Transcript Understanding Fidelity: Observing Implementation at

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 Center
Administration
National
Implementation
Team for children
Program director
4 National consultants
6 Regional coordinators
Research Unit
Research director
Research consultant
Data manager
7 Researchers
The logistics team
National
Implementation
Team for youth
Program director
6 National consultants
Factors influencing
program outcomes
Dissemination
Program
development
Fidelity/
Adherence
Implementation
Adoption
Readiness
Adaptation
Context
Outcomes
Implementation of Parent Management Training
in Norway
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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)
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Adoption and implementation of PMTO at
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a) the regional and
b) municipal level
Training 3 generations of PMTO therapists (1999-2006)
Therapist training program
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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).
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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
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The first generation of PMTO specialists working as trainers and
supervisors of new candidates
The PMTO training program
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Training program based on the principles of social interaction
learning theory (SIL) (Patterson, 1982;1996) and PMTO
procedures (Forgatch, 1994).
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Didactic instruction, videotaped examples, and role play
demonstrating the procedures.
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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)
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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)
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The 2nd generation also recruited from the specialist child and youth
services in a 1.5 year training program (G2: N=84, 2001-2003)
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Pre-assessment of 19 agencies (sites), negotiating administrative
support, adequate working conditions and necessary equipment for the
candidates
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The 3rd generation recruited from various municipal child and youth
services (G3: N=70, 2004-2006)
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The 4th generation starting 2006
PMTO – clinical outcome study
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A clinical trial with 100 families randomly distributed to PMTO and
treatment as usual
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Measuring changes in child behavior at home and at school using multiinformant behavioral assessment, parent reports, observations and
background information
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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
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Intervention: training in the core PMTO elements 1) encouragement, 2)
discipline, 3) monitoring, 4) problem solving and 5) positive involvement
Intake battery
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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
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Structured family interaction tasks are video recorded before and after
treatment (playing/planning, problem solving/hot topics, waiting and
evaluating)
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Reliable coding with Family and Peer Process Code (FPPC)
Real time coding of:
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Activity,
Withdrawal
Contents
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Affect is registered for each content code
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Total Aversive Behavior score (TAB)
Coders Impression Scale
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Studying implementation and
fidelity drift of PMTO
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A collaborative research project on implementation, outcome
effectiveness and fidelity drift between OSLC and the Behavior Center
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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
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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
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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.
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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 MODEL
Agency
Characteristics
Interventionist
Characteristics
Family
Characteristics
Fidelity
Change
Parenting
Change Child
Behavior
Assessment of treatment fidelity
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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)
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Hypothesis: High scores on the PMTO treatment
fidelity measure (FIMP) will increase the quality of the
parenting
Repeated measurements of treatment
fidelity over 4 years
Agency
Characteristics
Agency
Characteristics
Agency
Characteristics
Agency
Characteristics
Interventionist
Characteristics
Interventionist
Characteristics
Interventionist
Characteristics
Interventionist
Characteristics
Family
Characteristics
Family
Characteristics
Family
Characteristics
Family
Characteristics
Year 1
Fidelity
Year 2
Fidelity
Year 3
Fidelity
Year 4
Fidelity
Agency
Characteristics
Interventionist
Characteristics
G1
Fidelity
n = 33
Family
Characteristics
Training
Quality of G2
Agency
Characteristics
G2
Fidelity
n = 84
Interventionist
Characteristics
Family
Characteristics
Training
Quality of G3
The study of
therapist
intergenerational
fidelity drift
Agency
Characteristics
Interventionist
Characteristics
Family
Characteristics
G3
Fidelity
n = 70
Obstacles and challenges
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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:
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Adding research to the implementation increased the work-load and
challenges for the project
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Introducing randomized controlled trials and quantitative group designs
in clinical research
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The recruitment of therapist (intervention + control) and the
randomization procedure slowed down the referral process
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New and challenging procedures: Video recordings of family interaction
(FPPC) and therapy sessions (FIMP)
Overcoming obstacles at the program level
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Long term planning and implementation
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Continued and consistent support from the program developers
Marion Forgatch, Gerald Patterson and their colleagues at OSLC
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Establishing PMTO therapist networks and continued supervision
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Developing training programs, handbooks and material in
Norwegian
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Negotiating training programs and the scope and contents of
interventions with the municipalities
Facilitators at the national level
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Increased professional demand for effective and empirically
based methods to treat and prevent behavior problems in
children
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‘Champion advocates’ at the national, regional and local level
generating interest, motivation, enthusiasm and effort
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A genuine interest and commitment at the political and
administrative level - consistent funding
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Establishing a national implementation and research center and
a national training program
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Positive feedback from families and from the media
That was all!
Thank you!