Journal of Pediatric Health Care
Volume 25, Issue 2 , Pages 77-86, March 2011

Early Intervention in Pediatrics Offices for Emerging Disruptive Behavior in Toddlers

Received 11 May 2009; received in revised form 14 August 2009; accepted 16 August 2009. published online 07 January 2010.

Article Outline

Abstract 

Background

This study provides preliminary data about a parenting intervention for families of preschoolers with early attention deficit hyperactivity disorder/oppositional defiant disorder symptoms carried out in two diverse primary care pediatric offices.

Method

Parents of toddlers completed behavioral screening questionnaires at well-child visits. Eligible parents participated in a 10-week parenting education group using the Incredible Years program. Mothers completed several outcome measures at three time points: before participating in the group, immediately after the group ended, and 6 months thereafter. These measures assessed changes in parenting practices, parenting stress, and child symptoms. Parent and provider satisfaction also were assessed.

Results

Mothers reported improvements in parenting skills and a decrease in stress. They also reported a decrease in child aggression and an increase in compliance. Mothers and providers reported high levels of satisfaction.

Conclusions

Results support the benefits and feasibility of providing parenting education groups to parents of toddlers in pediatric practice settings.

Key Words: Pediatrics, intervention, parenting, parenting education, disruptive behavior, ADHD, ODD

 

Attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are among the most frequently diagnosed disorders in childhood; prevalence estimates for school-aged children range from 3% to 18% (American Psychiatric Association, 1994, Baumgartel et al., 1995, Esser et al., 1990, Kroes et al., 2001, Pope and Bierman, 1999, Vuchunich et al., 1992). A number of studies suggest that ADHD and ODD symptoms such as hyperactivity, impulsivity, and aggressiveness often emerge in early childhood and remain stable thereafter (Landy and Peters, 1992, Smith et al., 2004, von Stauffenberg and Campbell, 2007). Barkley (1998) has indicated that at least 50% of preschool children with ADHD symptoms will exhibit problematic symptoms into adolescence. Lavigne et al. (1998) found that a majority of preschoolers maintained a diagnosis of ADHD, ODD, or conduct disorder (CD) for 1 to 3 years after their initial assessment. In a comprehensive review, moderately high levels of stability (at least 50%) have been predicted for more than two years (Campbell, 1995).

Recent research also suggests that early externalizing symptoms predict diagnoses of ADHD and ODD later in childhood. In one study, more than 67% of mothers of children with ADHD traced the onset of their child's symptoms to before four years of age (Connor, 2002, Harvey et al., 2009). In a large prospective study, 47% of children with elevated ADHD/ODD behaviors at three years were found to have symptoms of ADHD at five years (Auerbach, Atzaba-Poria, Berger, & Landau, 2003). In contrast, none of the preschoolers without behavior problems had clinically significant problems at age five years (Hill, Coie, Lochman, & Greenberg, 2004). Children who exhibit early externalizing symptoms also are at higher risk for other psychological and social problems (Barkley, 1998, Danforth et al., 1991, DuPaul et al., 2001). Having a diagnosis of ADHD is one of the strongest predictors of a diagnosis of CD before the age of 10 years (Lahey & Loeber, 1997). Children with ADHD and ODD are at elevated risk for co-occurring internalizing symptoms such as depression and anxiety (Biederman et al., 1996, Loeber et al., 2000, Pierce et al., 1999, Wilens et al., 2002).

Notably, parents of preschool children displaying ADHD and ODD symptoms report higher levels of stress and more frequent use of negative parenting strategies (e.g., coercive discipline) than do other parents (Burke et al., 2002, Cunningham and Boyle, 2002, DuPaul et al., 2001, Fisher, 1990). Undeniably, the genetic underpinnings of ADHD are quite strong (Thapar, Hervas, & McGuffin, 1995). However, negative parenting practices may contribute to co-occurring diagnoses of ADHD and ODD. They also may lead to more severe impairments in the school, social, and home arenas among children with ADHD and play a direct causal role in the development of ODD (Patterson, 1998, Stormshak et al., 2000).

Stimulant medication is often the first-line treatment for school-aged children with ADHD, and recent research indicates that stimulants are effective for preschoolers (Vitiello et al., 2007, Wigal et al., 2006). At the same time, there is continued uncertainty about the effects of stimulants upon developing central nervous system structures, and guidelines have suggested the cautious use of these medications with preschoolers (Connor, 2002). Furthermore, studies suggest that long-term adherence to stimulant treatment is remarkably low (Concannon and Tang, 2005, Habel et al., 2005, Thiruchelvam et al., 2001). As such, behavioral treatment has been recommended as the first choice for preschoolers (Conners, March, Frances, Wells, & Ross, 2001). Parenting education programs are an important option in this category given the negative parent-child interaction patterns typically associated with early onset symptoms of ADHD and ODD (Barkley, 1998, DuPaul et al., 2001). The Incredible Years Program (IYP) by Webster-Stratton is one such program; the efficacy of the IYP for children with disruptive behavior has been documented extensively (Hartman et al., 2002, Scott et al., 2001; Taylor, Schmidt, Peplar, & Hodgins, 1998; Webster-Stratton & Hammond, 1997).

While the majority of efficacy studies have focused on school-aged children, preliminary evidence suggests that the IYP may be effective for younger children (Brotman et al., 2003, Gross et al., 2003, Tucker et al., 1998) and as a preventive intervention (Reid, Webster-Stratton, & Beauchaine, 2001). Targeting young children who are just beginning to display externalizing symptoms provides an ideal opportunity for change. For example, negative parent-child interaction patterns may not be rigidly set. Furthermore, recent research indicates that early parenting behaviors such as maternal verbosity may affect toddlers' compliance (Hakman & Sullivan, 2009). Parent-child synchrony during the toddler period also has been associated with children's self-control (Lindsey, Cremeens, Colwell, & Caldera, 2009). Thus, techniques provided in parenting education programs such as the IYP may increase the positive management of symptoms and decrease their severity.

Pediatric practices are an ideal context to identify young children exhibiting early symptoms of ADHD and ODD. Pediatricians and nurse practitioners have frequent and consistent contact with families during the first four years of life (Perrin, 1999, Schor, 2004). They also have increasingly embraced an expanded role overseeing the developmental, emotional, and social well-being of children (American Academy of Pediatrics, 1997, Green, 1994, McMenamy and Perrin, 2002, Perrin, 1999). Finally, they are called upon more than ever to provide mental health services such as formal behavioral screening, brief counseling, and prescribing psychotropic medications (Kelleher and Long, 1994, Schroeder, 1999). Indeed, more than 75% of office visits for ADHD are handled in pediatric primary care settings (Zarin, Tanielian, Suarez, & Marcus, 1998).

Pediatric practices are an ideal context to identify young children exhibiting early symptoms of ADHD and ODD.

The present study describes a combined screening and parenting education program, Parenting Resource and Education Project (PREP), for 2- to 3-year-old children displaying early symptoms of ADHD and ODD. In two diverse pediatric practices, parents completed brief behavioral screening questionnaires at well-child visits. Eligible families that enrolled in PREP attended a 10-week parenting education program located in their pediatrician's office. They also completed several outcome measures at three time points: before the parenting program began, immediately after the program ended, and six months thereafter. These measures assessed parenting practices, parenting stress, and child symptoms. Parents and providers also completed questionnaires about their satisfaction with the program. Thus, the present study provides preliminary data about the efficacy and feasibility of the program in two diverse primary care pediatric offices.

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Methods 

Participants 

The study was conducted at two sites. The primary site was a 10-provider practice (eight pediatricians and two nurse practitioners) located in a small city in central Massachusetts that serves families from a wide range of socioeconomic status. During a 7-month period, 620 children between the ages of two and three years were scheduled for well-child visits. Of these, 55% (n=341) completed screening questionnaires and 17% (n=59) met our criteria for elevated ADHD/ODD symptoms. Forty-three families were successfully contacted; 42% (n=18) of families agreed to join PREP. The most common reasons for non-completion of screening questionnaires were appointment cancellations or inability to complete the screener in English. Reasons for non-participation in PREP included logistical difficulties (e.g., work conflicts) and inability to commit to a long-term project.

Regarding the 18 participating families at this site, seven reported annual income below $25,000. Children of 13 families were White, 1 was Asian, and 4 were Hispanic. Mothers of all but one family completed high school, and eight completed college.

All caregivers for each child were invited to participate in PREP, but in only five families did more than one parent participate. Three families dropped out over the course of the parenting education sessions.

Our second site was an urban health center in Boston that serves primarily low socioeconomic status families from diverse cultural and racial backgrounds. During a 3.5-month period, 80 families were identified for screening. Of these, 74% (n=59) completed the screener and 29% (n=17) met our criteria for elevated ADHD/ODD symptoms and were invited to enroll in PREP. Ten of these families were successfully contacted, and 50% of the families (n=5) enrolled in PREP. Reasons for non-completion of the screening questionnaire and non-participation in PREP paralleled those at our primary site.

Regarding the five participating families at this site, four reported annual income below $25,000. Children of four families were Black and one was White. Mothers of all families completed high school, and three completed college.

None of the five families at our second site had more than one parent participate in PREP. All families completed the parenting group and the post-intervention assessment; one was lost to follow-up thereafter. Thus, the final sample from both sites was the primary caregivers of 23 children.

Measures 

Screening Questionnaire 

Our 10-minute screening measure consisted of five subscales of the Infant Toddler Social-Emotional Assessment (ITSEA) (Carter & Briggs-Gowan, 2000). The ITSEA assesses social-emotional problems and competencies of 12- to 48-month-old children and has solid reliability (Intraclass Correlation Coefficient [ICC]=.82, test-retest, externalizing problems; Uncertainty Correlation Coefficient [UCC] =.78 test-retest, attention competency) and construct validity (r=.71 with Child Behavior Checklist [CBCL] 2/3) (Carter et al., 2003). The subscales we used were Aggression, Hyperactivity/Impulsivity, Peer Aggression, Compliance, and Attention Skills. Families were eligible for PREP if their child scored at or above the 80th percentile on any of the five subscales. The screening questionnaire was re-administered post-intervention and at the 6-month follow-up assessment as an outcome measure.

Our screener performed well in the study. Internal consistency was satisfactory for all five subscales (α=.67-.87), as was retest reliability over a 1-month period (ICC=.66-.78). Furthermore, the overall externalizing scale of our measure correlated significantly with parent reports on the externalizing problem scale of the CBCL/1.5-5 (r=.46, P < .01).

Demographic Questionnaire 

Participants completed a demographic questionnaire assessing family structure, income and education levels, and preliminary health information about the child and family.

Achenbach Child Behavior Checklist (CBCL 2/3) 

The parent form of the CBCL 2/3 consists of 118 items assessing child behavior in several domains. This study will report data on the following domains: Total Problems, Externalizing, and Internalizing. The CBCL has strong psychometric properties (Achenbach & Rescorla, 2000): interclass correlations were .84 for test-retest reliability and .98 for inter-rater agreement.

The LIFT Parenting Practices Interview (PPI) 

The PPI is a 43-item questionnaire adapted by Webster-Stratton (1998) from the Oregon Social Learning Center's Discipline questionnaire and revised for preschoolers. Exploratory factor analysis isolated four parenting domains consisting of items related to: (a) harsh parenting: (b) inconsistent discipline; (c) appropriate discipline; and (d) positive parenting strategies.

The internal reliabilities for the three domains are adequate (α=.57-.73), and these domains also have displayed reasonable stability over time (r=.50-.77) (Webster-Stratton, Reid, & Hammond, M., 2004). The PPI has been used extensively in studies of the IYP.

Parenting Stress Index (PSI) 

The PSI short form consists of 25 items assessing the degree of perceived stress among parents related to parenting roles. The PSI is organized according to child and parent characteristics (Baydar, Reid, & Webster-Stratton, 2003). The PSI demonstrates adequate retest reliability (Cronbach's α ranging from .65-.85), and internal consistency (Cronbach's α ranging from .80-.91) (Abidin, 1983).

Parent Satisfaction Questionnaire (PSQ) 

The PSQ is a 40-item Likert scale questionnaire assessing topics such as parents' satisfaction with the attention paid to child behavior and development in the parenting group and the difficulty of the intervention. The measure has been used extensively be Webster-Stratton in her evaluations of the IYP and has been shown to have sound internal consistency (Webster-Stratton & Hammond, 1997). Participants in the present study completed a shortened version of the PSQ once during their involvement in PREP at the end of the parenting education sessions.

Pediatrician Satisfaction Questionnaire (PedSQ) 

The PedSQ is a 12-item Likert scale questionnaire assessing topics such as the degree to which the screening procedures provide useful information and/or disrupt the flow of well-child visits, and whether the screening procedures and/or parenting education program affect the time and effort demands related to managing patients' behavioral problems. The PedSQ was designed for use with PREP and is piloted in this study. Ten providers—eight pediatricians and two nurse practitioners—completed the PedSQ shortly after the screening and parenting education sessions had been completed in their practice.

Procedures 

All of the procedures were reviewed and approved by the Institutional Review Board at Tufts University School of Medicine.

Description of PREP Screening and Intervention Protocol 

On a weekly basis, a member of the pediatric office nursing staff notated all 2- and 3-year-old children who had a scheduled a well-child visit. Upon arrival at the practice for the well-child visit, receptionists gave parents the screening questionnaire and asked them to complete it while waiting for their appointments.

Parents of children who displayed high levels of ADHD or ODD symptoms were invited to participate in PREP. These families were contacted by mail by their primary care pediatrician and asked for permission to have PREP staff contact them. If they agreed, PREP was explained by a research assistant by telephone. Interested families were invited to meet on an individual basis with a research assistant to further review the content of the program and to complete demographic forms and informed consent documents. All caregivers for the child were invited to attend the initial meeting and participate in PREP. If only one caregiver could participate in the project, the family was still eligible for PREP.

Participating parents attended a 10-week parenting education group that met for two hours each week in the evening at the pediatric office. Each meeting began with a small dinner for participants, and families were given a small stipend to offset child-care costs. In families where only one caregiver participated, a workbook summarizing program content was provided for the co-parent.

The curriculum of the group session consisted of the IYP BASIC program. This program focuses upon strengthening parent skills through four modules: play, praise and reward, effective limit setting, and handling misbehavior. Concepts of the program are introduced through videotaped vignettes and are explicated through group discussion. Weekly homework assignments allow parents opportunities to try out concepts presented in the meeting. Parenting education sessions were run by a nurse practitioner with experience in group counseling and were co-led by a doctoral student in clinical psychology. Both the leader and co-leader completed training in the IYP program.

Description of Assessment Protocol 

Participants completed all outcome measures three times during their enrollment in PREP: at a pre-intervention interview, post-intervention within 1 week of the end of the parenting group, and six months after the end of the parenting group. Participants were able to complete the assessment packet at home after it was mailed to them, or at the pediatric practice with a research assistant present. Each assessment packet took about 70minutes to complete. Participants received $40 for each packet completed.

Analyses 

To examine change over time, we conducted repeated measures analyses of variance for each dependent measure. All analyses were based on intent-to-treat, meaning that participants who did not complete follow-up assessments were assumed to maintain symptoms at pre-intervention levels. Given that only a few families had more than one parent participate, even when more than one parent was involved (five out of 23 families), analyses included data only from the mother.

Tukey post-hoc tests were used to examine statistically significant change between the pre-intervention interview and the post-intervention interview and between the pre-intervention interview and the 6-month follow-up interview. Cohen's effect sizes and standard P values are reported for each test. To account for multiple comparisons, we controlled for a false discovery rate of α =.05 (Benjamini & Hochberg, 1995). The false discovery rate controls the expected proportion of incorrectly rejected null hypotheses (type 1 errors). Using this method, a probability (ai) is calculated for each test, indicating the chance that rejecting its null hypothesis will result in a type 1 error. The value ai is then compared to α to determine significance.

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Results 

Parent Outcomes 

Mothers reported high levels of satisfaction with the program. All mothers who completed the Parent Satisfaction Questionnaire at the end of the 10 sessions (n=19) reported that their overall feeling about the program was “positive” or “very positive.” Seventy-nine percent (n=15) reported being “satisfied” or “greatly satisfied” with their child's progress, and 100% of mothers reported that they would “recommend” or “strongly recommend” the program to a friend. Furthermore, 94% (n=18) considered the approach used to change child behavior “appropriate” or “very appropriate,” and 85% (n=16) felt “confident” or “very confident” about their abilities to manage future behavioral problems on their own. Ninety-four percent (n=18) also believed that the parenting program helped them with personal and/or family problems.

Mothers also reported significant improvements in their parenting skills. After intervention, mothers displayed improvement on four of five parenting measures (Table 1). Parenting stress (P < .005), use of harsh discipline (P=.02), and inconsistent use of discipline declined, and use of positive parenting techniques (P < .005) increased. Change was still apparent on these measures at 6-month follow-up, by which time the use of appropriate discipline displayed an increase as well (P=.03).

Table 1. Means and standard deviations for parent outcomes
AssessmentP valuesEffect sizes
DomainScalePre-interventionPost-intervention6-mo follow-upOverall model1 v 21 v 31 v 21 v 3
Parenting stressPSI total score
M85.7965.2069.550.000.00∗0.00∗−0.87−0.64
SD13.2431.7131.92
Negative parentingPPI harsh discipline
M2.802.282.410.010.02∗0.03∗−0.74−0.50
SD0.890.430.64
PPI inconsistent discipline
M3.342.962.840.010.03∗0.01∗−0.46−0.60
SD0.700.980.95
Positive parentingPPI appropriate discipline
M4.384.594.750.110.280.03∗0.210.39
SD0.981.000.92
PPI positive parenting
M4.224.764.570.000.00∗0.03∗0.750.51
SD0.720.720.67

PPI, Parenting Practices Interview; PSI, Parenting Stress Index.

∗Probability of false discovery (ai) < .05.

Child Symptoms 

After intervention, mothers reported that children displayed improvement on six of seven behavioral measures (Table 2). Competencies such as compliance (P < .005) and attention skills (P<01) increased. Internalizing symptoms decreased (P=.01), as did several externalizing scales, including the Externalizing domain on the CBCL (P < .005) and the ITSEA scales Activity Level (P=.01) and Aggression (P < .005). Change was still apparent on these measures at 6-month follow-up with one exception: the increase in attention skills from the pre-intervention assessment fell to a level just below statistical significance (P=.08).

Table 2. Means and standard deviations for child outcomes
AssessmentP valuesEffect sizes
DomainScalePre-interventionPost-intervention6-mo follow-upOverall model1 v 21 v 31 v 21 v 3
Externalizing problemsCBCL Externalizing
M25.8019.4018.350.000.000.00−0.76−0.93
SD7.268.627.78
ITSEA Activity Level
M2.202.001.890.000.01∗0.00∗−0.48−0.69
SD0.440.380.43
ITSEA Aggression
M2.111.771.760.000.00∗0.00∗−0.86−0.85
SD0.390.380.42
ITSEA Peer Aggression
M1.271.271.290.980.950.90−0.020.03
SD0.590.370.47
Internalizing problemsCBCL Internalize
M13.209.459.600.000.01∗0.01∗−0.59−0.54
SD7.265.266.06
CompetenciesITSEA Compliance
M2.032.302.370.000.00∗0.00∗0.760.91
SD0.330.380.41
ITSEA Attention Skills
M1.892.042.000.020.01∗0.080.410.30
SD0.390.340.36

CBCL, Child Behavior Checklist; ITSEA, Infant Toddler Social-Emotional Assessment.

∗Probability of false discovery (ai) < .05.

Pediatric Staff Satisfaction 

Pediatricians and nurse practitioners also described a high level of satisfaction with the screening and intervention protocols. Specifically, all 10 providers surveyed reported little or no negative impact on their collateral workload (e.g., paperwork and phone calls) and few or no additional burdens on office space. All providers reported little to no negative impact on the flow of their workload (e.g., running behind schedule). The majority claimed little to no burden on their schedules (9 of 10) and on the workload of support staff (7 of 10). In addition, seven of 10 providers reported “moderate” to “significant” changes with regard to the parent group improving overall care by offering a needed service. For example, in a follow-up discussion with a group of providers, one stated, “We receive so many questions about parenting and child development. Having a young child that displays challenging behaviors can be really stressful. It was really nice to have a resource to offer to these families.”

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Discussion 

The Report of the Surgeon General's Conference on Children's Mental Health (Department of Health and Human Services Administration, 1999) has cited the prevention of mental health problems among youths as a national priority. We have described a combined screening and parenting education program, PREP, that is consistent with this priority. PREP was designed to capitalize on the multiple opportunities for observation and conversation between pediatricians, nurse practitioners, and parents during the first several years of life. Through systematic screening during pediatric well-child visits at two and three years of age, we identified parents who reported early symptoms of ADHD and ODD in their children. In response, we integrated into a new context—the primary care pediatric office—an empirically validated parenting education program, the IYP, for these parents.

Many prior studies of the IYP include school-aged children already diagnosed with ADHD and/or ODD (Hartman et al., 2002, Scott et al., 2001, Taylor et al., 1998, Webster-Stratton and Hammond, 1997), and a few recent studies support the efficacy of the IYP for preschoolers (Brotman et al., 2003, Gross et al., 2003; Tucker at al., 1998) and for children who do not have any mental health diagnosis (Reid et al., 2001). The results of PREP are consistent with those in other reports. The mothers in our study reported less stress in their parenting roles and notable improvements in their parenting skills, including less frequent use of harsh and inconsistent discipline and more frequent use of positive parenting techniques. Mothers also reported improvement in their children's behaviors after the intervention; specifically, they saw their children as more compliant and attentive. They reported decreases in children's aggressive and hyperactive behaviors as well as in internalizing symptoms. Importantly, nine of the 10 significant changes in both the parent and child domains were maintained through the 6-month post-intervention follow-up.

The mothers in our study reported less stress in their parenting roles and notable improvements in their parenting skills, including less frequent use of harsh and inconsistent discipline and more frequent use of positive parenting techniques.

Despite the enormous potential for primary care pediatricians and nurse practitioners to be involved in the identification and early treatment of behavioral problems (Bauer & Webster-Stratton, 2006), the IYP program has rarely been incorporated in the pediatric context. Thus, the present study also provides important information about the feasibility of implementing parenting education programs in primary care pediatric offices. First, all of the mothers reported that participating in PREP was a positive experience and that they would recommend the program to a friend. The majority of mothers also were satisfied with their child's progress and felt confident about their abilities to manage future behavior problems.

Second, the 10 providers involved in this study also reported high levels of satisfaction with PREP. All of them reported that the screening procedures had little to no negative impact on their collateral workload and upon the flow of patients through their office. PREP also did not create any additional burdens upon their office space, and the majority did not believe that the workload of their office staff was negatively affected. The majority of providers believed that the parent groups improved overall patient care at their practice by offering a needed service.

Third, it is important to highlight that PREP was implemented in two diverse pediatric offices in very diverse communities. One was a large 10-provider private practice in a small central MA city that serves families from a wide variety of backgrounds; the other was an urban health center that serves families from a central Boston neighborhood. Small adaptations were needed at both locations to achieve successful screening rates. One consideration in implementing any group intervention is the volume of eligible participants. If the number is too small, the lag time between enrolling the first parents and beginning the intervention may become unacceptably long. Almost half of our sample reported an annual income of less than $25,000 and 40% were Black, Hispanic, or Asian. Unfortunately, one of the reasons for non-participation at both sites was limited English fluency. The ability to run groups in Spanish and other languages is vitally important to increase the availability of parenting education to families in need. Our success in carrying out a series of parenting education groups in these two very different practices with a very diverse sample provides initial evidence supporting the feasibility of implementing programs such as PREP in a range of pediatric settings.

Our success in carrying out a series of parenting education groups in these two very different practices with a very diverse sample provides initial evidence supporting the feasibility of implementing programs such as PREP in a range of pediatric settings.

This study has a number of limitations. Most notably, the absence of a comparison group precludes our ability to make statements about direct effects of PREP upon parent and child behaviors. Sample bias also may be present in that non-participating families may have been systematically different (e.g., socioeconomic status and the severity of their child's symptoms) from families that enrolled in PREP. While the results are robust, the small sample size might limit generalizability. Furthermore, our results are based solely on data from parent reports. An observational measure of parent-child interaction would better assess changes in parent and child behaviors. All of these limitations are being addressed in our current randomized controlled trial of our screening and intervention protocol in 10 diverse pediatric practices across Massachusetts.

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Conclusions 

This study contributes initial data about the efficacy and feasibility of PREP in two diverse pediatric offices. Despite the promising nature of these findings, it is important to note that the results are preliminary and that this pilot study is not a true test of the long-term viability of PREP. Although the project took place in a real-world community setting, several supports were in place to maximize the program's success. The group leaders were a trained nurse practitioner and psychologists that were part of our research team, and the majority of planning/set-up for the weekly group meetings also was done by research staff. Furthermore, parents were offered dinner before group meetings and a small child-care stipend. They also were reimbursed for completing assessments. All of these factors must be considered when evaluating the ability of a program to be transferred to a naturalistic setting.

Our long-term goal is to demonstrate the effectiveness of a routine screening and intervention protocol in pediatric practice settings. An effectiveness study will need to build upon the positive foundation established by our current data and address significant pragmatic considerations and barriers to the long-term viability of the program. For example, viable reimbursement mechanisms currently do not exist for both the screening and intervention components. We have begun discussions with major third-party payers in Massachusetts to explicitly authorize reimbursement for parenting education groups. Additional training is needed to provide pediatric staff with the skills and confidence to independently run parent groups. By continuing to provide positive data about the efficacy of our program and by addressing the aforementioned barriers, we hope to ensure sustainability of parenting education programs in pediatric primary care.

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We thank Carolyn Webster-Stratton, PhD, RN, for her consultation about the Incredible Years Program and Alice Carter, PhD, for her consultation on the development of our screening measure. We also thank Katie Kavanaugh, PhD, Leandra Godoy, MA, and Elizabeth Tannebring, RN, PNP, for all of their efforts in carrying out this project.

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Jannette McMenamy, Associate Professor, Department of Behavioral Sciences, Fitchburg State College, Fitchburg, MA.

R. Christopher Sheldrick, Assistant Professor, Division of Developmental-Behavioral Pediatrics, The Floating Hospital for Children, Tufts University School of Medicine, Boston, MA.

Ellen C. Perrin, Professor, Division of Developmental-Behavioral Pediatrics, The Floating Hospital for Children, Tufts University School of Medicine, Boston, MA.

 Conflicts of interest: None to report.

 This project was funded by grant 1R21 MH068035-01 from the National Institute of Mental Health and by The Commonwealth Foundation.

PII: S0891-5245(09)00248-X

doi:10.1016/j.pedhc.2009.08.008

Journal of Pediatric Health Care
Volume 25, Issue 2 , Pages 77-86, March 2011

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