Parenting Skills Training: An Effective Intervention for Internalizing Symptoms in Younger Children?

Journal of Child and Adolescent Psychiatric Nursing, Apr-Jun 2005 by Cartwright-Hatton, Sam, McNally, Deborah, White, Caroline, Verduyn, Chrissie

A number of interventions are effective in treating older children with internalizing symptoms. However, little is known about the efficacy of psychological interventions in treating younger children. This study examined the impact on internalizing symptoms of a parenting skills training program. Forty-three parents took part in a parenting skills training program. Externalizing and internalizing behaviors were measured before and after treatment and after a 6-month period. Externalizing symptoms fell after treatment. Interestingly, internalizing scores fell to an approximately equivalent degree. An intervention targeted towards parenting may be efficacious in the treatment of children's internalizing symptoms. Anxiety, childhood, depression, parenting

Introduction

In the past decade, there has been an increasing interest in children's internalizing symptoms. Until recently, children were not thought to experience "true" depression, and if they experienced anxiety, they were expected to grow out of it. We now know that this is not always the case.

Recent research has reported 1-year prevalence rates of depressive disorder in adolescents that are as high as 10% (Angold, Costello, & Worthman, 1998). We also know that the symptoms of depression can manifest in very young children (Rutter, 1991), and there is evidence that depressive disorders in the young may be increasing (Fombonne, 1995). Moreover, it is clear that children do not simply grow out of depression. Harrington, Fudge, Rutter, Pickles, & Hill (1990) followed a group of depressed children and a matched sample of control children over an 18-year period. The sample who were depressed as children were more likely to be depressed as adults than those in the control group.

The picture is similar for anxiety. Anxiety disorders are a very common form of psychological disturbance in childhood, and it is estimated that up to 17% of young people will meet criteria for an anxiety disorder (Costello & Angold, 1995). Again, these symptoms can manifest in very young children. Moreover, both anxiety and depression can lead to other serious problems. Children with depressive disorders are at an elevated risk of suicide and self-harm (Lewinsohn, Rohde, & seeley, 1994). Children with anxiety disorders often go on to develop depression (Kovacs, Gatsonis, Paulauskas, & Richards, 1989), and, if they attempt self-medication, may be at an increased risk of substance misuse (Kushner, Sher, & Beitman, 1990).

With these concerns in mind, new treatments for childhood anxiety and depression have developed. In particular, cognitive behavior therapy (CBT) has been shown to be a promising intervention for both depression (Harrington, Whittaker, & Shoebridge, 1998), and anxiety (e.g., Barrett, 1998; Flannery-Schroeder & Kendall, 2000). The efficacy of CBT, however, is known only for older children. It is not thought to be as effective for children under the age of about 8 years.

In a search of the literature to find interventions for internalizing disorders of younger children, the authors found very little empirical evidence for any treatment. Barrett (2000) also highlights this lacuna in her review of the anxiety literature.

In fact, there is very little in the way of empirically validated treatments for any of the psychological disorders of early childhood. There is, however, one exception: in the past 20 years, a large body of literature has developed chronicling the success of behavioral parent skills training (BPST) for families of children with externalizing disorders (Scott, Spender, Doolan, Jacobs, & Aspland, 2001; Webster-Stratton, 1990). This approach teaches parents behavioral skills, which they then use to manage their children's difficult behaviors. Broadly, the aim of this approach is to help parents to play more effectively with their children, praise and reward desirable behaviors more effectively, set effective and reasonable limits, and handle misbehavior using ignoring and mild negative consequences. Parents are taught to apply these procedures consistently and to interact more calmly with their children. These programs are also thought to improve family relationships and increase parent-child warmth.

It is now widely accepted that BPST is an effective intervention for externalizing symptoms in young children. However, over the course of running many sessions of parent-training programs themselves, the authors often received informal reports from parents, suggesting that their children were improving not just in terms of their behavior, but also in terms of their confidence and self-esteem. Upon reflection, this comes as no surprise, as a number of researchers have reported a relationship between children's internalizing disorders and parenting style (e.g., Wood, McLeod, Sigman, Hwang, & Chu, 2003). In a review of the literature, Krohne (1990) showed that lower use of praise, higher use of blame and punishment, and inconsistent use of child management techniques have all been associated with internalizing disorders. It is these aspects of parenting that are targeted by behavioral parent skills training programs. Similarly, there is evidence that early attachment difficulties may be associated with later anxiety disorders (Bowlby, 1973; Cassidy, 1995). Parenting skills programs are thought to enhance infant-parent attachment.