PARENT MANAGEMENT TRAINING (PMTO) Program implementation and research in Norway

1. 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

2. The Behavior Center Administration National Implementation Team for children Research Unit National Implementation Team for youth Program director 4 National consultants 6 Regional coordinators Research director Research consultant Data manager 7 Researchers Program director 6 National consultants The logistics team

3. Factors influencing program outcomes Dissemination Fidelity/ Adherence Program development Implementation Out- comes Adoption Adaptation Readiness Context

4. Implementation of Parent Management Training in Norway • 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) • Adoption and implementation of PMTO at • a) the regional and • b) municipal level • Training 3 generations of PMTO therapists (1999-2006)

5. Therapist training program • 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). • 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 • The first generation of PMTO specialists working as trainers and supervisors of new candidates

6. The PMTO training program • Training program based on the principles of social interaction learning theory (SIL) (Patterson, 1982;1996) and PMTO procedures (Forgatch, 1994). • Didactic instruction, videotaped examples, and role play demonstrating the procedures. • All sessions were video-taped and about 20% were transcribed, translated into English and subject to feedback from experienced clinicians at the OSLC.

7. Training three generations of PMTO therapists/specialists(1999-2006) • 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) • The 2nd generation also recruited from the specialist child and youth services in a 1.5 year training program (G2: N=84, 2001-2003) • Pre-assessment of 19 agencies (sites), negotiating administrative support, adequate working conditions and necessary equipment for the candidates • The 3rd generation recruited from various municipal child and youth services (G3: N=70, 2004-2006) • The 4th generation starting 2006

8. PMTO – clinical outcome study • A clinical trial with 100 families randomly distributed to PMTO and treatment as usual • Measuring changes in child behavior at home and at school using multi-informant behavioral assessment, parent reports, observations and background information • 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 • Intervention: training in the core PMTO elements 1) encouragement, 2) discipline, 3) monitoring, 4) problem solving and 5) positive involvement

9. Intake battery • 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

10. Video recording and coding of structured family interaction tasks • Structured family interaction tasks are video recorded before and after treatment (playing/planning, problem solving/hot topics, waiting and evaluating) • Reliable coding with Family and Peer Process Code (FPPC) • Real time coding of: • Activity, • Withdrawal • Contents • Affect is registered for each content code • Total Aversive Behavior score (TAB) • Coders Impression Scale

11. Studying implementation and fidelity drift of PMTO • A collaborative research project on implementation, outcome effectiveness and fidelity drift between OSLC and the Behavior Center • 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

12. Aims of the study • 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 • 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. • To analyze PMTO fidelity changes within specialists over time and as a function of training successive generations of Norwegian PMTO therapists.

13. Agency Characteristics Fidelity Change Parenting Change Child Behavior Interventionist Characteristics Family Characteristics FIDELITY WITHIN THE SIL MODEL

14. Assessment of treatment fidelity • 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) • Hypothesis: High scores on the PMTO treatment fidelity measure (FIMP) will increase the quality of the parenting

15. Repeated measurements of treatment fidelity over 4 years Agency Agency Agency Agency Characteristics Characteristics Characteristics Characteristics Interventionist Interventionist Interventionist Interventionist Characteristics Characteristics Characteristics Characteristics Family Family Family Family Characteristics Characteristics Characteristics Characteristics Year 4 Year 3 Year 2 Year 1 Fidelity Fidelity Fidelity Fidelity

16. Agency Characteristics G1 Interventionist Fidelity Characteristics n = 33 Family Characteristics Training Quality of G2 Agency Characteristics G2 Interventionist Fidelity Characteristics n = 84 Family Characteristics Training Quality of G3 Agency Characteristics G3 Interventionist Fidelity Characteristics n = 70 Family Characteristics The study of therapist intergenerational fidelity drift

17. Obstacles and challenges • 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

18. Bringing research into the implementation: • Adding research to the implementation increased the work-load and challenges for the project • Introducing randomized controlled trials and quantitative group designs in clinical research • The recruitment of therapist (intervention + control) and the randomization procedure slowed down the referral process • New and challenging procedures: Video recordings of family interaction (FPPC) and therapy sessions (FIMP)

19. Overcoming obstacles at the program level • Long term planning and implementation • Continued and consistent support from the program developers Marion Forgatch, Gerald Patterson and their colleagues at OSLC • Establishing PMTO therapist networks and continued supervision • Developing training programs, handbooks and material in Norwegian • Negotiating training programs and the scope and contents of interventions with the municipalities

20. Facilitators at the national level • Increased professional demand for effective and empirically based methods to treat and prevent behavior problems in children • ‘Champion advocates’ at the national, regional and local level generating interest, motivation, enthusiasm and effort • A genuine interest and commitment at the political and administrative level - consistent funding • Establishing a national implementation and research center and a national training program • Positive feedback from families and from the media

21. That was all! Thank you!