Psychological Services 2015, Vol. 12, No. 3, 274 –282

© 2015 American Psychological Association 1541-1559/15/$12.00 http://dx.doi.org/10.1037/ser0000018

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Using Telepsychology to Provide a Group Parenting Program: A Preliminary Evaluation of Effectiveness Robert J. Reese

Norah C. Slone

University of Kentucky

Spalding University

Neelkamal Soares

Rob Sprang

Autism & Developmental Medicine Institute, Geisinger Health System, Lewisburg, PA

University of Kentucky

Telepsychology offers the potential to reach rural and underserved children and families with mental health concerns. The current study evaluated the effects of using videoconferencing technology to deliver an evidence-based parenting program, the Group Triple P Positive Parenting Program (Group Triple P; Turner, Markie-Dadds, & Sanders, 2002), with families who had a child experiencing behavioral problems. Using a pre/post design, families (N ⫽ 13) from low socioeconomic backgrounds in Kentucky completed the Group Triple P via a videoconferencing delivery format. A benchmarking strategy (Weersing & Hamilton, 2005) indicated that treatment effect sizes for the videoconferencing format were generally comparable to treatment effect sizes for Group Triple P studies conducted in-person. Specifically, child behavior and parenting outcomes were similar across delivery formats. Implications of the study’s findings and future directions for telepsychology research and practice with underserved families and children are discussed. Keywords: telepsychology, telehealth, parent training, rural, Group Triple P

psychiatrist or developmental-behavioral pediatrician (Soares & Langkamp, 2012). Moreover, the average wait time for an appointment with a pediatric mental health counselor, including child clinical psychologists, is almost three months. If families travel to the region’s two tertiary care centers for pediatric and mental health subspecialty consultations for children with special needs, they often face a 200⫹ mile round trip. Promising evidence exists supporting the use of telepsychology to address the mental health concerns of children and adolescents in rural or underserved areas (Christogiorgos et al., 2010; GraeffMartins et al., 2008; Hilty, Marks, Urness, Yellowlees, & Nesbitt, 2004; Nelson & Bui, 2010; Pesämaa et al., 2004; Slone, Reese, & McClellan, 2012; Van Allen, Davis, & Lassen, 2011). Although encouraging, more research is needed to better understand the benefits and possible limitations of using innovative service delivery methods.

Mental illness is the leading cause of disability in American children (Mental Health America, 2008; World Health Organization, 2008), and without effective intervention, it has a lifelong impact. Specific to Kentucky, the state has among the highest rates of childhood mental health disorders in the nation (National Center for Health Statistics, 2009). Yet, many children with developmental, behavioral, and emotional problems in Kentucky are not receiving any special education or mental health services, with a disproportionate number of these residing in rural Appalachia (Kentucky Youth Advocates, 2014). The use of technology (e.g., videoconferencing, computer, or telephone) to facilitate the provision of psychological services, often referred to as “telepsychology,” has been proffered as a means to improve access to services for those who have geographic and economic barriers to receiving services. For example, most parents and their children in eastern and far western Kentucky must wait 4 – 6 months for an appointment with a child

Telepsychology Outcome Research With Children and Adolescents The majority of telepsychology research addressing youth mental health has been focused on services provided directly to the child or adolescent. Such services have generally been found to be effective, but the number and quality of such studies are limited. In a review of the telepsychology outcome literature, Slone et al. (2012) identified only five videoconference-focused studies that used an experimental design (we discuss only videoconferencing studies, given the focus of our study; see Slone et al., 2012 for a review of other telepsychology delivery formats). The studies evaluated psychotherapy (Nelson, Barnard, & Cain, 2003) and

This article was published Online First January 19, 2015. Robert J. Reese, Department of Educational, School, and Counseling Psychology, University of Kentucky; Norah C. Slone, School of Professional Psychology, Spalding University; Neelkamal Soares, Autism & Developmental Medicine Institute, Geisinger Health System, Lewisburg, PA; Rob Sprang, University of Kentucky College of Medicine. Correspondence concerning this article should be addressed to Robert J. Reese, Department of Educational, School, and Counseling Psychology, University of Kentucky, 245 Dickey Hall, Lexington, KY 40506. E-mail: [email protected] 274

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supportive counseling (Glueckauf et al., 2002), psychological assessment (Elford et al., 2000), and consultation (Yellowlees, Hilty, Marks, Neufeld, & Bourgeois, 2008). Three randomized controlled trial studies that compared psychological services delivered through videoconferencing or in-person conditions suggested that youth in a videoconferencing condition benefitted similarly to those who received services in-person (Elford et al., 2000; Glueckauf et al., 2002; Nelson et al., 2003). However, Nelson et al. (2003) found that depressed children randomized to receive cognitive– behavioral therapy in a videoconferencing format reported more improvement than children receiving the same treatment in-person. Even fewer telepsychology studies have focused on interventions provided to parents that are designed to benefit youth emotional and behavioral well-being, although there is solid empirical support for their efficacy when delivered in-person. For example, parent training, which is typically focused on teaching parents skills, providing support, and improving youth behavior has strong empirical support (see Sexton, Datchi, Evans, LaFollette, & Wright, 2013 for a review). Examples of such programs include Parent-Child Interaction Therapy (Timmer, Ware, Urquiza, & Zebell, 2010), the Incredible Years Parent Training (WebsterStratton, 1984), and the Triple P Positive Parenting Program (Triple P; Sanders, 1999). All of these programs have several randomized clinical trial studies with large samples that support their efficacy, with meta-analytic studies reporting a mean effect size of d ⫽ 0.44 (Sexton et al., 2013). The use of technology for providing parent training has included the telephone to provide coaching/consulting as an adjunct to self-help materials (e.g., handouts/workbooks, videos; Borowsky, Mozayeny, Stuenkel, & Ireland, 2004; Cann, Rogers, & Worley, 2003; McGrath et al., 2011; Sanders, 1999), videoconferencing (Vismara, McCormick, Young, Nadhan, & Monlux, 2013), or self-directed websites with no professional interaction (Baggett et al., 2010) or that include a videoconference format with some professional interaction (Enebrink, Hogstrom, Forster, & Ghaderi, 2012). Generally, these studies have reported positive findings for improving child or adolescent behavior. However, these studies typically rely on waitlist control conditions and fail to answer whether the interventions are comparable to parent training programs delivered in-person. When a randomized clinical trial study is not possible or feasible, a benchmarking strategy (Weersing & Hamilton, 2005) is one approach to evaluate the effectiveness of an intervention. The methodology of benchmarking permits the comparison of the delivery of services in a natural setting against a reliably determined effect size based on clinical trials or metaanalyses of clinical trials (McFall, 1996; Minami et al., 2008). Benchmarking is a methodological approach that can be used to establish the effectiveness of an empirically supported treatment that is transported to a naturalistic setting (Weersing & Hamilton, 2005). For the current study, we utilized a benchmark strategy to evaluate the effectiveness of delivering a well-known parent training program, the Group Triple P program (Turner, Markie-Dadds, & Sanders, 2002) using a videoconferencing format.

Group Triple P The Triple P program is a public health approach to educate parents on how to interact with their children regardless of background or socioeconomic level. Triple P accommodates varying

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degrees of problematic behavior by incorporating five different levels of intervention for parents of children whose ages range from birth to 17 years. Each level differs in intensity and can be tailored to meet the individual needs of the family. There are 18 basic core parenting skills that are taught throughout each of the levels of intervention. One of the benefits of this program is its flexibility and a multifaceted approach to parent training (Briesmeister & Schaefer, 2007). The program is a behavioral family intervention grounded in social learning theory that is a considered an evidence-based program for children with behavioral issues (Sanders, Turner, & Markey-Dadds, 2002; Sexton et al., 2013). Parents are taught skills that help them to increase their level of positive interaction with their children and reduce practices that are coercive and inconsistent in nature (Cann et al., 2003). The program has a variety of delivery modalities (self-study, individual, group) and all have been associated with high levels of parent satisfaction, improvements in child behavior, parenting selfefficacy and adjustment, and reduced marital conflict that are stable over time (Cann et al., 2003). For the current study, we selected the Group Triple P because of the efficiency of a group format and the potential for providing additional support for families in rural remote settings. There are several meta-analyses that support the use of the Triple P to treat child misbehavior (e.g., de Graaf, Speetjens, Smit, de Wolff, & Tavecchio, 2008; Nowak & Heinrichs, 2008; Thomas & Zimmer-Gembeck, 2007), with medium effect sizes typically being found. Specific to the Group Triple P, Thomas and ZimmerGembeck (2007) reported effect sizes of d ⫽ 0.67 for child behavior and d ⫽ 0.69 for self-reported improved parenting and parenting distress. These benchmarks were utilized for comparison to our sample in the current study. Specifically, we evaluated effectiveness by comparing the Group Triple P delivered via videoconferencing on outcome variables of child behavior and parent/family functioning to benchmarks derived from a metaanalysis comprised of experimentally designed (treatment vs. waitlist control) of Group Triple P studies (N ⫽ 2; Thomas & ZimmerGembeck, 2007).

Method Participants Parents. Participants for this study were parents or guardians (N ⫽ 13) from rural areas and small towns in Kentucky recruited from a community mental health agency and two public elementary schools. There were 16 participants who completed seven of the eight sessions, but three did not attend the final session or complete the postintervention measures. The remaining 13 participants identified as Caucasian (100%) and mostly female (84.6%), ranging in age from 21– 64 years (M ⫽ 39.1 years, SD ⫽ 10.8). The majority of parent participants reported being married (84.6%). Although a majority of participants reported being married, only two couples attended the program together and provided outcome data. Parents identified their children (N ⫽ 11) as mostly male (72.7%) and Caucasian (72.7%; n ⫽ 3 children were biracial) with an age range of 5–11 (M ⫽ 7.6 years, SD ⫽ 2.03). Five of the children were reported to have a diagnosis of attention-deficit/ hyperactivity disorder (AD/HD) and the other six children were reported to have attention/concentration problems (n ⫽ 2) or

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general behavioral issues (n ⫽ 4). Parents may have had multiple children in their family; however, only one was included in the evaluation of program effectiveness. For simplicity, we refer to parents/guardians as parents in this study. Facilitators. Group Triple P facilitators were a male licensed psychologist and a female counseling psychology doctoral student from a large university in an urban area within Kentucky. The licensed psychologist was an accredited Triple P facilitator and provided weekly supervision to the doctoral student facilitator. He had provided clinical supervision using videoconferencing technology in both individual and group formats, but had no previous experience with providing clinical services using videoconferencing. The doctoral student also had no previous experience with providing clinical services using videoconferencing. Both facilitators did have previous experience with providing group-based clinical services, including the Group Triple P. Fidelity to the intervention, updates on families’ progress, and degree of technology functioning (i.e., audio/video glitches) were discussed during supervision.

Procedures This study used a pre/post design to compare effects of the Group Triple P provided via videoconferencing on child and parent/family functioning outcomes. Approval was obtained from the first author’s university Institutional Review Board. Parents were referred by counseling professionals at a community mental health facility or by Family Resource Coordinators at two public elementary schools. Criteria for inclusion included that the target child be between the ages of 5 and 12 years, not diagnosed with an intellectual disability or a thought disorder, and, based on parents’ report, had a clinically significant behavioral problem (T ⱖ 63 on the Child Behavioral Checklist [CBCL]; Achenbach & Rescorla, 2000). Eight children met these criteria, but three parents whose child was below the CBCL cut-score were allowed to participate. This exception was made due to reported persistent behavioral difficulties by either a parent or mental health professional and difficulty with recruitment. For parents referred, research personnel contacted parents via telephone to provide more information about the research study and the Group Triple P. A brief intake history (i.e., symptoms and severity of misbehaviors that occur at home and school, treatment history) was gathered at that time. In efforts to maximize convenience, participants were asked to provide their availability to schedule the group at a time that would accommodate the majority of interested parents. Children were asked not to attend, since childcare was not provided. Group composition. Groups were formed one 8-week training period at a time and were comprised of parents who were available during the selected time. Three parenting groups were conducted via videoconferencing (one in a hospital setting [n ⫽ 4] and two in public schools [n ⫽ 9]). The parenting groups ranged in size, from 4 to 6 parents. Evaluation procedures. Participants were provided with measures of child and parent/family functioning at pre/post. Prior to the first session, parents received packets containing the informed consent, demographics questionnaire, the CBCL (Achenbach & Rescorla, 2001), the Parenting Scale (PS; Arnold, O’Leary, Wolff, & Acker, 1993), Parent Problem Checklist (PPC; Sanders

& Dadds, 1993), the Relationship Quality Index (RQI; Norton, 1983), Depression Anxiety Stress Scale-21 (DASS-21; Lovibond & Lovibond, 1995), and a complimentary Every Parent’s Group Triple P Workbook (Turner et al., 2002) that was used as part of the program for homework in between sessions. During the last session, parents were asked to complete posttest measures (CBCL, PS, PPC, RQI, and DASS-21), as well as answer open-ended questions regarding their experience. This process was done as consistent with the Group Triple P manual for evaluating the effectiveness of the program. To minimize demand characteristics and social desirability, measures were completed without the facilitators present, participants were deidentified by having an assigned number for the purpose of anonymity, and completed measures were placed in a sealed envelope.

Intervention The Group Triple P is a Level 4 (out 5 total) intervention within the Triple P System (Sanders, 1999). As a Level 4 intervention, Group Triple P is designed to target a range of child behavioral concerns, including more severe problem behaviors (e.g., conduct disorder or A), within the context of a group format. The intervention is based on principles of social learning and is designed to improve parents’ knowledge and confidence with providing skills in an environment that fosters child development, positive relationships, effective management of misbehavior, and prevention of future problem behavior (Sanders, 1999; Turner et al., 2002). Group Triple P is delivered using both a group and individual format that is comprised of eight weekly sessions. The first four sessions are in a group format and two hours each, using primarily a psychoeducational approach to teach positive parenting concepts and behavioral management techniques. Video clips are also provided to illustrate concepts and techniques. The following three sessions are individualized telephone consultations (30 – 45 min) with the group facilitator to monitor parents’ progress, problem solve any concerns, and to tailor the training to the individual child’s and family’s needs. A wrap-up session occurs during the final week of the intervention to reflect on parents’ progress with their goals and to answer any final questions in regard to the intervention. For the current study, if a parent missed a session, they were able to make up the session by scheduling an appointment to watch a recording of the session. This occurred for three parents. Although not formally evaluated statistically, fidelity of the intervention was monitored by completing a session checklist within the treatment manual and the aforementioned weekly supervision to ensure that the components of the program were delivered as intended.

Technology Videoconferencing technology was utilized to connect the facilitators at the university and parents who attended the four skills sessions (Sessions 1– 4) as well as the wrap-up session (Session 8). Videoconferencing services were conducted using standards-based H.323 videoconferencing equipment (i.e., camera, microphone, speaker, monitor, network connection) supported by a 384Kbandwidth over the Kentucky Tele-Linking Network to connect facilitators with three different groups of parents at three different

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sites throughout the study. Facilitators were in a room outfitted with two 52 in. HDTV monitors (1 for local and 1 for remote site viewing), a desktop computer, overhead microphones, and a Polycom HDX 9004 system. The monitor/projector screen for participants was at least 27 in. at each site. Technology at remote sites was comprised of equipment from various manufacturers, though the three sites were able to use their respective systems to link into the telehealth network at the university. The three sites had comparable equipment that aided in the synchronous communication in real time, such as a microphone, camera, and at least one monitor/ projector screen to view the facilitator and video clips.

Measures Child Behavior Checklist-Parent Report (CBCL). The CBCL is a parent or guardian reported standardized measure of a wide range of child emotional, behavioral, and social functioning (Achenbach & Rescorla, 2000). The checklist consists of openended items covering parent reports of their child’s physical problems, concerns, and strengths. A version has been normed for both school-age children/adolescents (CBCL/6 –18, 113 items; Achenbach & Rescorla, 2001) and preschoolers (CBCL/1.5–5, 100 items; Achenbach & Rescorla, 2000). Both forms of the CBCL consist of Syndrome Scales (i.e., Anxious/Depressed, Somatic Complaints) as well as broader grouping of syndromes: Internalizing and Externalizing Scales. Items comprising the Internalizing scale are related to the self of the child. Items that comprise the Externalizing scale consist of those related to conflicts with other people or parent expectations of the child. Parents rate how true each item is now, or was within the past 6 months, using a 3-point scale from 0 –2 (0 ⫽ Not True, 1 ⫽ Somewhat or Sometimes True, 2 ⫽ Very or Often True). Scores said to be in the clinical range on this measure are T ⱖ 63. An analysis of psychometric properties suggest that scores generated by this measure demonstrate adequate internal consistency estimates, ranging from .78 to .97 on the CBCL scales (Achenbach & Rescorla, 2001). Estimates of construct validity were generated by correlating scales with a Diagnostic and Statistical Manual IV Checklist (Hudziak, 1998) comprised of critical symptoms for diagnoses that are common in childhood. Results varied by scale, ranging from r ⫽ .60 for Oppositional Defiant Disorder to r ⫽ .80 for Attention Deficit-Hyperactivity Problems (Achenbach & Rescorla, 2001). For this study, both forms for school-aged and preschool-aged children were used, given the fact that our sample incorporated a range of ages. Prior to analyses, T scores were calculated from both forms and used to determine means, standard deviations, and subsequent effect sizes. For the current sample, coefficient alpha was for the Total Score was .95. The Parenting Scale (PS). The PS is a 30-item questionnaire that measures parents’ dysfunctional discipline styles across a 7-point Likert scale (Arnold, O’Leary, Wolff, & Acker, 1993). Three subscales are used to measure dysfunctional discipline strategies: Laxness, which describes permissive discipline, Overreactivity, which describes parenting in an authoritarian manner with displays of anger, harshness, and irritability, and Verbosity, which describes parenting through overly long reprimands and reliance on talking. An analysis of psychometric properties suggested good internal consistency with overall estimates of .82 (Harvey, Danforth, McKee, Ulaszek, & Friedman, 2003). Construct validity was

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also estimated to be adequate, with findings of r ⫽ .82 (Laxness) and r ⫽ .76 (Overreactivity) when correlated with the Behavioral Assessment Scales for Children Parent Rating Scales. Coefficient alpha for the current sample were .84 (Total score), .83 (Laxness), .82 (Overreactivity), and .63 (Verbosity). Parent Problem Checklist (PPC). The PPC is a 16-item checklist that measures interparent conflict over child rearing practices (Dadds & Powell, 1991). Items on the PPC measure the extent parents disagree on rules and discipline related to child misbehavior, the amount of open conflict over child-rearing issues, and the degree to which parents undermine each other’s relationship with their children. Parents may rate the extent of the conflict on a 7-point Likert scale (Not at all a problem to Very much a problem). Studies evaluating the reliability of the PPC were found to have adequate internal consistency ratings of .82 (Problem scale) and .89 (Extent scale). Convergent validity estimates were established using correlations of the PPC with relationship satisfaction through Relationship Quality Index with r ⫽ .69 (Problems scale) and r ⫽ .73 (Extent scale; Stallman, Morawska, & Sanders, 2009). Coefficient alpha was .85 for the current sample. The Relationship Quality Index (RQI). The RQI is a 6-item index that measures marital and relationship quality and satisfaction (Norton, 1983). The first five items are rated on a 7-point Likert scale and the last item is a global measure of happiness in the relationship and is rated on a 10-point scale. A total score on this index may range from 6 – 45 with higher scores being more indicative of a positive relationship and very low scores indicate shorter estimates of future time together with possible discussions of ending the relationship. Coefficient alpha was .97 for the current sample. Depression Anxiety Stress Scale-21 (DASS-21). The DASS-21 is a 21-item questionnaire measuring symptoms of depression, anxiety, and stress in adults (Lovibond & Lovibond, 1995). The DASS-21 is a shortened version from the DASS created by Lovibond and Lovibond, which is a 42-item measure. Seven items comprise each subscale measuring features of depression, hyperarousal (anxiety), and tension (stress). Items were rated across a 4-point Likert scale (Did not apply to me at all to Applied to me very much or most of the time). Lovibond and Lovibond (1995) found that the DASS-21 generates internally consistent scores with an adult clinical sample (N ⫽ 258) who presented with a range of anxiety and mood disorders. Coefficient alphas were .92 (Anxiety scale), .95 (Stress), and .97 (Depression scale). Evidence of concurrent validity was indicated with strong to moderately strong correlations with the Beck Anxiety Inventory (Beck & Steer, 1993; r ⫽ .84) and the Beck Depression Inventory (Beck, Steer, & Brown, 1996; r ⫽ .77). Coefficient alpha for the current sample was .94 for Depression, .83 for Anxiety, and .91 for Stress.

Benchmarking The effectiveness of the videoconferencing sample was evaluated using a benchmarking strategy. We employed the four steps outlined by Weersing & Hamilton (2005). First, we circumscribed our treatment population to children with significant behavioral problems whose parents completed the Group Triple P. Second, the “gold standard” benchmark we selected were studies that used an experimental design and evaluated the Group Triple P delivered

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in an in-person format. The current standard for psychosocial service delivery is in-person; therefore, we used in-person studies. The benchmarks were taken from the Thomas and ZimmerGembeck (2007) meta-analysis which isolated the effects of Group Triple P studies (N ⫽ 2) from other Triple P formats (individual, self-help). The two studies, collectively, had 136 participants. Third, we computed effect sizes using standardized pre/post mean differences (i.e., Cohen’s d) consistent with the Thomas and Zimmer-Gembeck study (Mpost ⫺ Mpre/SDpre). Fourth, we made comparisons on both child behavior and parenting outcomes. There are multiple analytical strategies we could have employed (Minami et al., 2008, 2009; Weersing & Weisz, 2002), but given the small number of studies and our small sample size we used Weersing and Weisz’s strategy of evaluating if the videoconferencing sample effect size fell within the two-tailed 95% confidence interval of the benchmark effect sizes. Specifically, if the Group Triple P videoconferencing effect sizes fell within the benchmark effect size 95% confidence interval (CI) “band,” it could be argued that the videoconferencing and benchmark effect sizes were comparable and that service delivery formats for the Group Triple P were equivalent.

behavior benchmark (d ⫽ 0.67) but fell within the benchmark 95% CI. This suggests that the videoconferencing format produced similar treatment outcomes for reducing child problem behavior as the in-person Group Triple P studies.

Parenting Outcomes Most of the effect sizes calculated for the parenting outcome variables also indicated improvement. When compared to the parenting outcome benchmark, the videoconferencing participants had similar improvement on interparent conflict over discipline (d ⫽ 0.74) and dysfunctional disciplinary styles (d ⫽ 0.61). The videoconferencing sample had improvement on measures of parent distress (d ⫽ 0.21) and relationship satisfaction (d ⫽ 0.25), but the effects were smaller. The videoconferencing sample had an effect size that fell below the 95% CI benchmark, suggesting that the videoconferencing-delivered Group Triple P was less effective in reducing parenting stress than the in-person format. The videoconferencing sample effect size for relationship satisfaction fell within the 95% CI benchmark, but was at the lower end.

Feasibility Results Given that participants were nested within three groups, we inspected the pre/post means of all the outcome measures to evaluate interdependence at the group level. Descriptively, the mean pre/post differences were negligible and suggest that the data could be presented at the individual level. Data below were analyzed in the aggregate irrespective of the group attended.

Child Problem Behavior As can be seen in Table 1, results from pre/post treatment for the Group Triple P delivered using videoconferencing indicated improvement for child problem behavior. Group Triple P yielded a medium effect size on the CBLC Total Problems Scale (d ⫽ 0.56; positive effect size indicates improvement and negative effect size denotes worsening), which was smaller than the child problem

Although not a primary purpose of the study, we asked parents to respond to open-ended questions regarding their experience with the videoconferencing-delivered parenting program. Three questions asked what they liked, what they did not like, and to compare their satisfaction of receiving the information using videoconferencing versus in-person. Results were mostly positive and consistent with previous research (e.g., Hilty et al., 2004). Parents reported two primarily positive and two primarily negative comments that described facets of their satisfaction with being able to attend the Group Triple P in their community. First, all participants shared how attending the Group Triple P in their community was cost efficient and convenient in that it saved them time and/or money not traveling longer distances to an urban area. Second, nine participants reported being as satisfied with the information they received from the training as they anticipated they would in-person. Although parents reported high levels of satisfaction

Table 1 Means, Standard Deviations, and Effect Sizes for Child and Parent Group Triple P Outcomes Video conferencing condition (N ⫽ 16)

Child behavior outcome Child Behavior Checklist Parent outcomes Parent Problem Checklist Parenting Scale Laxness Verbosity Overreactivity DASS-21 Depression Anxiety Stress Relationship Quality Index

Pre M

SD

Post M

SD

53.80

22.32

41.36

17.93

44.25 100.93 36.50 33.30 33.50 11.64 3.82 1.91 5.91 32.63

12.48 24.13 16.19 5.12 9.97 14.21 5.98 4.11 5.17 6.76

35.00 86.27 30.73 27.73 26.73 8.64 2.09 2.00 4.55 35.78

7.29 24.00 11.89 8.46 8.79 11.08 3.86 2.76 4.93 9.58

Benchmark (N ⫽ 136) d

d

95% CI

0.56

0.67

0.26–1.08

0.74 0.61 0.36 1.09 0.68 0.21 0.29 ⫺0.02 0.19 0.47

0.69 0.69

0.27–1.11 0.27–1.11

0.69

0.27–1.11

0.69

0.27–1.11

Note. N ⫽ sample size; Pre M ⫽ mean scores at pretreatment; SD ⫽ standard deviation; Post M ⫽ mean scores at posttreatment; effect size ⫽ effect size; DASS-21 ⫽ Depression Anxiety Stress Scales-21.

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with the quality of information they received from the program, some process level differences were noted. For example, four parents reported they missed the in-person interaction with a facilitator although they were satisfied with the delivery of information they received through the program. Lastly, technology functioning influenced participants’ experience of the parenting program. Nine of the parents discussed that the functioning of technology was at times distracting (i.e., frozen picture, difficulty with clear audio at times).

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Discussion Parents who participated in a parent training program (Group Triple P) delivered using videoconferencing technology generally reported improvement for child behavior and parent functioning. We found effect sizes comparable to the benchmark effect sizes derived from a meta-analysis comprised of in-person Group Triple P studies (Thomas & Zimmer-Gembeck, 2007). The videoconferencing participants did, however, report less improvement on parenting distress. Overall, the results suggest that the videoconferencing format is a viable option for delivering the Group Triple P. To broaden the context, a meta-analysis by Nowak and Heinrichs (2008) reported within-group effect sizes for 55 studies ranging from d ⫽ 0.45– 0.57 across in-person Triple P interventions. Using this comparison, the videoconferencing format results look even more favorable. However, we selected a benchmark that specifically evaluated the group format independent of the other intervention formats (individual, self-study). There are, however, two considerations when comparing the videoconferencing sample to the selected benchmark. First, studies comprising the in-person benchmark were conducted in Hong Kong (Leung, Sanders, Leung, Mak, & Lau, 2003) and Australia (Martin & Sanders, 2003). The potential cultural influences on treatment outcome are not well understood, but are certainly worth noting. For example, multiple parents in the current study commented on having some difficulty with the Australian accents of actors and the narrator in the Triple P video clips. Difficulty ranged from not liking the accent to having some trouble understanding what was said. Second, the reported child behavioral problems were less severe than those in the benchmark studies. Inclusion in the benchmark studies required a score in the clinical range on a child behavior measure. Although we initially had the same inclusion criterion, this became untenable from a recruitment standpoint. The mean pretreatment CBCL scores were below the clinical cut-off, which may have created a restriction of range and limited the capacity to find treatment differences. Almost half of the children in our sample (n ⫽ 5) were reported to have an AD/HD diagnosis, but many reported having sought out other professional assistance (e.g., medication, other parenting interventions) prior to the current intervention provided. Conversely, our sample may have been biased, given that it is these same motivated parents who were most likely to implement the program components with their child. The lack of improvement for parent distress and the lower effect sizes for improving relationship quality also seems likely due to the lack of initial parenting and relationship distress. For example, scores on the DASS-21 indicated that parents were below the clinical cut-off. These lower levels are not consistent with the benchmark studies.

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Overall, the findings are encouraging for the use of videoconferencing to deliver the Group Triple P but should be interpreted with caution given the small sample and the sample characteristics. The lower initial severity of child and parent outcomes scores suggests the potential for a restriction of range concern; however, it may be that parents who are less distressed and have children with moderate behavioral concerns are better candidates for a videoconferencing treatment format than parents who are more distressed and have children with more severe behavioral issues. Future research is needed to clarify these distinctions.

Feasibility Findings We found three primary benefits and two primary challenges in our feasibility evaluation. The first benefit simply was the opportunity for parents to receive an evidence-based intervention, some of which indicated not having access to such services previously. All indicated that this opportunity was convenient and saved time and/or money with regard to travel. Although many of the parents had already received specialized behavioral health services for their child, others had not. The expansion of services via telepsychology provided school and mental health personnel with a timely and convenient treatment referral option for children and families who often have to travel long distances and wait for several months to receive behavioral health services. A second benefit was that the majority of parents felt that the quality of the service delivered would be equivalent to an in-person format. A third benefit of the videoconferencing format was that parents who missed a group training session were able to watch a recording of the session they missed. This was quite helpful for a small number of parents who had scheduling difficulties. This benefit was not acknowledged by participants in the open-ended questions but verbalized through informal feedback. One challenge delivering the Group Triple P via videoconferencing noted by some participants was the lack of in-person interaction with the facilitators. From a facilitator perspective, there appeared to be some subtle differences in communicating through the videoconferencing system compared to an in-person format. For example, the use of humor seemed to “translate” differently using the videoconferencing format. The facilitators have also provided the Group Triple P in person and noted that some of the same anecdotes or comments intended to be funny, especially the use of subtle or “dry wit,” did not seem to be received as well over videoconferencing. Humor can be very contextually dependent and the videoconferencing format may be a barrier for this at times. Also, open-ended discussions were initially difficulty given that parents seemed uncertain as to when to initiate speaking in their group. This seemed mostly related to being mindful of talking over each other or the facilitator, given the slight delay in communication transmission. The second challenge was the reliability of the technology. We occasionally had the picture freeze or had difficulty with audio quality. Participants noted these difficulties and expressed some frustration. Preparing parents to anticipate such difficulties seemed to be a helpful strategy to shape expectations.

Limitations There are several limitations to note in this study. First, we recognize that the findings should be considered preliminary,

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given the small sample size and the lack of a direct control condition. A pre/post design without a control condition can result in overestimating treatment effects due to a variety of threats to internal validity (e.g., regression to the mean, demand characteristics, maturation). The benchmark strategy was used to address these limitations. Our pre/post method of administering the measures was consistent with the other Group Triple P benchmark studies, so the concerns of regression to the mean and demand characteristics could at least be considered comparable to these randomized clinical trial benchmarks. Of course, a benchmark strategy also has inherent limitations (Minami et al., 2008, 2009) with making comparisons. For example, the benchmarks were constructed using different outcome measures and may be different with regard to sensitivity to change. Second, as previously noted, parents seemed to be in less distress and the severity of child behavioral issues was moderate compared to many Triple P studies, including the benchmark studies. Third, our sample represented little ethnic diversity, which further limits generalizability of our findings. Fourth, we also encountered difficulty with parents’ attending the final session to complete the postintervention measures (three did not attend the final session, and therefore, could not be included in the analysis). The last session does not provide new content but is to consolidate what has been learned and to provide a sense of closure to the group. Given this, there may have been less incentive for attending, combined with knowing they would have to complete the postintervention measures.

Future Directions Despite the challenges and limitations of the current study, we believe the current study can be helpful for informing future directions in telepsychology practice and research. Practice. We found that becoming part of a routine referral source (e.g., public school) yielded our greatest success with recruitment. Being incorporated into existing resources at the public schools proved to an effective way to connect families with our services and perhaps lessen the stigma of receiving such services, especially because we utilized the schools as a place for parents to receive the videoconferencing-delivered parenting program. In terms of service delivery, we found that we had to use a more directive style of intervening through videoconferencing as compared to our natural styles of providing interventions inperson. Managing the differences in communicating through technology as well as the group dynamics took some thought (parents were in a group at a location and the facilitator was as a different location). We found being more structured (e.g., starting with one parent and working our way around the group) when processing open-ended questions seemed to work best for getting group conversation started and for managing group processes. For example, subtle social cues (e.g., eye contact, nodding, body language) seemed to be less effective in the videoconferencing format when trying to get more talkative parents to allow room for other parents or the facilitator to talk or to encourage more input from less talkative parents. Research. Telepsychology outcome research needs to become more consistent with the standards of outcome research conducted in-person with youth and their families (Slone et al., 2012; Zirkelback & Reese, 2010). More rigorous well-designed studies are needed to better evaluate and understand how videoconferencing

and other technologies mediate behavioral health services (Elford et al., 2000; Nelson et al., 2003). These studies should occur at both the outcome and process levels. For example, our study indicated promise for using videoconferencing as a group-based intervention. However, there may have been elements we did not control for (e.g., child severity, parent distress, presenting issues) that may have influenced both treatment outcome and response, specifically, to the videoconferencing format. Such research needs to address not only how to maximize the use of technology for the delivery of evidence-based interventions for youth and families, but to also identify how to disseminate these services to best meet the needs of those experiencing behavioral health disparities in underserved areas.

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Received February 3, 2014 Revision received June 17, 2014 Accepted October 29, 2014 䡲

Using telepsychology to provide a group parenting program: A preliminary evaluation of effectiveness.

Telepsychology offers the potential to reach rural and underserved children and families with mental health concerns. The current study evaluated the ...
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