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THE PREDICTIVE ABILITY OF ADHERENCE TO HOMEWORK AND SKILL
ACQUISITION FOR TREATMENT OUTCOME IN PARENT-CHILD INTERACTION
LAURA J. SCHOENFIELD
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
UNIVERSITY OF FLORIDA
Laura J. Schoenfield
Thank you to my family and friends.
I would like to thank Dr. Sheila Eyberg for all of her help with this proj ect. I
would also like to thank everyone at the Child Study Lab for their support.
This proj ect was supported by the National Institute of Mental Health (RO 1
TABLE OF CONTENTS
ACKNOWLEDGMENT S .............. .................... iv
LIST OF TABLES ................ ..............vi. .......... ....
AB STRAC T ................ .............. vii
INTRODUCTION .............. ...............1.....
M ETHOD .............. ...............7.....
Participants .............. ...............7.....
M measures ................. ...............8.................
Procedure ................ ...............12.................
RE SULT S .............. ...............14....
Predicting Length of Treatment ................. ........... ...............14. ....
Predicting Post-treatment Attachment Security ................. ................ ......... .14
Predicting Child Negative Behavior ................. ...............15........... ...
Predicting Change in Parenting Stress ................. ...............16........... ...
DI SCU SSION ................. ...............2.. 1..............
LIST OF REFERENCES ................. ...............25........... ....
BIOGRAPHICAL SKETCH .............. ...............28....
LIST OF TABLES
Demographic Data of Participants (N = 5 1) ................ ...............17..............
Kappa Coefficients for DPICS Categories .............. ...............18....
Correlation Matrix of Potential Control Variables and Treatment Outcome Variables ....19
Summary of Simultaneous Linear Regression Analysis for Variables Predicting Child
Attachment Security (N=3 8) ................. ......... ...............20. ....
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science
THE PREDICTIVE ABILITY OF ADHERENCE TO HOMEWORK AND SKILL
ACQUISITION FOR TREATMENT OUTCOME IN PARENT-CHILD INTERACTION
Laura J. Schoenfield
Chair: Sheila M. Eyberg
Major Department: Clinical and Health Psychology
Parent-child interaction therapy (PCIT) is a parenting skills training program for
preschoolers with disruptive behavior disorders. The treatment emphasizes the
importance of adherence to homework and skill acquisition, yet the extent to which
homework adherence and skill acquisition influence treatment outcome is not known.
This study examined the relations between adherence to homework and treatment
outcome for PCIT while incorporating the variable of skill acquisition. Participants were
51 preschoolers with Oppositional Defiant Disorder and their mothers. The mothers were
taught skills to increase warmth and security in the parent-child relationship and were
assigned to practice these skills in daily play sessions throughout treatment. Therapists
collected data on daily homework completion. Skill acquisition was measured by coding
mothers' skills during parent-child interactions before and after treatment. Homework
completion significantly predicted better attachment security at post-treatment. This study
supports the purpose of the homework assignment, which is to strengthen the parent-child
Incorporating homework assignments into psychotherapy is a common practice.
Assignments are included in treatments for many disorders, including depression,
anxiety, phobias, and Obsessive Compulsive disorder (OCD) (DeAraujo, Ito, & Marks,
1996; Edelman & Chambless, 1995; Kazantzis, Deane, & Ronan, 2000). Homework is
thought to add several benefits to standard therapy. Patients may show greater
improvement if they practice and apply the skills learned in therapy to situations outside
of treatment. The practice of new skills may speed both acquisition of the skills and
generalization of treatment gains to new situations. In addition, the review of homework
assignments in treatment sessions provides an opportunity for the therapist to check the
patient' s understanding of session content and assess how the client may cope with
problematic situations once therapy has ended (Kazantzis & Lampropoulos, 2002).
Studies have found that rates of homework adherence are substantially less than 100%,
suggesting that many patients may not be receiving the full benefits of therapy
(Abramowitz, Franklin, Zoellner, & DiBernardo, 2002; Addis & Jacobson, 2000). It is
important to determine the impact of less than perfect adherence on treatment outcome.
Most studies suggest that homework adherence and treatment outcome are
related. In cognitive-behavioral therapy for depression, Addis and Jacobson (2000)
found significant correlations between homework adherence and improvement early in
treatment, at the midpoint of treatment, and at treatment end. In a treatment for OCD,
adherence during the first week of treatment alone predicted improvement in several
areas of treatment outcome (DeArauj o et al., 1996). Prediction of long-term outcome was
found in a treatment of phobia. During the first eight weeks of a fourteen week
treatment, therapist ratings of adherence significantly predicted outcome at 3-month and
2-year follow-up (Park et al., 2001). These studies provide strong evidence of the
benefits of homework. A meta-analysis of 16 studies revealed an effect size of .22,
indicating a small but real effect of homework adherence on treatment outcome
(Kazantzis et al., 2000).
Although most studies support the relation between homework adherence and
treatment outcome, it is important to note that the associations have been modest and not
supported by all studies. For example, Edelman and Chambless (1993) found that for
exposure treatment of agoraphobia, there was no difference in outcome for individuals
assigned to a homework condition versus a no-homework condition. Taylor et al. (2001)
found no difference in adherence between responders and partial responders to PTSD
treatment. In addition, Abramowitz et al. (2002) found that for OCD treatment, initial
severity predicted 16% of the variance in outcome, and after controlling for initial
severity, homework adherence was not a significant predictor.
Differences in methodology help to explain the variation in findings. One
methodological distinction is the source of adherence data. It is possible to have ratings
of adherence made by patient, therapist, or independent observer. Timing of the
assessments of adherence may vary among studies as well. Assessments may be
conducted daily, weekly, or at the end of treatment, retrospectively. As Abramowitz et al.
(2002) noted, retrospective assessment may be less reliable than weekly assessment,
biased by the patient's improvement in therapy or other factors. Finally, the Kazantzis et
al. meta-analysis (2000) suggested that type of disorder and treatment may affect the
relation between adherence and treatment outcome. They found that treatments for
anxiety and depression showed a stronger relation between homework completion and
treatment outcome than treatments for other disorders. The possibility that this relation
may be stronger for some disorders and treatments than others is noteworthy. The studies
previously cited used adult participants who were in treatment for their own disorders.
The participants, then, were using skills learned in therapy and through homework to
benefit themselves directly.
Unlike adult psychotherapy, the adults in parent training are taught skills designed
to benefit their child, and the parents' homework completion constitutes the greater part
of the child' s treatment. The children receive treatment not only during therapy sessions,
but also each time parents practice their skills with their children. It is unknown how well
existing studies examining homework adherence and treatment outcome in adult
psychotherapy generalize to parent training. No published studies were found examining
the relation between adherence to homework and outcome for parents in a parenting
skills training program.
The importance of skill acquisition to treatment outcome is also unknown.
Homework is considered "practice" that enables parents to learn the skills taught in
treatment. Yet studies have focused almost exclusively on relations between homework
adherence and treatment outcome, rather than skill acquisition and outcome (Edelman &
Chambless, 1993). Although some patients may need to complete homework to gain the
full benefits of therapy, others may be able to acquire the needed skills with minimal
practice, resulting in good treatment outcome without high levels of adherence. For
example, Neimeyer and Feixas (1990) found that participants in group cognitive
treatment for depression with better acquisition of skills maintained treatment gains,
regardless of assignment to homework or no-homework conditions. Conversely, repeated
homework completion may benefit some individuals even if they never achieve optimal
levels of skill.
The purpose of this study was to assess the relations among homework adherence,
skill acquisition, and treatment outcome for parenting skills training. These relations are
important to understand because both adherence to homework completion and therapy
skill acquisition are strongly emphasized in parent training programs without evidence
that either influences outcome. Rapport between therapist and parent can be jeopardized
if the therapist emphasizes adherence to parents who feel unable to complete homework.
Strain can also develop if therapists hold parents back to master skills when parents wish
to move ahead to new skills. Increased knowledge of the relations between homework
adherence, skill acquisition, and treatment outcome would help to inform clinical
This study examined the relations of homework adherence and skill acquisition to
treatment outcome for one particular type of parenting skills training program, Parent-
Child Interaction Therapy (PCIT). PCIT is designed for young children with disruptive
behavior, and its effectiveness is well supported by the literature (Gallagher, 2003). PCIT
has two phases, child-directed interaction (CDI) and parent-directed interaction (PDI). In
CDI, parents are taught play therapy skills designed to increase the warmth and
attachment between the parent and child and to decrease mildly disruptive behaviors. For
example, parents are instructed to reflect the child's appropriate verbalizations and to
imitate the child's play. These skills help the child to feel that the parent is really listening
and thinks that what the child has chosen to do is interesting and worthwhile. Parents are
also taught to ignore inappropriate behaviors such as whining. This strategic ignoring
decreases the frequency of the negative behaviors. Therapists teach these skills by
coaching parents in vivo during treatment sessions. Parents interact in play with their
child while wearing a device, the "bug-in-the-ear," that enables the therapist to
communicate with them from an observation room. Coaching provides a way to correct
mistakes immediately, and the therapist can aid in troubleshooting difficult parent-child
situations. Families are encouraged to attend sessions regularly each week throughout
therapy. In addition to practicing these skills in the clinic, parents are assigned to practice
their new CDI play therapy skills in 5-minute sessions each day at home with their
children. Although parents move to the PDI phase of treatment after their CDI skills meet
mastery criteria, they continue to practice the CDI skills during the 5-minute homework
sessions throughout treatment.
These CDI play therapy skills are thought to be an important foundation for the
second part of PCIT. In PDI, parents are taught to use "time-out from positive
reinforcement" (i.e., timeout). Timeout is only effective if children are separated from
something that they enj oy, which in PCIT is the play with their parent and parental
attention. Thus, CDI is taught first to increase the warmth of the relationship. PCIT is not
a time-limited therapy. Treatment ends only when parents demonstrate mastery of the
CDI and PDI skills, the child's behavior is within the normal range on a parent rating
scale of disruptive behavior, and the parents are satisfied that they are able to manage
their child on their own.
Four hypotheses guided this study. Hypothesis one was that adherence to
completing the CDI homework would predict number of sessions needed to complete
treatment. Parents who practice these skills more frequently would be expected to acquire
them more quickly and therefore move through treatment faster (i.e., have fewer
treatment sessions). The second hypothesis was that homework adherence and skill
acquisition would predict child attachment security at the end of treatment. Hypothesis
three was that the measures of adherence and skill acquisition would significantly predict
parent-report of child negative behavior at the end of treatment. Hypothesis four was that
homework adherence and skill acquisition would predict maternal stress at the end of
Participants were 51 families involved in a larger treatment study. The target
child in each family was between 3 and 6 years of age and had been referred for
treatment of behavior problems. The inclusion criteria for the larger study included a
diagnosis of oppositional defiant disorder (ODD) in the target child. For this study, the
diagnosis of ODD is based on the criteria recommended by Jensen et al. (1996). That is,
the child must meet the criteria for ODD on the Diagnostic Interview Schedule for
Children (DISC IV-P) and must also score above a T score of 61 on the Child Behavior
Checklist (CBCL) Aggressive Behavior Scale (Achenbach & Rescorla, 2000, 2001). By
requiring criteria to be met on both instruments for diagnosis, some children may have
been excluded who would otherwise have been accepted on the basis of only a single
approach to diagnosis. Additional criteria included a standard score of >75 on a test of
cognitive ability for the parents and children, the Wonderlic Personnel Test and the
Peabody Picture Vocabulary Test, respectively (Dodrill, 1981; Dunn & Dunn, 1997). In
addition, if taking medication for behavioral or emotional difficulties, children had to
have been stabilized on the medication for at least one month. All families included in
this study had met treatment completion criteria in the larger study and had been assessed
at pre- and post-treatment. Participant demographic information is shown in Table 1.
Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999)
The Eyberg Child Behavior Inventory (ECBI) is a measure of child disruptive
behavior, designed for children ages 2 to 16. It contains two scales, the Intensity Scale,
measuring the frequency of child negative behavior, and the Problem Scale, measuring
how much of a problem the behaviors are perceived to be by the parents. Only the
Intensity Scale was using in this study. The ECBI has good psychometric properties,
including discriminant validity, and has shown to be sensitive to treatment change in
clinic-referred children (Tynan, Schuman, & Lampert, 1999; Webster-Stratton & Eyberg,
1982). For the current sample, Cronbach's alpha for the ECBI Intensity Scale ranged
from .82 to .93, depending on the time point of administration.
Parenting Stress Index- Short Form (Abidin, 1995)
Parenting stress was measured using the Parenting Stress Index- Short Form (PSI-
SF). The PSI-SF is a 36-item self-report scale containing three factor-analytically-derived
subscales (Parental Distress, Parent-Child Dysfunctional Interaction, Difficult Child) and
a Total Scale. The PSI-SF has been shown to have good psychometric properties (Abidin,
1995). In this study, Cronbach's alpha ranged from .81 to .93, depending on the subscale
and time point of admini station.
Length of Treatment
Total number of treatment sessions was used as the measure of length of
Attachment Q-Set (Waters, 1987)
The Attachment Q-Set is a parent rating of child attachment. Parents are asked to
rate different child descriptions as to how accurately they describe their own child.
Waters and Deane (1985) reported correlations between parent and observer Q-sorts of
the same child from .59 to .93, with a mean correlation of .80.
Achenbach Child Behavior Checklist (Achenbach & Rescorla, 2000, 2001)
Child negative behavior was measured using the Child Behavior Checklist
(CBCL; Achenbach & Rescorla, 2000, 2001). The CBCL is designed to assess the
frequency of various child behaviors and internalizing problems. The CBCL consists of
two forms for children, for ages 2 to 3 and 4 to 18. Two broad-band scales may be
derived from the items, an Intemnalizing scale and an Externalizing scale. Scores on each
scale are standardized into T scores. The T score of the Extemnalizing Scale from the
CBCL was used in this study as a measure of child negative behavior. Cronbach's alphas
from this sample ranged from .80 to .88 for the Externalizing Scale, depending on form
and time of administration.
A homework adherence variable was created for each family. At each session,
parents reported to the therapists how often they had practiced the CDI skills since the
previous treatment session, and homework adherence was based on this self-reported
information. Although parents are also taught PDI skills, this study used only CDI
homework adherence. Parent directed interaction homework assignments vary for each
family and the PDI skills are used throughout the day, not in discreet practice sessions,
making it difficult to assess adherence to PDI. Homework adherence was defined as the
number of days the mother practiced CDI during treatment divided by the total number of
possible practice days. As noted earlier, treatment is separated into two phases, with the
earlier treatment sessions focusing on CDI skills and the later treatment sessions focusing
on PDI skills. Although later sessions focus on PDI, the parents are asked to practice CDI
during this phase as well as during the earlier sessions. Therefore, adherence was
separated into two variables, CDI homework completion during the CDI phase of
treatment and CDI homework completion during the PDI phase of treatment. Researchers
commonly separate homework adherence by time in treatment because it is possible for
early adherence to have a different relation to treatment outcome than adherence later in
treatment (Addis & Jacobson, 2000).
Dyadic Parent-Child Interaction Coding System (Eyberg, Duke, McDiarmid, Boggs,
& Robinson, 2004)
The Dyadic Parent-Child Interaction Coding System (DPICS) was used to assess
parent skill acquisition. This observational coding system is designed to assess the
interaction between parent and child, including vocalizations, verbal behaviors, physical
behaviors, and responses to questions and commands. The behaviors included in this
study were positive parent verbal behaviors (behavior descriptions, reflections, labeled
praises, and unlabeled praises) and negative parent verbal behaviors (questions,
commands, and criticisms). During the pre- and post-treatment assessments, parents were
observed playing with their children in three situations, each of which is coded separately
using the DPICS. In the first situation, the parents are instructed to allow the children to
lead the play. Next, the parents are instructed to lead the play and attempt to have the
children follow their rules. Finally, the parents are told to have the children clean up the
toys by themselves. As the CDI play therapy skills are intended to be used in the first
situation, where the children lead the play, only the first situation was used in this study.
Coders were graduate and undergraduate research assistants who had read the
DPICS manual and completed DPICS training as outlined in the DPICS coder training
manual. Before coding study tapes, the coders obtained .80 accuracy with a criterion tape.
The Kappa coefficients for this study ranged from .49 to .77 for the categories used in
this study (see table 2).
Skill acquisition was measured using observational data from the DPICS. Based
on two 5-minute coded observations, one each at the pre- and post-treatment assessments,
two skill acquisition variables were created for each female caregiver. A "positive
behavior" skill acquisition variable included the total frequency of occurrences of
Labeled Praise, Unlabeled Praise, Behavior Description, and Reflective Statement. The
total frequency of these behaviors was measured during the 5-minute pre- and post-
treatment assessment observations, separately. Then, the total number of positive skills
demonstrated at the pre-treatment assessment was subtracted from the number of positive
skills demonstrated at the post-treatment assessment, resulting in a change variable
referred to as the "positive behavior" skill acquisition variable. The same procedure was
completed for negative behaviors, creating one variable of "negative behavior" skill
acquisition, using the DPICS categories of Information Question, Descriptive/Reflective
Question, Indirect Command, Direct Command, and Criticism. The idea of "negative
behavior" skill acquisition can be thought of as a parent learning to avoid certain
It is important to note the use of change variables rather than measuring skill
acquisition scores at one time point, post-treatment. When mothers began PCIT, they had
widely varying skill levels. For example, some mothers gave many commands and little
praise whereas others came to treatment already using praises and avoiding giving
commands. Therefore, each mother had a different amount of change to make in her own
behavior to acquire the skills at criterion levels. This amount of change was
conceptualized as a piece of skill acquisition. A change variable captured the variability
in the amount of change that each mother needed to make to arrive at the final criteria of
skill frequencies required for treatment completion.
Families were seen for a pre-treatment assessment that included a clinical
interview, demographic questionnaire, questionnaires regarding the parents'
psychological functioning and parenting behaviors, and questionnaires regarding the
child's behavior. Cognitive screening measures were administered to the parents and
child, and the mother completed a computerized, structured diagnostic interview.
Finally, the families were observed in the three play situations. In order to obtain a
reliable measure of parent-child interaction, the pre-treatment assessment was completed
on two separate days, and play situations were completed on each day.
Lead therapists were graduate students in clinical psychology with training in
PCIT and prior experience as a PCIT co-therapist. Therapists were involved in weekly
group supervision throughout treatment. Once treatment began, families were scheduled
to attend weekly sessions that lasted approximately one hour, and they were strongly
encouraged to attend weekly. The first treatment session included a description of
assigned homework, how to structure the play in the home and, often, problem-solving
around where and what time of day to complete the homework. Assignments for daily
homework began at the first treatment session. Families were given homework sheets
each week on which to record their homework completion. Parents were asked to record
their individual practice sessions every day, which included whether they practiced or
not, what toys were used in the play, and whether any problems occurred. Families
returned the completed sheets to the therapist at the next treatment session.
At the beginning of each session, the therapist reviewed the homework sheets
with the parent. If parents had not practiced a maj ority of the assigned days, they were
strongly encouraged to practice daily and the benefits of completing homework were
reviewed. Therapists also guided parents in problem-solving how to increase homework
completion, as needed. After reviewing the homework, therapists observed each parent
interacting individually with the child for five minutes and coded the parents' skill
acquisition. The first phase of treatment focused on learning the CDI play therapy skills.
When the parents demonstrated mastery level CDI skills during a 5-minute observation
period, they were able to move on to the second phase of treatment, PDI, in which
parents learned skills to direct their child's behavior effectively. During the PDI phase of
treatment, families continued to practice CDI skills in session along with the PDI skills,
and the homework assignments continued to include daily 5-minute CDI sessions.
Treatment was not time-limited and ended once several criteria had been met.
During play observation, parents had to demonstrate mastery-level CDI and PDI skills,
and the child had to comply to at least 75% of commands issued by the parent. In
addition, parents had to rate the child' s behavior within V/2 Standard deviation of the
normative mean on the ECBI Intensity Scale, a score of less than 114, and to report
feeling comfortable ending treatment.
At the post-treatment assessment, families completed the same diagnostic
interview and questionnaires as in the pre-treatment assessment, and they were again
observed in the structured play interactions. As in the pre-treatment assessment, the post-
treatment assessment was completed on two separate days and the parents and children
were observed in the play situations on each day.
Two demographic variables were considered for use as control variables,
socioeconomic status (SES) and maternal IQ. Pretreatment severity of child behavior
problems on the ECBI Intensity Scale and maternal stress on the PSI-SF Total Scale were
also considered as control variables (Table 3 shows the correlation matrix of potential
control variables and the treatment outcome variables). Only those demographic or other
control variables that were significantly correlated with a particular treatment outcome
variable were included in the analysis of that outcome variable.
Predicting Length of Treatment
Only homework adherence was examined as a predictor of the number of sessions
to successful treatment completion. Skill acquisition was not examined as a predictor of
treatment length because the skill acquisition variables could not be created until the end
of treatment and, for that reason, were not considered to be useful as predictors. One
simultaneous linear regression analysis was conducted, predicting number of treatment
sessions. Homework adherence to the CDI homework during each of the two phases of
treatment were used as predictors. The model was not significant.
Predicting Post-treatment Attachment Security
The Attachment Q-set security score was the Einal outcome variable examined (see
Table 4). A hierarchical regression was conducted, using the pre-treatment PSI-SF Total
score as a control variable and the adherence and skill acquisition variables in the second
block. The model predicted a significant amount of variance, R2 change = .337, F change
(4,32) = 5.077, p < .01. The variables contributing significantly to the model were
homework adherence during the first half of treatment, P = .420, t = 2.773, p < .01, and
change in maternal negative behavior skill acquisition, P = -.280, t = -2.029, p = .051.
Although skill acquisition was conceptualized as the change in maternal skills from
pre-treatment to post-treatment, it was possible that the frequency of post-treatment skills
was the important factor in prediction of attachment security. Therefore, a second
hierarchical regression was conducted, with pre-treatment maternal negative behavior in
the first block and post-treatment maternal negative behavior in the second block,
predicting attachment security at post-treatment. After controlling for pre-treatment
maternal negative behavior, post-treatment negative behavior did not significantly predict
Predicting Child Negative Behavior
Hierarchical regression was used to predict child negative behavior at post-
treatment, as measured by the Externalizing Sub scale T score of the CBCL. No
demographic control variable was used because none correlated significantly with the
post-treatment CBCL score. However, the initial severity of child behavior problems, as
measured by the pre-treatment Extemnalizing T score of the CBCL, was used as a control
variable in the first block because it was correlated with the CBCL score at post-
treatment. The two adherence and two skill acquisition variables were analyzed
simultaneously in the second block. After controlling for pre-treatment CBCL scores,
adherence and skill acquisition did not predict a significant amount of variance in the
CBCL score at post-treatment.
Predicting Change in Parenting Stress
Scores at post-treatment on each of the subscales of the PSI-SF, Difficult Child,
Parent-Child Dysfunctional Interaction, and Parental Distress, were predicted from the
two homework adherence variables and the two skill acquisition variables, each in a
separate regression. A hierarchical regression was used to predict the Difficult Child
subscale at post-treatment, as two control variables were used. Maternal IQ and SES were
included as control variables in the first block. The two homework adherence variables
and the two skill acquisition variables were included in the second block. The model was
not significant. Two simultaneous linear regressions were used to predict the Parent-
Child Dysfunctional Interaction and the Parental Distress subscales at post-treatment, as
no control variables were used because none were significantly correlated with the
treatment outcome variables. Neither model was significant.
Table 1. Demographic Data of Participants (N = 51)
Age 4.58 (1.13)a
SES 39.82 (13.68)a
Maternal IQ 107.84 (10.60)a
a Numbers in parentheses indicate standard deviations.
Table 2. Kappa Coefficients for DPICS Categories
DPICS Category Kappa Coefficient Classification
Behavior Description .74 Good
Reflective Statement .76 Good
Labeled Praise .77 Good
Unlabeled Praise .77 Good
Information Question .67 Good
Descriptive Question .63 Good
Direct Command .57 Fair
Indirect Command .68 Good
Criticism .49 Fair
Table 3. Correlation Matrix of Potential Control Variables and Treatment Outcome
Treatment Socioeconomic Maternal IQ PSI-SF Total ECBI Intensity
Outcome Status Pre-treatment Pre-treatment
Number of -. 133 .063 .147 .022
ECBI Intensity .291* .126 .069 -.068
CBCL -.016 -.002 -.007 -.011
ECBI Intensity 6- .156 -.046 .015 .058
PSI-SF Difficult .369** .341* .021 -.087
PSI-SF .243 .003 .243 -. 149
Par.-Ch. Dys. Int.
PSI-SF Parental .007 .111 .269 -.054
PSI-SF Diff. .452** .144 .151 .043
PSI-SF Par.-Ch. .263 -. 139 .390* -.035
Dys. Int. subscale
PSI-SF Parental .062 .036 .462** .017
Q-Set .039 -. 121 -.314* -.059
* p < .05, **p < .01
Table 4. Summary of Simultaneous Linear Regression Analysis for Variables Predicting
Child Attachment Security (N=38)
Variable B SEE BP
Homework during CDI 4.07E-03 .001 .420**
Homework during PDI 1.171E-03 .001 .138
Change in positive skills 1.295-04 .003 .007
Change in maternal -3.923E-03 .002 -.280*
* p =.051
Results from this study provide important information about adherence to
completing CDI homework. Partial support was found for hypothesis two, predicting
attachment security from adherence to homework and skill acquisition. Parents who
practiced CDI homework more often early in treatment rated their children as more
securely attached at post-treatment. This finding strengthens one of the basic tenets of
PCIT, that CDI is designed to increase attachment in children. However, the result also
suggests that CDI homework is more important early in treatment rather than later, as
completion of CDI homework later in treatment was not predictive of child attachment at
post-treatment. It is possible that CDI homework completion improves child attachment
security, but that this improvement is made early in treatment. After this early
improvement, child attachment security may reach a plateau, which is why CDI
homework later in treatment is not predictive of child attachment security.
Adherence to completing CDI homework was not predictive of length of
treatment or ratings of child negative behavior and parenting stress at post-treatment. As
attachment is a significant piece of treatment outcome, the lack of prediction of other
treatment outcome measures does not negate the importance of CDI homework.
However, it does indicate that therapists who encourage parents to increase their
frequency of CDI homework may expect to observe an increase in child attachment
security, but not an improvement in child negative behavior or parenting stress. In
addition, a low frequency of CDI homework practice sessions may not be the appropriate
explanation for why parents may report little or no improvement in child negative
behavior or parenting stress. Therapists should also not expect a relation between the
frequency with which parents practice CDI and how quickly they move through
Results provided less information about the importance of skill acquisition to
treatment outcome. Maternal skill acquisition of the positive skills (e.g., labeled praise
and reflective statements) was not predictive of any treatment outcome measure. Skill
acquisition of negative skills (i.e., learning to avoid questions, commands, and criticisms)
did not predict treatment outcome in the expected direction. Our results conflict with the
earlier findings by Neimeyer and Feixas (1990), suggesting that skill acquisition would
be a better predictor of treatment outcome than homework completion. One explanation
for our findings is that it is likely that the function of the skills is different at the
beginning than at the end of treatment. At the beginning of treatment, when the children
are oppositional and defiant, it is important for the parents to avoid questions and
commands because the children tend to choose to respond provocatively or defiantly.
However, by the end of treatment, when the children's attitudes and behavior have
improved, those same parental questions and commands tend not to elicit a negative child
reaction. The parents' new, positive skills, such as praising and reflecting, may act
initially as substitute verbalizations for the negative parenting behaviors and differ from
questions and commands primarily by not requiring a response from the child. In this
way, the new skills may not be conducive to an escalation of negative interaction and also
provide the child with attention for positive behavior. By the end of treatment, the
positive skills have become a habitual part of the parent' s verbal repertoire and can be
used outside the 5-minute CDI practice sessions to give the child positive reinforcement.
Several limitations of this study must be addressed. First, due to the retrospective
design, parents were not randomized to particular levels of homework adherence and
were all encouraged to reach the same level of skill acquisition. There may be parental
factors, such as motivation, which influenced homework adherence and skill acquisition
and may also have been related to treatment outcome. In addition, quality of CDI
homework practice sessions was not measured. Some parents did not complete the
practice sessions in the way instructed by the therapists (e.g., use of inappropriate toys or
activities). Further, parents began CDI practice sessions before they had learned the skills
adequately. These early practice sessions may have a different quality when the parents
are not using the skills appropriately and at a high frequency. If the quality of homework
were measured, the data would provide additional information about adherence and
treatment outcome. These limitations on analyses indicate that the complete picture of
skill acquisition and adherence in PCIT needs further study.
More research is required to clarify relations between homework adherence, skill
acquisition, and treatment outcome for parent training. This study analyzed one aspect of
homework adherence, frequency of CDI homework completion by the mother, CDI skill
acquisition, and treatment outcome. Replication of the finding that early homework
adherence predicts stronger attachment security would support the continued use of CDI
homework early in treatment. A more complete picture of the relation between CDI
homework adherence, skill acquisition, and treatment outcome would be given by
incorporating the quality of the CDI homework sessions.
Results from this study support previous results suggesting a moderate predictive
ability of homework adherence early in treatment for treatment outcome (DeArauj o et al.,
1996). However, results did not support the earlier findings showing skill acquisition to
be more predictive of treatment outcome than homework adherence (Edelman &
Chambless, 1993; Neimeyer & Feixas, 1990). It is likely that results from this study are
not consistent with previous findings because the relations between homework
adherence, skill acquisition, and treatment outcome are significantly different for parent
training and adult psychotherapy. This calls attention to the need for more research in this
area. As parent training programs generally incorporate homework assignments and
measurement of skills, it is essential to understand their relations with treatment outcome.
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Laura Schoenfield comes from the town of Wilmette, Illinois. She received her
Bachelor of Arts degree from Colorado College in Colorado Springs, Colorado. She
currently attends the University of Florida.