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  Interventions to Reduce Behavioral Problems inChildren With Cerebral Palsy: An RCT WHAT ’ S KNOWN ON THIS SUBJECT:  One in 4 children withcerebral palsy (CP) have a behavioral disorder. Parentinginterventions are an ef  󿬁 cacious approach to treating behavioraldisorders. There is a paucity of research on parentinginterventions with families of children with CP. WHAT THIS STUDY ADDS:  This is the  󿬁 rst study to demonstrate the ef  󿬁 cacy of a parenting intervention in targeting behavioralproblems in children with CP. Further, results suggest thatAcceptance and Commitment Therapy delivers additive bene 󿬁  tsabove and beyond established parenting interventions. abstract OBJECTIVE: To test Stepping Stones Triple P (SSTP) and Acceptance andCommitment Therapy (ACT) in a trial targeting behavioral problems inchildren with cerebral palsy (CP). METHODS:  Sixty-seven parents (97.0% mothers; mean age 38.7 6 7.1years) of children (64.2% boys; mean age 5.3  6  3.0 years) with CP(Gross Motor Function Classi 󿬁 cation System = 15, 22%; II = 18, 27%; III=12, 18%; IV = 18, 27%; V = 4, 6%) participated and were randomlyassigned to SSTP, SSTP + ACT, or waitlist. Primary outcomes werebehavioral and emotional problems (Eyberg Child Behavior Inventory[ECBI], Strengths and Dif  󿬁 culties Questionnaire [SDQ]) and parentingstyle (Parenting Scale [PS]) at postintervention and 6-month follow-up. RESULTS:  SSTP with ACT was associated with decreased behavioralproblems (ECBI Intensity mean difference [MD] = 24.12, con 󿬁 dence in- terval [CI] 10.22 to 38.03,  P   = .003; ECBI problem MD = 8.30, CI 4.63 to11.97,  P   ,  .0001) including hyperactivity (SDQ MD = 1.66, CI 0.55 to2.77,  P   = .004), as well as decreased parental overreactivity (PS MD =0.60, CI 0.16 to 1.04,  P   = .008) and verbosity (PS MD = 0.68, CI 0.17 to1.20,  P   = .01). SSTP alone was associated with decreased behavioralproblems (ECBI problems MD = 6.04, CI 2.20 to 9.89,  P   = .003) andemotional symptoms (SDQ MD = 1.33, CI 0.45 to 2.21,  P   = .004).Decreases in behavioral and emotional problems were maintainedat follow-up. CONCLUSIONS:  SSTP is an effective intervention for behavioral prob-lems in children with CP. ACT delivers additive bene 󿬁  ts.  Pediatrics  2014;133:1 – 9 AUTHORS:  Koa Whittingham, PhD, a , b Matthew Sanders,PhD, b Lynne McKinlay, MD, c and Roslyn N. Boyd, PhD a a  Queensland Cerebral Palsy and Rehabilitation Research Centre  , School of Medicine, and   b  Parenting and Family Support Centre,School of Psychology, The University of Queensland, Brisbane,Australia; and   c  Queensland Paediatric Rehabilitation Service,Royal Children  ’    s Hospital, Brisbane, Australia  KEY WORDS parenting, behavioral family intervention, cerebral palsy,acceptance and commitment therapy, mindfulness ABBREVIATIONS ACT — Acceptance and Commitment TherapyANCOVAs — analyses of covarianceASDs — autism spectrum disordersCI — con 󿬁 dence intervalCP — cerebral palsyECBI — Eyberg Child Behavior InventoryGMFCS — Gross Motor Function Classi 󿬁 cation SystemMD — mean differencePS — Parenting ScaleRCT — randomized controlled trialSDQ — Strengths and Dif  󿬁 culties QuestionnaireSSTP — Stepping Stones Triple PTriple P — Positive Parenting ProgramWL — waitlist controlDr Whittingham conceptualized and designed the study, withmentorship from senior authors, managed the randomizedcontrolled trial, conducted the analysis, and drafted the initialmanuscript; Drs Sanders, McKinlay, and Boyd providedmentorship in the conceptualization and design of the study, andreviewed and revised the manuscript; and all authors approved the  󿬁 nal manuscript as submitted.This trial has been registered with the Australian New ZealandClinical Trials Registry (identi 󿬁 er 00336291) for publication Feb 14, 2014Address correspondence to Koa Whittingham, PhD, QueenslandCerebral Palsy and Rehabilitation Research Centre, Level 7, Block 6, RBWH Herston, Brisbane, Australia 4029. (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).Copyright © 2014 by the American Academy of Pediatrics (Continued on last page) PEDIATRICS Volume 133, Number 5, May 2014  1 ARTICLE  by guest on June 10, from   Cerebral palsy (CP) is a permanentdisorder of the development of move-ment and posture that is caused bynonprogressive disturbance to the de-veloping fetal or infant brain. 1 It is themost common physical disability inchildhood, occurring in 2.0 to 2.5 of ev-ery 1000 live births. 2 Children with CP,akin to children with disabilities gener-ally, are more likely to experience be-havioral and emotional problems. 3 – 5 Arecent meta-analysis showed that 1 in 4children with CP have a behavioral dis-order 6 compared with 1 in 10 typicallydeveloping children 7 ; however, despiterecognition of the problem, there isa paucity of research and clinical ser-vices to address this issue.Parenting interventions target behav-ioral and emotional problems of child-hood through enhancing parenting. 8 Parenting interventions based in sociallearning theory and behavioral analysishave wide empirical support with typi-cally developing children. 9 – 11 SteppingStones Triple P (SSTP) is a variant of thewidely disseminated Positive ParentingProgram (Triple P) that targets familiesof children with disabilities. 12 A recentmeta-analysis found that SSTP hasa moderate effect on child behavioraloutcomes (d = 0.537) and a large effecton parenting style (d= 0.725), 13 consis- tent with meta-analyses of Triple P with typically developing children. 14 – 17 Fur- ther, SSTP has demonstrated ef  󿬁 cacyspeci 󿬁 cally for families of children withautism spectrum disorders (ASDs). 18 Although parenting interventions, suchas SSTP, are an evidence-based ap-proach for targeting behavioral andemotional problems in childhood andare readily accessible by parents, therearenopublishedrandomizedcontrolled trials (RCTs) of a parenting interventionfor families of children with CP. 19 Acceptance and Commitment Therapy(ACT) is a new cognitive behavioral therapy that emphasizes nonjudgmentalpsychological contact with presentmoment experience and engagementin meaningful, values-driven activi- ties. 20 The goal of ACT is to increasepsychological  󿬂 exibility, the ability topersist or change one ’ s behavior, withfull awareness of the situational con- text and one ’ s own present-momentexperience, in the service of chosenvalues. ACT has a growing evidencebase; it is at least as effective as oldercognitive behavioral therapy modelswith some evidence suggesting greateref  󿬁 cacy. 21 – 23 ACT may enhance estab-lished behavioral parenting interven- tions by addressing parental cognitionand emotions. 24,25 This new approach isparticularly promising for families of children with disabilities, with RCTs ur-gently needed. 26 Ouraim was to test the ef  󿬁 cacy of SSTP,with and without ACT, in targeting childbehavioral and emotional problemsand dysfunctional parenting in familiesof children with CP. METHODS Design The study design is detailed in full in thestudy protocol. 27 This was a 2-phase RCTwith 3 groups (SSTP, SSTP + ACT, waitlistcontrol [WL]). The  󿬁 rst phase, the pri-mary focus of the study, involved a com-parison among SSTP, SSTP with ACT, andWL groups at postintervention. Afterpostintervention assessment, the WLgroup, for ethical reasons, was offeredSSTP. If WL families completed SSTP, then they also completed additional post-intervention assessment, along with6-month follow-up assessment. The sec-ond phase of the study examined effectsat follow-up and included all familieswho received an intervention and com-pleted 6-month follow-up assessment.The second phase included a pre-postdesign component, examining the re- tention of intervention effect from post-intervention to 6-month follow-up, aswell as a comparison between familieswho received SSTP and families whoreceived SSTP with ACT at 6-monthfollow-up.EthicalclearancewasobtainedfromtheChildren ’ s Health Queensland HumanResearch Ethics Committee, the Univer-sityofQueenslandBehavioralandSocialSciences Ethical Review Committee, and the Cerebral Palsy League of Queens-land Research Ethics Committee; allparticipating parents signed a consentform before participation. Participants Participantswereparentsofchildren(2 – 12 years) with a diagnosis of CP (allgross motor functioning severity levels)who self-identi 󿬁 ed as needing a parent-inginterventionafterdiscussiononwhata parenting intervention could target.Participants were recruited from thedatabases of the Queensland CerebralPalsy and Rehabilitation Research Cen- tre, the Cerebral Palsy League, and theQueensland Cerebral Palsy Register, and through presentation at the QueenslandCerebral Palsy Health Service (Fig 1). Sample Size Calculation Samplesizecalculationswerebasedon theprimaryoutcome:childbehavior.Aneffectsizeof0.25wasassumedbecauseit is consistent with a clinically im-portant difference of 0.5 SD and iscomparable to the effect size for SSTPobtained with families of children withASD,  h 2 = 0.27. 18 This leads to a totalsample size of 98 (power 0.8, 2-tailed, P  =.05) and110accountingforattrition.Thiswas not obtained, with recruitmentefforts in the available population lead-ing to a  󿬁 nal sample size of 67. Procedure The randomization process was com-pleted by computerized sequence gen-eration with block randomization toensure equal (or near equal) allocationof participants to groups. The groupallocations were placed inside sealed,opaque, and numbered envelopes by 2  WHITTINGHAM et al  by guest on June 10, from   FIGURE 1 Study protocol and participant  󿬂 ow. ARTICLE PEDIATRICS Volume 133, Number 5, May 2014  3  by guest on June 10, from   astaffmembernotinvolvedinthisstudy.On enrolment of a family, the study co-ordinator opened the next envelope insequence. Each study participant wasrandomized to 1 of 3 groups: SSTP, SSTPwith ACT, or WL.The interventions (SSTPand SSTP + ACT)were delivered in a combined group (3 – 10 families per group) and telephoneformat. SSTP consisted of 6 (2-hour)group sessions plus 3 (30-minute) tele-phone consultations and was deliveredby psychologists with accreditation inSSTP. SSTP sessions included strategiesfor building a positive parent-childrelationship, encouraging desirablebehavior, teaching new skills and be-haviors, managing misbehavior, andmanaging high-risk situations. Parentsmadespeci 󿬁 cgoalsforchangeandweresupported in enacting plans for manag-ing challenging parenting situations.For the SSTP with ACT group, the ACTsessions (two 2-hour group sessions)preceded SSTP. ACT sessions includedidentifyingvalues, mindfulness,cognitivedefusion (distancing from thoughts),acceptance of emotions, and makingspeci 󿬁 c goals for acting on values. Forsome groups, a weekend workshop for-mat was used to allow for interventiondelivery as an outreach program in farNorth Queensland (Table 1). Assessment The Family Background Questionnairewasusedtogatherdemographicdata 28 and the Gross Motor Function Classi 󿬁 -cation System (GMFCS) was used toclassify gross motor functional abil-ity. 29 This article focuses on reporting the primary outcomes: child behavioraland emotional problems (Eyberg ChildBehavior Inventory [ECBI], Strengths andDif  󿬁 culties Questionnaire [SDQ]) andparenting style (Parenting Scale [PS]).All outcomes are parent-report. TheECBI 30 produces 2 scales, the intensityand the problem scales, and is consid-ered to show high reliability andvalidity. 31,32 The SDQ 33 produces 5 sub-scales (emotional symptoms, conductproblems,inattention/hyperactivity,peerproblems, and prosocial behavior) andis considered to have high reliabilityand validity. 34 The PS 35 is a measure of 3dysfunctional discipline styles: laxness,overreactivity, and verbosity. The PSshows strong reliability and validity. Forfull details, see the study protocol. 27 Statistical Analysis The  󿬁 rst phase, a comparison amongSSTP, SSTP with ACT, and WL groups atpostintervention,wasachievedthrougha series of analyses of covariance(ANCOVAs),withpreinterventionscoresas a covariate. Signi 󿬁 cant results werefollowed-up with linear contrasts ex-amining group-by-group differences(ie,WLvsSSTP,WLvsSSTP+ACT,SSTPvsSSTP+ACT).ABonferronicorrectionwasapplied to linear contrasts to correctfor multiple comparisons, resulting in a P   value of .0167. A sensitivity analysiswasconductedwiththelastobservationcarriedforwardforallparticipantswhofailed to complete the postinterventionassessment.Thesecondphaseofthestudyexaminedeffects at follow-up and included allfamilies who received an interventionand completed 6-month follow-up as-sessment ( n   = 28; SSTP = 12, SSTP+ ACT= 11, WL = 5). A pre-post examinationof the retention of the intervention ef-fect from postintervention to 6-monthfollow-up was tested with a series of  t   tests. A comparison between familieswho received SSTP( n   = 16) andfamilieswho received SSTP with ACT ( n   = 12) at6-month follow-up was conducted via TABLE 1  Comparison of Intervention Content: SSTP and ACT Intervention Content SSTP ACTDiscussion of how parents cope with stress with a focus on identifying theworkability of various coping strategies. —  xUseofmetaphor topromotepsychological 󿬂 exibility(eg,thequicksandmetaphoris used to explain how struggling with psychological distress often increasespsychological distress). —  xIdenti 󿬁 cation of values, that is, overarching desired qualities of living (eg, beinga loving parent). —  xMindfulness exercises to promote psychological contact with the presentmoment, including thoughts and emotions. Exercises included mindfulness of breathing, mindfulness of thoughts and mindfulness of emotions. —  xCognitive defusion exercises to create psychological distance from thoughts (eg,saying the thought in the voice of a cartoon character). —  xSetting speci 󿬁 c goals for acting on values (eg, acting on the value being a lovingparent by responding to child ’ s requests for physical affection). —  xDiscussion of positive parenting (eg, using assertive discipline). x  — Discussion of the causes of child behavior problems (eg, accidentally rewardingchild ’ s behavior with attention).x  — Setting speci 󿬁 c goals for change in parent and child behavior (eg, reducing thefrequency of temper tantrums).x  — Monitoring of child behavior (eg, recording the frequency of temper tantrums). x  — Reviewing parenting strategies to develop a positive parent-child relationship(eg, quality time).x  — Reviewing parenting strategies to encourage desirable behavior (eg, usingdescriptive praise).x  — Reviewing parenting strategies to teach new skills and behaviors (eg, using ask,say, do to teach new skills in steps).x  — Reviewing parenting strategies to manage misbehavior (eg, planned ignoring). x  — Creating planned activities routines for high-risk parenting situations (eg,creating a plan, including various parenting strategies to improve childbehavior while shopping).x  — Reviewing implemented planned activities routines, as well as other behavioralchange goals, and considering future changes in a structured way.x  — — , not included. 4  WHITTINGHAM et al  by guest on June 10, from 
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