Treatment Effectiveness of PMTO for Children's Behavior Problems in Iceland: Child Outcomes in a Nationwide Randomized Controlled Trial

• Date: 01 September 2015
• Published date: 01 September 2015
• Author: Margrét Sigmarsdóttir,Edda Vikar Guðmundsdóttir,David S. DeGarmo,Örnólfur Thorlacius
• DOI: http://doi.org/10.1111/famp.12109

Treatment Effectiveness of PMTO for Children’s

Behavior Problems in Iceland: Child Outcomes in a

Nationwide Randomized Controlled Trial

MARGRE

´T SIGMARSDO

´TTIR*

,†,‡

O

¨RNO

´LFUR THORLACIUS

§

EDDA VIKAR GUðMUNDSDO

´TTIR

†,‡

DAVID S. DEGARMO

¶,**

Well-documented treatment methods must be tested following their implementation in

community service agencies and across different cultures to ensure continuing effective-

ness. This study was a randomized controlled trial (RCT) of Parent Management Training

—the Oregon model (PMTO), conducted within a nationwide implementation in Iceland.

Families of 102 clinically referred children with behavior problems were recruited from

five municipalities throughout Iceland. Child age ranged from 5 to 12; 73% were boys.

Families were randomly assigned to either PMTO or services usually offered in the commu-

nities (SAU). Child adjustment was measured with a latent construct based on parent,

child, and teacher reports of externalizing and internalizing problems and social skills.

Prepost intent-to-treat analyses showed that PMTO treatment led to greater reductions in

child adjustment problems relative to the comparison group, obtaining a modest to med-

ium effect size based on the construct score. Only one indicator (parent -rated Social Skills)

showed significant change independently and information on amount and kind of treat-

ment in the SAU was limited. Overall, findings indicate that PMTO is an effective method

to treat children’s behavior problems in a Northern European culture and suppl y evidence

for the method’s successful implementation in community settings in Iceland. This is one of

few nationwide implementation studies of PMTO outside the United States and the first

RCT in Iceland to test a treatment model for children’s behavior problems.

Keywords: Behavior Problems; PMTO; Treatment Effectiveness; Randomized Control

Trial; Child Outcome

Fam Proc 54:498–517, 2014

Behavior problems of children in Iceland have become the principal source for referrals

to specialist services in municipalities throughout the country, indicating an emer-

gent need for effective treatments to address children’s internalizing and externalizing

problems (e.g., Sk

olaskrifstofa Suðurlands, 2006–2007). Children with behavior problems

*Department of Psychology, University of Copenhagen, Copenhagen, Denmark.

†

The School Administration Office, Hafnarfj€

ordur, Iceland.

‡

The Government Agency for Child Protection, Reykjav

ık, Iceland.

§

Department of Psychology, University of Iceland, Reykjav

ık, Iceland.

¶

Oregon Social Learning Center, Eugene, OR.

**Department of Educational Methodology, Policy, and Leadership, University of Oregon, Eugene, OR.

Correspondence concerning this article should be addressed to Margr

et Sigmarsd

ottir, Government

Agency for Child Protection, 105 Reykjav

ık, Iceland. E-mail: margret@bvs.is.

The project was accepted by The National Bioethics Committee in Iceland in 2007, VSN: 07-040-S1.

498

Family Process, Vol. 54, No. 3, 2015 ©2014 Family Process Institute

doi: 10.1111/famp.12109

are at great risk of developing other disorders later in life, including depression and

anxiety, learning difficulties, alcohol and drug abuse, as well as limited social skills

(Karnik & Steiner, 2005; Kazdin, 1997, 2005; McMahon, Wells, & Kotler, 2006; Nock, Kaz-

din, Hirip, & Kessler, 2007). Parent management training (PMT) approaches represent

one of the more widely tested and evidence-based efforts to address children’s internaliz-

ing and externalizing behavior problems (Brestan & Eyberg, 1998; Kaminsky, Valle,

Filene, & Boyle, 2008; Kazdin, 2005; Silverman & Hinshaw, 2008). A newly published

review of the efficacy of family systems therapy for childhood and adolescent externalizing

disorders (e.g., treatments like Multisystemic Therapy and Functional Family Therapy)

also shows positive results for externalizing behavior from the majority (Von Sydow, Retz-

laff, Beher, Haun, & Schweitzer, 2013). This study reports findings from the nationwide

implementation of the Oregon model of Parent Management Training (PMTO) in Iceland

where the criterion outcome was operationalized as a latent construct of child adjustment

problems measured by validated instruments of problem behaviors, social skills, and

depressive symptoms.

PMTO is an evidence-based treatment (EBT) developed by Gerald Patterson and his

colleagues at the Oregon Social Learning Center (e.g., Forgatch & Patterson, 2010; Patter-

son, Reid, & Eddy, 2002). PMTO meets EBT standards, including manual-based specifica-

tion of program details, careful descriptions of client samples, demonstrated efficacy in

several randomized between-group-design experiments, and replications by independent

investigators (Chambless & Hollon, 1998). The main reason for implementing PMTO in

Iceland was a growing need to address community-level increases in children’s behavio r

problems. This study reports an evaluation of child outcomes from a randomized control

trial (RCT) of PMTO following its implementation in Iceland. Because this trial was

funded with scarce resources provided by local communities and supplemented with some

small national grants, the study must be viewed as an early step in the evaluation of a

wide-scale implementation.

To some extent, PMTO is a prototype of other parent training EBTs (Brestan & Eyberg,

1998); these include: Positive Parenting Program (Sanders, 1999), Incredible Years (Web-

ster-Stratton & Hammond, 1997), the Family Check Up (Dishion et al., 2008), and Parent

Child Interaction Therapy (Eyberg & Robinson, 1982). PMTO was the method of choice in

Iceland as it is theoretically informed and has been demonstrated effective across a range

of developmental periods and contexts, including family, community, agency, and schoo l

settings (Forgatch & Patterson, 2010; Patterson et al., 2002). PMTO also employs a vali-

dated measure of competent adherence to the method (Fidelity of Implementation Rating

System [FIMP]; Knutson, Forgatch, Rains, & Sigmarsd

ottir, 2009). Variance in the FIMP

measure has been shown to predict treatment outcomes in both an efficacy trial and in a

nationwide implementation of the program (Forgatch & DeGarmo, 2011; Forgatch, Patter-

son, & DeGarmo, 2005; Hukkelberg & Ogden, 2013). Use of a valid fidelity measure

enables program administrators to evaluate the extent to which the model is provided

with fidelity during community practice, which is a critical factor for successful implemen-

tation (Fixsen, Naoom, Blase, Freidman, & Wallace, 2005).

Theoretical Model of PMTO

PMTO is based on the Social Interaction Learning model (SIL), which postulates that

children learn behavior through their interactions with others. Parents’ child-rearing

methods exert a primary influence on children’s adjustment and have a direct effect on

how children adapt to their environments. Parenting methods that are characterized by

coercion increase the likelihood that the child will develop behavior problems, and coercive

patterns of behavior between parent and child can generalize from home to school as well

Fam. Proc., Vol. 54, September, 2015

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