adversity, and cost one third less than PCIT.

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