Reducing Problem Behavior During Care-Giving in Families of Preschool-Aged Children With Developmental Disabilities

Research in Developmental Disabilities 28 (2007) 362–385
Reducing problem behavior during care-giving in

families of preschool-aged children with
developmental disabilities
Karen M. Plant, Matthew R. Sanders *
The University of Queensland, Qld, Australia
Received 28 October 2005; received in revised form 21 February 2006; accepted 23 February 2006
Abstract
This study evaluated two variants of a behavioral parent training program known as Stepping Stones
Triple P (SSTP) using 74 preschool-aged children with developmental disabilities. Families were randomly
allocated to an enhanced parent training intervention that combined parenting skills and care-giving coping
skills (SSTP-E), standard parent training intervention alone (SSTP-S) or waitlist control (WL) condition. At
post-intervention, both programs were associated with lower levels of observed negative child behavior,
reductions in the number of care-giving settings where children displayed problem behavior, and improved
parental competence and satisfaction in the parenting role as compared with the waitlist condition. Gains
attained at post-intervention were maintained at 1-year follow-up. Both interventions produced significant
reductions in child problem behavior, with 67% of children in the SSTP-E and 77% of children in the SSTP-
S showing clinically reliable change from pre-intervention to follow-up. Parents reported a high level of
satisfaction with both interventions.
# 2006 Elsevier Ltd. All rights reserved.
Keywords: Children; Developmental disability; Care-giving; Behavioral parent training
Caring for a young child with a developmental disability can be a daunting and challenging
experience for parents. These parents spend more time involved in direct care-giving tasks (e.g.
bathing, feeding, toileting) with their children than parents of typically developing children
(Erickson & Upshur, 1989; Quittner et al., 1998) and are often required to undertake tasks (e.g.
lifting and positioning, administering medication) which are physically demanding and
* Correspondence to: Parenting and Family Support Centre, The University of Queensland, St. Lucia, Qld 4072,
Australia.
E-mail address: matts@psy.uq.edu.au (M.R. Sanders).
0891-4222/$ – see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2006.02.009
K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385 363
unpleasant (Leyser, Heinze, & Kapperman, 1996; McDonald, Couchonnal, & Early, 1996).
Furthermore, the challenges and burden associated with these tasks can be compounded when a
child has a severe developmental disability (Haveman, van Berkum, Reijnders, & Heller, 1997).
However, when a child with a developmental disability also has behavior problems, this has an
added impact upon a parent’s ability to undertake the numerous tasks associated with care-
giving, and thus increases the burden of care for parents. In typically developing children certain
parenting tasks (e.g. mealtimes, shopping, when visitors present) can pose more difficulty for
parents because of contextual factors such as time constraint, setting, people present, and
competing demands (Sanders & Christensen, 1985; Sanders & Dadds, 1982). Parents of children
with developmental disabilities are faced with these same high risk parenting tasks, however,
they are also required to complete additional tasks which are specific to their child’s disability.
These tasks may include assisting their children with self-care (e.g. bathing, feeding, toileting),
providing ongoing supervision to prevent behaviors which may be a risk to self or others (e.g.
road safety, choking), completing therapy to extend their child’s learning and development,
locating social and recreational activities in which children can participate independently,
educating the public about disability, advocating for their children, and working with a range of
professionals (Harris & McHale, 1989; Shearn & Todd, 1997). Recent research (Plant & Sanders,
in press) investigating care-giving tasks and burden has found helping and supervising their child
at mealtimes, cleaning up after their child, settling their child at bedtime, helping and supervising
with toileting, and advocating to professionals on behalf of their child as the five most stressful
and burdensome care-giving activities.
A range of factors including the time involved in completing care-giving tasks may contribute
to parent distress and burden associated with caring for a child with a developmental disability
(Quittner et al., 1998; Quittner, Opipari, Regoli, Jacobsen, & Eigen, 1992). These factors include
the difficulty of completing activities (Leyser et al., 1996; McDonald et al., 1996), the level of a
child’s disability (Haveman et al., 1997), and the presence of child problem behavior (Floyd &
Gallagher, 1997; Hastings, 2002; Saloviita, Italinna, & Leinonen, 2003). Researchers
investigating these factors have consistently demonstrated that negative child behavior is one
of the best predictors of burden of care or parental distress (Blacher, Lopez, Shapiro, & Fusco,
1997; Plant & Sanders, in press; Saloviita et al., 2003). This finding highlights the need for
parents of children with developmental disabilities to receive training in behavior change
strategies in order to reduce the burden and distress associated with care-giving.
The need to focus on changing children’s problem behavior is further highlighted by the high
prevalence rates of behavior problems in young children with developmental disabilities
(Emerson, 2003). Epidemiological studies suggest that behavioral disorders are three to four
times more common in children with developmental disability as compared with typically
developing children (Rutter, Tizard, Yule, Graham, & Whitmore, 1976). For example, an
Australian study (Einfeld & Tonge, 1996) found that 40.7% of children with developmental
disabilities had severe behavioral or emotional problems using the Developmental Behavior
Checklist (DBC; Einfeld & Tonge, 1991). Researchers also suggest that the severity and
persistence of challenging behaviors is greater in children with developmental disabilities
(Matson, Gardner, Coe, & Sovner, 1991); and that behaviors such as severe aggression,
stereotypic and ritualistic behaviors, autistic-related behaviors, self-stimulation, and self-injury
may occur in high frequencies in this population (Baron-Cohen, 1989; Quine, 1986).
It has been consistently documented in the literature that behavioral parent training results in
positive changes to parent behavior, reductions in child problem behavior, and the development
of more prosocial and adaptive behaviors in children with developmental disabilities (Gavidia-
364 K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385
Payne & Hudson, 2002; Horner, Carr, Strain, Todd, & Reed, 2002). Parent training approaches
have generally utilized contingency management training which teaches parents to use consistent
consequences and clear instructions, planned activities training which teaches parents to
restructure antecedents and thus prevent behavior problems, and compliance training which
teaches parents effective ways of requesting behaviors from their children (Lutzker, Huynen, &
Bigelow, 1998). These programs produce generalized changes in both parent and child behavior.
For example, Sanders and Plant (1989) used the planned activities (PAT) procedures of Sanders
and Dadds (1982) with parents of preschool-aged children with developmental disabilities to
demonstrate that both parents and children generalized positive changes in behavior across
settings after parents had received training in contingency management and planned activities
procedures. Similarly, Harrold, Lutzker, Campbell, and Touchette (1992) and Huynen, Lutzker,
Bigelow, Touchette, and Campbell (1996) have shown the efficacy of contingency management
and planned activities training for parents of children with developmental disabilities.
More recently, Hudson et al. (2003) investigated the effectiveness of a behavioral parent
training program which focused on enhancing parent–child interactions, replacing problem
behavior with appropriate behavior, planning for appropriate behavior, and teaching children
new skills. Following training parents reported improved child behavior, that they were more
effective in managing their child’s behavior, and were less stressed. These positive outcomes
were present regardless of whether parents received self-directed, telephone-supported or group-
supported intervention.
The Triple P-Positive Parenting Program (Sanders, 1999) has recently been adapted for
families of children with developmental disabilities. The Stepping Stones Triple P (Sanders,
Mazzucchelli, & Studman, 2003) was evaluated in a randomized clinical trial (Roberts,
Mazzucchelli, Studman, & Sanders, 2006) with parents of preschool-aged children with
developmental disabilities and problem behaviors. Training was associated with lower levels of
child problem behavior, improved maternal and paternal parenting style, and lower levels of
maternal stress as compared with a waitlist control group. Effects were maintained at 6-month
follow-up.
In the behavioral parent training literature relating to typically developing children, a number
of studies have examined whether the addition of enhanced or adjunctive interventions for
families add to the effectiveness of parent training alone. Parents’ capacities to acquire parenting
skills can be complicated by factors such as marital conflict, poor psychological adjustment,
single parent status, and stressful life events (Webster-Stratton & Hammond, 1990). Additional
interventions to address these additional family risk factors may be required for children to derive
significant benefits. It has also been argued that the inclusion of adjunctive interventions may
address problems such as treatment adherence, lack of generalization across behaviors and
settings, and poor maintenance of effects which have been reported in some parent training
studies (Lucyshyn, Albin, & Nixon, 1997). In relation to parents of children with developmental
disabilities, it is plausible that adjunctive interventions are also important. These parents are at
increased risk of experiencing psychological maladjustment (e.g. stress, anxiety, depression)
than parents of typically developing children (Dyson, 1997), are often restricted in their
relationships and social roles (Turnbull & Ruef, 1996), and often feel burdened and overwhelmed
by the numerous tasks associated with their care-giving role (Quittner et al., 1998).
Adjunctive interventions that target parents capacity to cope with stress and anxiety, improve
social supports, enhance relationship satisfaction, and cope with care-giving tasks are likely to
result in reduced child problem behaviors across a range of care-giving tasks in a child’s daily
routine, and thus parent burden and distress should be reduced. Although standard parent training
programs are effective in reducing child problem behavior and improving parent behavior in
families of children with developmental disabilities (Harrold et al., 1992; Hudson et al., 2003;
Huynen et al., 1996; Roberts et al., 2006; Sanders & Plant, 1989), the inclusion of adjunctive
training components which address other family problems contributing to care-giving may add to
the efficacy of these interventions. This finding is supported in a recent review (Hastings & Beck,
2004) which concludes that stress interventions for parents of children with developmental
disabilities have a positive impact upon parent adjustment and mental health.
Studies investigating the efficacy of behavioral parent training programs with parents of
children with developmental disabilities have generally shown positive outcomes for both parent
and child behavior, and have shown good generalization effects across settings and behaviors.
However, conclusions from these studies have been limited by small sample sizes, lack of control
or comparison groups, absence of or short follow-up periods, reliance on self-report measures,
lack of multiple outcome measures, and limited replication. There is a paucity of studies
examining the impact of parent training interventions on the care-giving tasks undertaken by
parents of children with developmental disabilities and their capacity to reduce the burden
associated with particular care-giving tasks.
This study compares the effectiveness of an adjunctive intervention, Stepping Stones Triple
P-Enhanced (SSTP-E) with a standard individual intervention program, Stepping Stones Triple
P-Standard (SSTP-S; Sanders et al., 2003) and a waitlist (WL) control group. The standard
parent training program used in the study consisted of SSTP-S which is an adaptation of the well-
validated Standard Triple P-Positive Parenting Program (Sanders, 1999). The SSTP-S has been
specifically adapted for parents of children with developmental disabilities. The enhanced
intervention (SSTP-E) consisted of the SSTP-S as well as an additional training component
which focused on assisting parents to cope with caring for a child with a developmental
disability. This training module was specifically devised for use in the study, and was modelled
on evidence-based adjunctive interventions designed to address family risk factors (Sanders,
Markie-Dadds, & Turner, 1998; Schultz & Schultz, 1997). This training related to grief and loss
issues, stress and coping, time management, working collaboratively with professionals, and
strengthening social supports. The present study expands on previous research as there has only
been one previous randomized controlled trial comparing the efficacy of SSTP-S to a waitlist
control group (Roberts et al., 2006).
Overall, we predicted that both intervention programs (SSTP-S and SSTP-E) would result in
greater improvements on all outcome measures as compared to the waitlist control (WL). It was
also anticipated that changes on outcome measures for the SSTP-E and SSTP-S would be
maintained at 1-year follow-up. Furthermore, it was predicted that better outcomes on all
measures would be found for the more intensive adjunctive intervention (SSTP-E) as compared
with the standard parent training program (SSTP-S). Hypothesis 1 predicted that immediately
post-intervention, the enhanced condition (SSTP-E) would be associated with greater reductions
on observed and parent-reported measures of overall child problem behavior and child problem
behavior specifically associated with care-giving than the standard condition (SSTP-S), and that
both treatment conditions would result in greater reductions of child problem behavior than the
waitlist control (WL). Hypothesis 2 predicted that at post-intervention the SSTP-E would result
in greater reductions in observed parental negativity as compared with the SSTP-S, and that both
interventions would produce lower levels of negative parent behavior than the waitlist control
(WL). In addition, parent-reported measures of parenting skills and competence would show
more favourable outcomes for the intervention conditions (SSTP-E and SSTP-S) as compared
with the waitlist control (WL), and the SSTP-E condition would be superior to the SSTP-S.
Hypothesis 3 predicted a similar pattern of results in relation to parental distress and adjustment
such that immediately post-intervention the SSTP-E would result in lower levels of parental
distress and improved adjustment compared to the SSTP-S, and that both interventions would
result in more positive outcomes than the waitlist control (WL). Hypothesis 4 addressed long-
term outcomes, and predicted that on all observed and parent-reported measures (child behavior,
parent behavior, parental distress and adjustment), changes at post-intervention would be
maintained at 1-year follow-up. Furthermore, the SSTP-E would produce better maintenance of
intervention gains at 1-year follow-up than the SSTP-S.
1. Method
1.1. Participants
Participants in this study consisted of 74 families with a preschool-aged child (<6 years) with
developmental disability from the geographical catchment area of South East Queensland,
Australia. Families were randomly assigned to one of three treatment groups, namely Stepping
Stones Triple P-Enhanced (SSTP-E), Stepping Stones Triple P-Standard (SSTP-S) or a waitlist
(WL) control group. Recruitment was on a voluntary basis after ethical clearance was attained to
distribute information brochures to families receiving government early intervention services.
Eligibility criteria for the study were that (a) the child was receiving early intervention services
due to identified developmental disability, (b) the child presented with developmental disability
or was ‘at risk’ due to a diagnosed condition, (c) the child had not yet commenced primary school
education, and (d) mothers rated their child’s behavior as being in the elevated range on the
Eyberg Child Behavior Inventory (ECBI; intensity score 131 or problem score 15; Eyberg &
Pincus, 1999).
Demographic characteristics for the 74 families are summarized in Table 1. The majority of
parents were married or in a defacto relationship (78%), had at least one parent in paid
employment (93% of fathers and 38% of mothers). Thirty-nine percent of families had a
combined income of more than AUS$ 50,000 per annum. The majority of children were males
(74%). Diagnoses included Autism Spectrum Disorder (32.4%), Global Developmental Delay
(17.6%), Down Syndrome (10.8%), chromosomal abnormality other than Down Syndrome
(9.5%), and Cerebral Palsy (6.8%). Level of disability ranged from borderline or ‘at risk’ (6.8%)
to mild (29.7%) to moderate (47.3%) and severe (16.2%). There were no significant differences
among the three groups on sociodemographic characteristics prior to intervention.
1.2. Measures
1.2.1. Family background

A semi-structured interview was used to attain demographic information about the child with
developmental disability, family details such as parents’ name, age, marital status, education
level, employment status, and family income, and information about gender and ages of other
family members.
1.2.2. Level of disability

1.2.2.1. Vineland Adaptive Behavior Scale (VABS). The child’s level of disability was
determined using the Vineland Adaptive Behavior Scale-Survey Form (Sparrow, Balla, &
Cicchetti, 1984). This instrument measures adaptive behavior in children and adolescents from
Table 1
Demographic characteristics of sample
Variable SSTP-E (n = 24) SSTP-S (n = 26) WL (n = 24)
M S.D. M S.D. M S.D.
K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385

Child’s age (months) 56.63 12.36 54.62 15.25 54.04 13.16
Mother’s age (years) 36.38 3.91 36.27 5.60 37.83 8.82
Father’s age (years) 40.91 5.50 39.53 5.51 39.18 6.07
Number children in family 2.42 1.02 2.81 1.81 2.13 0.80
% N % N % N
Child’s gender
Male 70.8 17 69.2 18 83.3 20
Female 29.2 7 30.8 8 16.7 4
Child disability
Down Syndrome 4.2 1 19.2 5 8.3 2
Other chromosomal abnormality 16.7 4 7.7 2 4.2 1
Cerebral Palsy 12.5 3 7.7 2 0.0 0
Autism Spectrum Disorder 25.0 6 26.9 7 45.8 11
Global developmental delay 16.7 4 19.2 5 16.7 4
Other 25.0 6 19.2 5 25.0 6
Level of disability
Borderline/at risk 4.2 1 0.0 0 16.7 4
Mild 33.3 8 38.5 10 16.7 4
Moderate 45.8 11 50.0 13 45.8 11
Severe 16.7 4 11.5 3 20.8 5
Siblings
No 16.7 4 15.4 4 20.8 5
Yes 83.3 20 84.6 22 79.2 19
Marital status—parents
Married 83.3 20 65.4 17 62.5 15
Defacto 8.3 2 7.7 2 8.3 2
Separated/divorced 4.2 1 15.4 4 20.8 5
Never married 4.2 1 7.7 2 4.2 1
367
Widowed 0.0 0 3.8 1 4.2 1
368
Table 1 (Continued )
% N % N % N
Family income
Less than AUS$ 12000 per annum 0.0 0 7.7 2 4.2 1

AUS$ 12001–AUS$ 25000 per annum 29.2 7 23.1 6 20.8 5
AUS$ 25001–AUS$ 35000 per annum 4.2 1 26.9 7 16.7 4
AUS$ 35001–AUS$ 50000 per annum 8.3 2 15.4 4 16.7 4
AUS$ 50001–AUS$ 70000 per annum 20.8 5 11.5 3 25.0 6
Over AUS$ 70000 per annum 37.5 9 11.5 3 12.5 3
Do not know 0.0 0 3.8 1 4.2 1
Mother Father Mother Father Mother Father

(%) (N) (%) (N) (%) (N) (%) (N) (%) (N) (%) (N)
Educational level
Primary 0.0 0 0.0 0 0.0 0 0.0 0 4.2 1 4.2 1
Secondary year 10 20.8 5 12.5 3 34.6 9 26.9 7 25.0 6 29.2 7
Secondary year 12 8.3 2 12.5 3 26.9 7 19.2 5 33.3 8 25.0 6
TAFE/college 16.7 4 16.7 4 15.4 4 7.7 2 4.2 1 .0 0
Tertiary 54.2 13 50.0 12 23.1 6 19.2 5 33.3 8 12.5 3
Unknown 0.0 0 8.3 2 0.0 0 26.9 7 0.0 0 29.2 7
Employment
Home 58.3 14 4.2 1 61.5 16 0.0 0 50.0 12 4.2 1
Professional 8.3 2 20.8 5 3.8 1 23.1 6 16.7 4 16.7 4
Teaching 8.3 2 4.2 1 7.7 2 0.0 0 0.0 0 0.0 0
Administration 8.3 2 8.3 2 11.5 3 3.8 1 12.5 3 8.3 2
Technical/trade 8.3 2 25.0 6 0.0 0 15.4 4 0.0 0 20.8 5
Health/medical 8.3 2 12.5 3 7.7 2 0.0 0 8.3 2 0.0 0
Self-employed 0.0 0 8.3 2 0.0 0 3.8 1 0.0 0 0.0 0
Business/management 0.0 0 4.2 1 0.0 0 7.7 2 0.0 0 8.3 2
Sales 0.0 0 0.0 0 3.8 1 3.8 1 0.0 0 4.2 1
Student 0.0 0 0.0 0 3.8 1 7.7 2 12.5 3 0.0 0
Unskilled 0.0 0 4.2 1 0.0 0 7.7 2 0.0 0 8.3 2
Unknown 0.0 0 8.3 2 0.0 0 26.9 7 0.0 0 29.2 7
Note: SSTP-E = Enhanced Stepping Stones Triple P; SSTP-S = Standard Stepping Stones Triple P; WL = waitlist control.
birth to 18 years. The scale was completed via a semi-structured interview. Items are scored on a
three point rating scale (0 = no never, 1 = sometimes or partially, 2 = yes usually). The scale
provides standard scores (mean = 100, standard deviation = 15), percentile ranks, stanines,
adaptive levels, and age equivalents for an overall adaptive behavior composite, as well as scores
for four domains – communication, daily living skills, socialization, and motor skills. Adaptive
behavior composite reliability co-efficients for children aged 5 years and under show internal
consistency from .96 to .98, test–retest reliability from .89 to .90, and interrater agreement of .74.
Content, construct and criterion validity are also adequately demonstrated. The scale is widely
used in clinical, educational and research settings.
1.2.3. Parent–child interaction

Mother and child behavior was assessed using a 30 min videotaped home observation. The
observation was divided into three 10 min tasks recorded consecutively without interruption: (a)
parent engaged in interaction with another adult whilst child engaged in free play, (b) parent
involved in household tasks whilst child involved in free play, and (c) parent and child involved
together in structured play activities (e.g. threading, puzzles, drawing/colouring, reactive toys).
These settings were chosen to replicate a number of experiences that occur regularly during a
family’s daily routine. To minimise reactivity effects, observers did not interact with participants
and positioned themselves in a minimally obtrusive location.
Observation sessions were coded in 10 s time intervals, using the Revised Family Observation
Schedule (FOS-RIII; Sanders, Waugh, Tully, & Hynes, 1996). Two composite scores were
computed. Negative parent behavior comprised the percentage of intervals the parent displayed
any negative behavior during the 30 min observation as coded by negative physical contact,
aversive question or instruction, aversive attention or interruption. Negative child behavior
comprised the percentage of intervals during which the child displayed any category of negative
behavior namely non-compliance, complaint, aversive demand, physical negative, or
oppositional behavior. The FOS has demonstrated reliability and discriminant validity, and is
sensitive to the effects of behavioral intervention on children with behavior problems (Sanders &
Christensen, 1985).
Three trained observers coded the interactions. Each rater coded a selection of interactions
from each of the three assessment phases (i.e. pre-, post-intervention, and follow-up). All coders
were blind to the intervention conditions of participants, stage of assessment, interactions used
for reliability checks, and the specific hypothesis being tested. To maintain reliability, coders
completed training using precoded tapes, coded practice interactions in supervision meetings,
and computed kappa statistics on a regular basis. Interrater agreement was assessed by having
one-fifth of the observations randomly selected and coded by a second rater. A satisfactory level
of interrater agreement (kappa) was achieved with .77 for parent behavior and .74 for child
behavior.
1.2.4. Child behavior

1.2.4.1. Eyberg Child Behavior Inventory (ECBI). The ECBI (Eyberg & Pincus, 1999) was
used as an initial eligibility screening tool to assess child behavior problems and determine
inclusion in the study. It is a 36-item measure of parental perceptions of disruptive behavior in
children aged 2–16 years. It provides two measures: frequency of disruptive behaviors (intensity
score) rated on 7-point scales; and the number of disruptive behaviors that parents list as
problematic (problem score). The ECBI has been shown to have high internal consistency for
both the intensity (a = .95) and problem (a = .94) scores. Eyberg and Pincus (1999) recommend
clinical cut-off scores of greater than or equal to 131 on the intensity scale and greater than or
equal to 15 on the problem scale which represent scores of at least one standard deviation above
the mean for a normal population.
1.2.4.2. Developmental Behavior Checklist—Parent Version (DBC). The DBC (Einfeld &
Tonge, 1991) was used to attain measures of child problem behavior. On this checklist,
respondents are required to rate the presence or absence of specific behaviors according to a 3-
point scale (0 = not true, 1 = somewhat or sometimes true, 3 = very true or often true). The scale
provides a score for Total Problem Behavior, as well as scores for six sub-scales – disruptive, self-
absorbed, communication disturbance, anxiety-relating, autistic-relating, and anti-social. Total
Problem Behavior reliability studies (Einfeld & Tonge, 2002) have revealed interrater agreement
between parents of .80, test–retest reliability of .83 over a 2-week period, and an internal
consistency co-efficient of .94. Content, construct and concurrent validity studies have also been
conducted with satisfactory results. In the present study Total Problem Behavior Scores (DBC-T)
and Disruptive Behavior Subscale Scores (DBC-D) are used in the primary analyses, and internal
consistency is adequate for DBC-T (a = .93) and DBC-D (a = .88).
1.2.4.3. Care-giving Problem Checklist (CPC)—Difficult Child Behavior. To assess frequency

of difficult child behavior when completing care-giving tasks, respondents were required to rate
how often their child engaged in difficult child behavior in seven different care-giving areas.
These areas included: (a) direct care tasks such as bathing, feeding, dressing, toileting; (b) in-
home therapy which involves the completion of special activities recommended by medical
practitioners, therapists and teachers; (c) attendance at medical appointments, therapy sessions,
and educational programs; (d) supervision of the child’s activities and whereabouts; (e)
involvement in leisure and play activities; (f) education and information about child disability;
and (g) advocating for services. Respondents used a 7-point Likert scale to rate frequency of
difficult child behavior in these seven care-giving areas, and this ranged from 1 (never) to 7
(always). Ratings for each of the seven care-giving areas were summed, and a total score
calculated. Higher scores are indicative of higher frequency of problematic behavior. Internal
consistency was adequate (a = .78).
1.2.4.4. Care-giving Problem Checklist (CPC)—Problematic Care-giving Tasks. To assess

frequency of problematic care-giving tasks, respondents were required to identify the presence or
absence of problem child behaviors across 22 different care-giving tasks over a 1-week period.
The checklist of care-giving tasks was developed by examining the topography of a typical day
for parents and identifying common tasks that parents undertake in their daily routine. Once the
preliminary list was established it was reviewed by a panel of clinicians and parents, and then
compared with relevant literature on developmental disability and typical development which
pertained to high-risk parenting tasks (Dadds, Sanders, & James, 1987; Harris & McHale, 1989;
Sanders & Plant, 1989). As a result of this process the measure was perceived as a valid index of
care-giving tasks undertaken by parents. The number of care-giving tasks where parents
experienced problematic child behavior was tallied for each family. Internal consistency was
adequate (a = .87).
1.2.5. Parenting skills and ability

1.2.5.1. Parenting Scale (PS). The PS (Arnold, O’Leary, Wolff, & Acker, 1993) is a 30-item
questionnaire which measures dysfunctional discipline styles in parents. It yields a total score
which is based on three factors: laxness (permissive discipline), over-reactivity (authoritarian

discipline, displays of anger, meanness and irritability), and verbosity (overly long reprimands,
reliance on talking). The total score has adequate internal consistency (a = .84), good test–retest
reliability (r = .84), and reliably discriminates between parents of clinic and non-clinic children
(Arnold et al., 1993). In the current sample, internal consistency is adequate for total score
(a = .91), laxness (a = .86), over-reactivity (a = .84), and verbosity (a = .71).
1.2.5.2. Parenting Sense of Competence Scale (PSOC). The PSOC (Gibaud-Wallston &
Wandersman, 1978) includes 16 items assessing parents’ views of their competence on two
dimensions of parenting: satisfaction with their parenting role which is an affective dimension
reflecting the extent of parental frustration, anxiety and motivation; and feelings of efficacy as a
parent which is an instrumental dimension reflecting competence, problem-solving ability and
capability in the parenting role. The total score, satisfaction score (nine items) and efficacy score
(seven items) show a satisfactory level of internal consistency (a = .79, .75 and .76, respectively:
Johnston & Mash, 1989). Internal consistency in the current sample is satisfactory for total score
(a = .74), satisfaction (a = .80), and efficacy (a = .70).
1.2.6. Parental adjustment

1.2.6.1. Depression, Anxiety and Stress Scales (DASS). The DASS (Lovibond & Lovibond,
1995) is a 42-item questionnaire that assesses symptoms of depression, anxiety and stress in
adults. The scale has high reliability for the depression (a = .91), anxiety (a = .81) and stress
(a = .89) scales, and good discriminate and concurrent validity (Lovibond & Lovibond, 1995).
Internal consistency in the current sample is adequate for total score (a = .97), depression
(a = .94), anxiety (a = .91), and stress (a = .94).
1.2.6.2. Abbreviated Dyadic Adjustment Scale (ADAS). The ADAS (Sharpley & Rogers, 1984)
is an abbreviated 7-item version of the 32-item Spanier Dyadic Adjustment Scale (Spanier,
1976). It measures the quality of dyadic relationship adjustment, with higher scores indicating
better adjustment. The ADAS reliably distinguishes between distressed and non-distressed
couples on relationship satisfaction, drawing upon aspects of communication, intimacy, cohesion
and disagreement. No items on child-rearing issues are included. The measure has moderate
reliability (a = .76). An item total correlation of .57 indicates that all items reflect dyadic
adjustment, and inter-item correlations ranging from .34 to .71 indicate that no items are
redundant (Sharpley & Rogers, 1984). In the current sample, internal consistency is adequate
(a = .85).
1.2.7. Intervention acceptability

1.2.7.1. The Client Satisfaction Questionnaire (CSQ). This measure is an adaptation of the
Therapy Attitude Inventory (Eyberg, 1993) which examines consumer satisfaction with parent
training programs. Administered at post-intervention the 13-item questionnaire addresses the
quality of service provided; how well the program met the parents’ needs, increased the parents’
skills, and decreased the child’s problem behaviors; and whether the parent would recommend
the program to others. The measure derived is a composite score of program satisfaction ratings
on a 7-point scale. Scores range from 13 to 91 with higher scores indicating higher levels of
consumer satisfaction with the program. The scale has a high internal consistency of .96
(Sanders, Markie-Dadds, Tully, & Bor, 2000) which is similar to scores in the current sample
(a = .92).
1.3. Design
A randomized group comparison design was used with three conditions (SSTP-E, SSTP-S,
and WL) and three time periods (pre-, post-intervention, and 1-year follow-up).
1.4. Procedure
Families completed eligibility screening via a telephone interview which included questions
about child’s age and disability type, involvement in government early intervention services, and
the completion of the ECBI. Information was provided about the random assignment to treatment
groups, and families willing to participate in the study were allocated to a specific group. Pre-
assessment (parent-report measures and videotaped home observations) was then conducted.
Families in the WL control group were informed that they would be required to do post-
assessment 16 weeks following completion of pre-assessment. Following post-assessment, they
then participated in the program of their choice, and did not take any further part in the study.
Families allocated to the SSTP-E and SSTP-S treatment conditions attended 60–90 min
individual sessions with a practitioner on a weekly basis. After-hours appointments were
available to encourage both parents to attend and some home-based intervention was provided
due to transport limitations. Following completion of the intervention (16 and 10 weeks for
SSTP-E and SSTP-S, respectively), families completed post-assessment (parent-report measures
and videotaped home observations). Intervention families were re-assessed 1 year after program
completion.
1.4.1. Treatment conditions

1.4.1.1. Stepping Stones Triple P-Standard. Families in the SSTP-S received the standard
version of Stepping Stones Triple P (SSTP) intervention program (Sanders et al., 2003) which is
an adaptation of the Triple P-Positive Parenting Program (Sanders, 1999). SSTP-S is specifically
designed for parents who have a child with a disability. The program involved teaching parents 25
core child management strategies. Fourteen of the strategies are designed to promote children’s
competence and development (i.e. quality time, talking with children, physical affection, praise,
attention, tangible rewards, engaging activities, activity schedules, setting a good example,
physical guidance, incidental teaching, Ask–Say–Do, teaching backwards, and behavior charts),
and 11 strategies focus on helping parents manage misbehavior (i.e. diversion, setting rules,
directed discussion, planned ignoring, clear and direct instructions, communication, logical
consequences, blocking, brief interruption, quiet time, and time-out). In addition, parents were
taught a six-step planned activities routine to enhance generalization and maintenance of
parenting skills (i.e. plan ahead, set rules, select engaging activities, identify rewards and
consequences, and provide feedback to child) which allowed parents to apply parenting skills to a
broad range of target behaviors in both home and community settings.
Parents were provided with a workbook which enabled them to set and monitor their own
goals for behavior change, and received active skills training and support from their trained
practitioner as described by Sanders, Markie-Dadds, and Turner (2000). This approach includes
training methods such as modelling, role plays, feedback, and the use of specific homework tasks.
Parents receiving SSTP-S participated in 10 intervention sessions. Session 1 involved completion
of the family background checklist and administration of a standardised measure of adaptive
functioning. Session 2 focused on a review of assessment data, discussion of causes of child
behavior problems, and setting treatment goals. In Sessions 3 and 4, the 25 management
strategies were introduced and discussed. The next two sessions were conducted in the family
home, where parents were observed implementing parenting skills with their child. They then
received feedback from the practitioner on their strengths and weaknesses. Planned activities
training was conducted in Sessions 7–9, and issues of maintenance and closure were covered in
the final session.
1.4.1.2. Stepping Stones Triple P-Enhanced. Families in the SSTP-E condition initially
received the same 10 session intensive behavioral parent training as families in the SSTP-S
condition. In addition, parents in the SSTP-E received an additional six sessions which focused
on assisting parents to cope with caring for a child with a developmental disability. As with the
behavioral parent training component, parents were provided with a workbook which allowed
them to set and monitor their own goals. In addition, practitioners provided active skills training
and support (Sanders et al., 1998) which included modeling, role plays, feedback, and homework
tasks. Session 1 of the adjunctive intervention focused on parent reactions to child disability, and
grief and loss issues. Parents were encouraged to discuss their own personal experiences
associated with having a child with a disability. In addition, parents were introduced to the
concepts of stress and coping. The next two sessions emphasised the development of effective
coping skills which assist parents experiencing personal adjustment issues such as depression,
anger, anxiety, and stress. Using a cognitive behavioral approach, parents were taught relaxation
strategies, and techniques to identify and challenge maladaptive cognitions about their child,
themselves, their parenting abilities, and other stressful situations. Session 4 aimed to assist
parents to acquire skills in working collaboratively with professionals, utilizing effective time
management strategies, and developing coping plans to assist with community reaction and
attitudes to disability. The next session focused on strengthening social supports available to
parents, and the content varied depending on whether families consisted of one or two parents.
For two parent families, the emphasis was on partner support and the development of skills to
enhance teamwork in the parenting role. Specifically, it aimed to help parents improve their
communication, increase consistency in their use of parenting routines, and provide mutual
support for parenting efforts. Parents were also taught positive ways of listening and speaking to
each other, how to provide constructive and non-judgemental feedback to each other about
parenting issues, and how to use a problem-solving approach to solve disagreements about
parenting. Single parents were provided with practical strategies to assist in developing effective
social support networks with extended family, friends and professionals/external agencies. In
addition, there was discussion about ways that parents can support themselves. Also, single
parents received similar training to two parent families in the areas of listening and speaking with
other adults, the use of problem-solving strategies, and how to provide constructive feedback to
other adults. The issues of maintenance and independent future problem solving were discussed
in the final session.
1.4.2. Treatment integrity

Six practitioners (one clinical psychologist and five psychologists completing post-graduate
training in psychology) received a 2-day training workshop on the delivery of the interventions.
In addition, weekly supervision sessions were held. Detailed written protocols that specified the
content of each session, in-session exercises, and homework tasks were developed for the
standard and enhanced conditions. Practitioners completed protocol adherence checklists for
each session, and videotaped 33% of intervention sessions. Analysis of the practitioner-
completed checklists and reliability checks on the videotaped sessions indicated that
practitioners demonstrated a 100% adherence to content, in-session exercises, and homework

tasks for respective treatment conditions.
2. Results
2.1. Preliminary analyses
A series of univariate ANOVAs was conducted on report and observational data to compare
the samples of families in each condition. There were no significant differences across conditions
on any measure at pre-intervention, indicating that the three groups were well matched prior to
intervention.
2.2. Attrition
Of the 74 families who were assigned to the three groups (SSTP-E, SSTP-S and WL), 74 (100%)
completed intervention and post-assessment which indicated no differences in the rate of completion
versus non-completion across conditions. One year following completion of intervention, families
in the SSTP-E and SSTP-S were reassessed. Of the 24 families in the SSTP-E, 23 (95%) completed 1-
year follow-up whilst of the 26 families in the SSTP-S, 22 (84%) completed 1-year follow-up
assessment. There were no significant differences in the rate of completion versus non-completion
across the two conditions. In addition, using 2 (SSTP-E versus SSTP-S) by 2 (completers versus non-
completers) ANOVAs there were no significant interactions or main effects at 1-year follow-up
suggesting that differential attrition across conditions was not present.
2.3. Statistical analyses
Short-term intervention effects were analysed using a series of three groups (SSTP-E versus
SSTP-S versus WL) ANCOVAS with pre-intervention scores as covariates and post-intervention
scores as dependent variables. These analyses were conducted on the observational measures of
negative child (FOS-NCB) and parent behavior (FOS-NPB); and the parent-report measures of
disruptive child problem behavior (DBC-D), problem behavior during care-giving (CPC-B),
problem care-giving settings (CPC-T), parenting skills (PS) and competence (PSOC), parental
distress (DASS), and relationship satisfaction (ADAS). Significant effects were examined using
pairwise comparisons (t-statistics) that compared effectiveness of each intervention condition
with the WL condition and with one another. Analyses of long-term intervention effects consisted
of 2 (condition: SSTP-E versus SSTP-S) by 2 (time: post-intervention versus follow-up) repeated
measures ANCOVAs, using pre-intervention scores as covariates. Where significant
condition time interactions were found, two-group ANCOVAs using 1-year follow-up scores
as dependent variables followed by pairwise comparisons were conducted.
2.4. Short-term intervention effects
Table 2 shows the means and standard deviations for observational and mother-reported
measures at pre- and post-intervention, univariate F values as well as t-statistics for all pairwise
comparisons.
In relation to the four measures of child behavior, ANCOVA scores were significant (FOS-
NCB: F(3,73) = 6.92, p = .002; DBC-D: F(3,73) = 4.62, p = .013; CPC-B: F(3,73) = 8.18,
Table 2
Short-term intervention effects—home observation and mother-report of child behavior, parenting skills and competence, maternal and relationship adjustment at pre- and post-
intervention

Variable SSTP-E (n = 24) SSTP-S (n = 26) Waitlist (n = 24) Contrasts (t-statistics)
Pre Post Pre Post Pre Post 3-Group SSTP-E SSTP-S SSTP-E vs.
ANCOVA (F) vs. WL vs. WL SSTP-S
M S.D. M S.D. M S.D. M S.D. M S.D. M S.D.
Child behavior
FOS-NCB (% observed 25.03 18.61 17.81 15.95 31.26 21.97 17.24 15.30 27.11 13.84 28.77 16.49 6.92** 9.96* 13.55 * 3.59
negative child behavior)
DBC-D (disruptive) 13.71 6.84 11.25 6.92 16.85 8.54 11.69 6.52 14.58 8.49 13.46 8.89 4.62* 1.52 3.54** 2.02
CPC-B (difficult 28.38 7.31 20.38 4.38 29.12 7.49 24.85 6.73 28.58 8.25 25.33 4.65 8.18** 4.88** 0.69 4.18**
child behavior)
CPC-T (problem 9.08 4.40 4.46 3.01 10.04 4.77 6.35 3.30 8.63 3.02 8.92 3.86 18.62 *** 4.69*** 3.27*** 1.41
care-giving tasks)
Parenting skills and competence
PS (total) 3.00 0.58 2.72 0.71 2.93 1.04 2.41 0.72 2.87 0.87 2.96 0.65 5.72** 0.30 0.58** 0.29
PSOC (total) 57.54 6.25 68.25 8.87 56.73 8.36 65.85 10.91 57.13 15.41 58.46 11.56 5.59** 9.78** 7.40* 2.38
FOS-NPB (% observed 0.57 1.13 0.82 1.61 0.87 1.94 0.19 0.53 0.75 1.72 0.49 1.01 2.15 0.35 0.31 0.66
negative parent behavior)
Maternal distress
DASS (total) 22.50 18.81 18.79 20.43 31.46 19.25 20.23 17.56 31.96 23.85 28.33 24.77 1.30 3.88 7.81 3.93
ADAS (total) 23.75 5.17 21.17 9.13 22.28 4.74 15.92 11.63 20.84 7.27 15.33 12.42 0.28 1.16 1.14 0.22
Note: SSTP-E = Enhanced Stepping Stones Triple P; SSTP-S = Standard Stepping Stones Triple P; WL = waitlist control; ANCOVA = analysis of covariance; Pre = pre-
intervention; Post = post-intervention; FOS-NCB = Family Observation Schedule-% Observed Negative Child Behavior; DBC-D = Developmental Behavior Checklist-Dis-
ruptive Subscale; CPC-B = Care-giving Problem Checklist-Difficult Child Behavior; CPC-T = problematic care-giving tasks; PS = Parenting Scale; PSOC = Parenting Sense of
Competence; FOS-NCB = Family Observation Schedule-% Observed Negative Parent Behavior; DASS = Depression, Anxiety and Stress Scale; ADAS = Abbreviated Dyadic
Adjustment Scale.
*
p < .05.
**
p < .01.
***
p < .001.
375
p = .001; CPC-T: F(3,73) = 18.62, p = .000). As shown in Table 2, at post-intervention the SSTP-
E resulted in significant reductions in child problem behavior on three of the four measures as
compared with the WL condition. These included reductions in observed negative child behavior
(FOS-NCB), the number of problematic care-giving tasks (CPC-T), and difficult child behavior
associated with care-giving (CPC-B). There were no differences between SSTP-E and the WL
conditions on a measure of overall disruptive behavior (DBC-D). Similarly, at post-intervention
the SSTP-S revealed significant reductions in child problem behavior on three of the four
measures as compared with the WL condition. Measures where differences occurred were
slightly different to the SSTP-E, and included observed negative child behavior (FOS-NCB), the
number of problematic care-giving tasks (CPC-T), and the measure of disruptive behavior (DBC-
D). There were no differences between SSTP-S and the WL conditions on the measure of difficult
child behavior associated with care-giving (CPC-B). There were no differences between the
intervention conditions (SSTP-E, SSTP-S) on any measures of child behavior, with the exception
of difficult child behavior associated with care-giving where the SSTP-E produced better
outcomes.
On measures of parenting skills and competence, ANCOVA scores were significant for
parenting skills (PS: F(3,73) = 5.72, p = .005) and competence (PSOC: F(3,73) = 5.59,
p = .006). Using mother-report, a significant effect for condition was found for both parenting
skills and competence. At post-intervention, mothers in the SSTP-S group reported significantly
higher levels of functional parenting skills (PS) and parenting competence (PSOC) as compared
with mothers in the WL condition; and mothers in the SSTP-E group reported significantly higher
levels of parental competency (PSOC) as compared with the WL group, but no significant
differences in functional parenting skills (PS). No significant differences were evident between
the SSTP-E and SSTP-S conditions on measures of parenting skills and competence. ANCOVA
scores were not significant for observed negative parent behavior (FOS-NPB: F(3,73) = 2.15,
p = .124).
ANCOVA scores for maternal distress (DASS: F(3,73) = 1.30, p = .28) or relationship
adjustment (ADAS: F(3,73) = .28, p = .80) were not significant.
2.5. Long-term intervention effects
Table 3 shows the means, standard deviations and univariate F values for observational and
mother-reported measures at pre- and post-intervention, and at 1-year follow-up for the
intervention conditions (SSTP-E, SSTP-S).
In relation to child behavior, there was a significant main effect for time on the measure of
observed negative child behavior (FOS-NCB), F(1,43) = 4.22, p = .04. Specifically, negative
child behavior decreased significantly from post-intervention to 1-year follow-up for both SSTP-
E and SSTP-S groups. There were no main effects for time on other child behavior measures
(DBC-D, CPC-B, CPC-T). A significant condition time interaction occurred for overall
disruptive child behavior (DBC-D), F(1,39) = 5.10, p = .03, and this revealed significantly lower
rates of difficult child behavior at 1-year follow-up for children in the SSTP-E group as compared
with the SSTP-S group.
On measures of parenting skills and competence, there was a significant condition time
interaction for parenting skills (PS), F(1,39) = 4.99, p = .03. However, despite this finding,
pairwise comparisons did not reveal any significant difference between conditions (SSTP-E,
SSTP-S) at 1-year follow-up, and no significant time effect. Furthermore, there were no
significant main effects or interactions for other measures (PSOC, FOS-NPB).
Table 3

Long-term intervention effects—home observation and mother-report of child behavior, parenting skills and competence, maternal and relationship adjustment at pre- post-, and 1-
year follow-up
SSTP-E (n = 23) SSTP-S (n = 19) 2-Group
ANCOVA (F)
Pre Post 1 year Pre Post 1 year
M S.D. M S.D. M S.D. M S.D. M S.D. M S.D.
Child behavior
Observed negative child 24.62 18.92 18.58 15.84 10.07 8.17 34.28 24.27 17.79 16.52 9.71 8.09 1.89
behavior (%)
DBC (disruptive) 13.61 6.98 11.26 7.08 9.91 6.09 16.89 8.46 12.16 6.45 13.42 6.17 5.10*
CPC (difficult child behavior) 28.26 7.45 20.13 4.31 23.04 7.53 28.89 7.42 24.74 7.27 26.21 7.47 0.63
Problem care-giving tasks 9.17 4.48 4.30 2.98 4.35 3.64 10.26 4.60 7.00 3.20 5.89 3.40 2.87
Parenting skills and competence
PS (total) 3.02 0.58 2.70 0.72 2.53 0.57 2.86 0.80 2.22 0.64 2.38 0.67 4.99*
PSOC (total) 57.87 6.17 67.87 8.86 64.78 8.50 58.42 8.43 66.73 11.60 65.21 15.29 0.40
Observed negative parent 0.59 1.15 0.81 1.64 0.34 0.62 0.55 1.79 0.09 0.28 0.09 0.21 3.66
behavior (%)
Maternal distress
DASS (total) 22.61 19.22 18.96 20.87 14.91 12.98 33.37 19.61 20.00 18.11 20.89 16.57 2.68
ADAS (total) 23.63 5.28 20.91 9.25 22.48 4.77 22.80 4.92 17.68 11.74 23.21 4.08 0.97
Note: SSTP-E = Enhanced Stepping Stones Triple P; SSTP-S = Standard Stepping Stones Triple P; ANCOVA = analysis of covariance; Pre = pre-intervention; Post = post-
intervention; 1 year = 1-year follow-up; FOS-NCB = Family Observation Schedule-% Observed Negative Child Behavior; DBC-D = Developmental Behavior Checklist-
Disruptive Subscale; CPC-B = Care-giving Problem Checklist-Difficult Child Behavior; CPC-T = problematic care-giving tasks; PS = Parenting Scale; PSOC = Parenting Sense
of Competence; FOS-NCB = Family Observation Schedule-% Observed Negative Parent Behavior; DASS = Depression, Anxiety and Stress Scale; ADAS = Abbreviated Dyadic
Adjustment Scale. *p < .05, **p < .01, ***p < .001.
377
There were no significant main effects or condition time interactions for measures of
maternal distress (DASS, ADAS).
2.6. Clinical significance of changes in children’s problem behavior
Two criteria were used to assess the clinical significance of change: the Reliable Change Index
(RCI: Jacobson & Truax, 1991) and a 30% reduction in observed child disruptive behavior
(Webster-Stratton, Hollinsworth, & Kolpacoff, 1989). Table 4 displays the frequency and
percentage of children who had reliably improved from pre- to post-intervention and from pre-
intervention to follow-up. This includes the RCI for mothers’ ratings on the DBC Total Problem
Behavior scores, movement from clinical to normal range for DBC Total Problem Behavior
scores, and 30% reduction rate in observed negative child behavior. It also displays the Chi-
square values for comparison between conditions.
Using mothers’ DBC scores to calculate RCI at post-intervention, there was a significantly
greater proportion of children whose behavior had reliably improved in the SSTP-E and SSTP-S
conditions when compared to the WL condition. No significant differences were evident between
the SSTP-E and SSTP-S conditions. Scores showing movement from clinical to normal range on
DBC Total Problem Behavior scores did not reveal significant differences between the three
groups (SSTP-E, SSTP-S, WL). Using the 30% reduction criterion, a greater proportion of
children in the SSTP-E and SSTP-S showed significant change in observed negative child
behavior at post-intervention when compared to children in the WL condition. No significant
differences were evident between the SSTP-E and SSTP-S conditions.
At follow-up there were no significant differences in reliable change, movement from clinical
to normal range, or 30% reduction between the SSTP-E and SSTP-S conditions. On the
observational measure of negative child behavior 72% of children across the two intervention
conditions had achieved a 30% reduction in negative behavior.
Table 4
Frequency and percentage of reliable change for children’s problem behavior from pre- to post-intervention and pre-
intervention to 1-year follow-up
For each condition (%) Contrasts (x2)
SSTP-E SSTP-S WL SSTP-E SSTP-S SSTP-E vs.
WL vs. WL vs. WL SSTP-S
RCI > 1.96 for DBC (post) 46 62 13 4.94* 10.74** 0.69
RCI> 1.96 for DBC (f/up) 48 42 – – – 0.04
Movement from clinical (>45) to 25 31 13 0.55 1.48 0.02
normal range for DBC-T (post)
Movement from clinical (>45) to 35 32 – – – 0.01
normal range for DBC-T (f/up)
30% reduction for observed negative 67 58 21 8.47** 5.61* 0.13
child behavior (post)
30% reduction for observed negative 67 77 – – – 0.22
child behavior (f/up)
Note: SSTP-E = Enhanced Stepping Stones Triple P; SSTP-S = Standard Stepping Stones Triple P; WL = waitlist control;
RCI = Reliable Change Index; DBC-T = Developmental Behavior Checklist-Total Problem Behavior.
*
p < .05.
**
p < .01.
Table 5
Parental satisfaction with intervention for SSTP-E and SSTP-S
Statements SSTP-E SSTP-S
M S.D. M S.D. t
1 Quality of intervention was good 6.36 0.73 6.00 0.82 1.56
2 Intervention was the type of help I needed 5.86 1.04 5.68 0.89 0.62
3 Intervention met child’s needs 5.18 1.18 5.09 1.19 0.25
4 Intervention met parent’s needs 5.32 0.72 5.27 1.08 0.17
5 Intervention helped to deal more effectively 5.95 1.05 6.18 0.85 0.79
with child’s behavior
6 Intervention helped to deal more effectively 6.09 0.81 5.72 0.77 1.53
with family problems
7 Intervention helped improve relationship 4.64 1.09 4.13 1.41 1.26
with partner
8 Intervention helped develop skills 6.10 1.07 5.77 1.11 0.97
with other family members
9 Satisfaction with amount of help received 6.00 0.98 5.86 0.94 0.47
10 Satisfaction with overall intervention 6.27 0.98 6.00 0.93 0.95
11 Would seek same intervention again 5.82 1.26 5.59 1.26 0.60
12 My child’s behavior is improved 6.05 0.79 6.09 0.75 0.20
13 Feelings about child’s progress 6.05 0.95 6.14 0.77 0.35
Total score 75.50 9.18 73.75 9.89 0.55
Note: SSTP-E = Enhanced Stepping Stones Triple P; SSTP-S = Standard Stepping Stones Triple P.
2.7. Client satisfaction
Table 5 summarizes mothers’ satisfaction with the interventions for both SSTP-E and SSTP-S
conditions. In terms of satisfaction, no significant difference between conditions was evident on
this measure for individual items or total score t(50) = .55, p = .59. All mothers reported high
levels of satisfaction with the program they received (SSTP-E: M = 75.50, S.D. = 9.18); SSTP-S:
M = 73.75, S.D. = 9.89).
3. Discussion
A unique feature of the present research is that it is the first study in the child disability field
which compares a standard behavioral parent training intervention to an enhanced adjunctive
intervention. Results of the study generally support the primary hypotheses that SSTP-S and
SSTP-E interventions would be associated with positive changes in child behavior. In addition,
findings suggest that interventions result in more adaptive parenting skills and increased parental
competence. However, findings from the study did not support hypotheses that intervention
would result in reduced parental distress and improved adjustment. In addition, contrary to
predictions, there was only partial support for the hypotheses suggesting that the enhanced
intervention (SSTP-E) would be superior to the standard behavioral parent training intervention
(SSTP-S) on outcome measures.
With regard to Hypothesis 1, as predicted both interventions (SSTP-S and SSTP-E) were
associated with significantly lower levels of observed negative child behavior (FOS-NCB) and
fewer problematic care-giving tasks (CPC-T) as compared to the WL condition at post-
intervention. There were no differences between the two intervention conditions on these
measures. In addition, mothers who received SSTP-E reported significantly lower levels of
difficult child behavior during care-giving (CPC-B) and mothers who received SSTP-S reported
significantly less overall disruptive child behavior (DBC-D) following participation in the
program as compared with the WL. There was also a significant difference between the
intervention conditions on the measure of difficult child behavior during care-giving, suggesting
that the SSTP-E was more effective in producing positive changes in child behavior during
parents’ completion of care-giving tasks.
Hypothesis 2 relating to parent behavior was partially supported. Results showed that
parenting competence and satisfaction (PSOC) showed significant improvements following
intervention for both the SSTP-E and SSTP-S as compared with the WL condition. However, in
relation to parenting skills (PS), the SSTP-S but not the SSTP-E resulted in significant changes
following intervention as compared with the WL condition. Observed measures of negative
parent behavior (FOS-NPB) did not reveal any differences between the three groups following
intervention. Inspection of pre-intervention means shows extremely low rates of negative parent
behavior which likely accounts for the absence of any change. There were no differences between
the intervention conditions on any measures of parent behavior.
Hypothesis 3 relating to changes in parental distress and adjustment was not supported with no
significant differences between the three groups (SSTP-E, SSTP-S, WL) following intervention.
Inspection of the means at pre-intervention reveals low scores on the measure of parental distress
(DASS) and high scores on relationship adjustment (ADAS) for all three groups. The fact that
pre-intervention scores are not in the clinical range may explain the absence of significant
changes post-intervention.
Hypothesis 4 predicted that positive changes on all observed and parent-reported measures
including child behavior, parent behavior, parental distress and adjustment at post-intervention
would be maintained at 1-year follow-up, and that the enhanced intervention (SSTP-E) would be
superior to the standard intervention (SSTP-S) in the maintenance of these effects. Although,
there were significant differences identified at post-intervention which maintained at 1-year
follow-up, there was only partial evidence to support the superiority of the SSTP-E over the
SSTP-S. Differences between intervention groups at 1-year follow-up only occurred on the
measure of overall disruptive child behavior where lower rates of disruptive child behavior were
evident for the SSTP-E condition at 1-year follow-up. This finding is interesting given that at
post-intervention there was no difference between the SSTP-E and WL on this measure.
Inspection of the means shows that whilst the significant reduction in overall disruptive child
behavior was maintained but did not reduce further for the SSTP-S, rates of overall disruptive
child behavior for SSTP-E continued to reduce over time.
Further confirmation for the efficacy of both interventions (SSTP-E, SSTP-S) is demonstrated
through reports of clinically reliable change (Table 4) and parental satisfaction with interventions
(Table 5). Sixty-seven percent of the SSTP-E children and 77% of the SSTP-S children showed
clinically reliable improvement in observed negative child behavior from pre-intervention to 1-
year follow-up. This is consistent with results of other behavioral parent training studies (Bor,
Sanders, & Markie-Dadds, 2002; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks,
2001). In relation to clinically reliable change, differences between the interventions are not
significant at 1-year follow-up, and this further supports the study’s findings that the enhanced
adjunctive intervention (SSTP-E) is not superior to the standard intervention (SSTP-S). Overall
parents in both the SSTP-E and SSTP-S interventions reported a high degree of satisfaction with
the programs, and there were no differences between groups. This further suggests that both
interventions were associated with similar levels of parent satisfaction.
This study supports and extends the findings of previous research (Harrold et al., 1992;
Hudson et al., 2003; Huynen et al., 1996; Roberts et al., 2006; Sanders & Plant, 1989) which
demonstrates the efficacy of behavioral parent training with parents of children with
developmental disabilities. These studies have generally reported reductions in child problem
behavior and improvements in positive parent behavior following parent programs involving
contingency management training, planned activities training, compliance training, or a
combination of these programs. In addition, the study supports the findings of Roberts et al.
(2006) which is the first controlled trial examining the efficacy of the Stepping Stones Triple P
(SSTP). Results of the present study are consistent with these findings and provide further
confirmation of the efficacy of Stepping Stones Triple P.
Results of the present study do not fully support hypotheses that the adjunctive intervention
(SSTP-E) would be superior to the standard behavioral parent training intervention (SSTP-S),
but rather suggest that both interventions are equally effective in producing positive changes
in child and parent behavior. Whilst this finding has not previously been demonstrated in the
parent training literature pertaining to children with developmental disabilities, it is consistent
with results of Triple P-Positive Parenting Program (Sanders, 1999) comparison trials which
suggest that enhanced interventions do not consistently produce better short- or long-term
effects (Bor et al., 2002; Sanders, Markie-Dadds, Tully et al., 2000) as compared with standard
interventions. These researchers (Bor et al., 2002; Sanders, Markie-Dadds, Tully et al., 2000)
argue that the standard parenting program has been empirically validated as being a powerful
intervention in its own right, and that changes in parenting practices and associated changes in
negative child behavior resulting from this program may act as a catalyst for producing
changes in other areas of family functioning. This may mean that there is little scope for the
enhanced interventions to impact further on both parent and child behavior. An additional
factor in explaining the absence of a significant difference between the standard and enhanced
interventions may relate to the considerable variability that exists for families on variables
such as parent distress, relationship adjustment, and parenting style. In the present study,
eligibility was determined primarily on the basis of child developmental disability and
problem behavior; rather than on the basis of parent characteristics such parenting skills and
competence, parental distress or relationship adjustment which are more the focus of
enhanced interventions. It may be that some families who received the enhanced intervention
did not require support in relation to coping skills, relationship enhancement, and social
supports; and this was reflected in the outcome measures. This highlights the importance of
interventions to be specifically tailored to meet the needs of individual families. Adjunctive
interventions may be useful in clinical practice where further assessment can be conducted
with families following completion of standard behavioral parent training to identify
additional areas of unmet need.
A major focus of the current study was to examine the impact of the interventions on
children’s disruptive behavior, as problematic behavior is shown to be one of the best
predictors of burden of care and parent distress (Blacher et al., 1997; Saloviita et al., 2003).
Findings demonstrated that both the SSTP-E and SSTP-S are effective interventions for
reducing negative child behavior, and that these changes in behavior are maintained over
time. Furthermore, the findings showed that following intervention, parents are able to
facilitate changes in their child’s behavior across numerous care-giving tasks. This finding is
particularly important given that child problem behavior has a negative impact on the ability
of parents to undertake care-giving tasks, and that problem behavior during tasks compounds
the difficulties experienced by parents. It is assumed that by reducing child problem behavior,
parent’s burden of care is reduced as they are more readily able to undertake their care-giving
role.
The absence of any effect on measures of parental distress and adjustment requires
explanation, especially given that research indicates that parents of children with developmental
disabilities are at increased risk for parental distress and maladjustment as compared with parents
of typically developing children (Blacher et al., 1997; McDonald et al., 1996). In the present
study, there were no differences between the intervention and waitlist groups at post-intervention
on measures of parental distress and relationship adjustment. Inspection of the means show that
parents in all three groups had distress and relationship satisfaction scores within the normal
range prior to intervention which suggests there may have been limited scope for improvements
following intervention. It may be useful for future research to have eligibility criteria which
requires concurrent clinically significant levels of child problem behavior and parent distress.
This may result in different findings in relation to comparisons about the respective efficacy of
the two intervention conditions.
There are several methodological issues that require consideration in interpreting findings of
the present study. Firstly, results are based on observational and self-report data provided by
mothers. Whilst fathers’ participation in the program was recommended, it was not possible for
all fathers to be involved in the intervention program due to work commitments and/or child care
arrangements. In addition, even where fathers were involved it was difficult to include them in
observational measures as they were less inclined to complete questionnaires. In addition,
approximately 30% of the sample consisted of one-parent families where the mother was the
primary carer. Secondly, in the present study, participation was voluntary and based on self-
referrals. Parents recruited for the study may have been more motivated and committed to
change; and more distressed and maladjusted parents may have been less inclined to participate.
Pre-intervention scores in the normal range on measures of parental distress and relationship
adjustment support this. Thirdly, this study consisted of a pre- to post-intervention WL control
design, and no follow-up data is available for families in the waitlist condition. While it would
have been useful to examine changes in child behavior across time in the absence of intervention,
it was considered unethical to allow preschool-aged children with problem behavior to remain
without intervention through to 1-year follow-up.
In summary, this study contributes to the literature on behavioral parent training by
demonstrating the efficacy of the Stepping Stones Triple P (Sanders et al., 2003) as a useful
intervention for parents of children with developmental disabilities. In addition, while we did
not find that the enhanced adjunctive intervention (SSTP-E) was superior to the standard
intervention (SSTP-S), it has resulted in the development of a new intervention for clinical use
with parents requiring support in relation to coping with their care-giving role. Similar outcomes
were achieved in fewer sessions by the SSTP-S intervention, suggesting that it is more cost
effective than SSTP-E. However, the present study suggests that the enhanced intervention
appears to be a useful adjunct that should be reserved for either non-responders to the standard
intervention or for families with additional risk factors that are not changed by the standard
intervention.
Acknowledgements
The authors would like to thank the Australian Research Council and Apex Foundation for
funding support, the families who participated in the study, and the government services which
supported the project.
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Reducing Problem Behavior During Care-Giving in Families of Preschool-Aged Children With Developmental Disabilities

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Research in Developmental Disabilities 28 (2007) 362–385

Reducing problem behavior during care-giving in

Keywords: Children; Developmental disability; Care-giving; Behavioral parent training

1.2.1. Family background

1.2.2. Level of disability

K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385

K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385

Mother Father Mother Father Mother Father

1.2.3. Parent–child interaction

1.2.4. Child behavior

1.2.4.3. Care-giving Problem Checklist (CPC)—Difficult Child Behavior. To assess frequency

1.2.4.4. Care-giving Problem Checklist (CPC)—Problematic Care-giving Tasks. To assess

1.2.5. Parenting skills and ability

which is based on three factors: laxness (permissive discipline), over-reactivity (authoritarian

1.2.6. Parental adjustment

1.2.7. Intervention acceptability

1.4.1. Treatment conditions

1.4.2. Treatment integrity

practitioners demonstrated a 100% adherence to content, in-session exercises, and homework

2.1. Preliminary analyses

2.3. Statistical analyses

2.4. Short-term intervention effects

K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385

2.5. Long-term intervention effects

K.M. Plant, M.R. Sanders / Research in Developmental Disabilities 28 (2007) 362–385

2.6. Clinical significance of changes in children’s problem behavior

2.7. Client satisfaction

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