Department of Clinical Psychology, Central Manchester and Manchester Childrens University Hospitals Trust
Academic Division of Clinical Psychology, School of Psychiatry and Behavioural Science, University of Manchester
Carol Kendrick Unit, Withington Hospital, Manchester
Academic Division of Clinical Psychology, School of Psychiatry and Behavioural Science, University of Manchester
Department of Child Psychiatry, School of Psychiatry and Behavioural Science, University of Manchester, Manchester, UK
Correspondence: Chrissie Verduyn, Department of Clinical Psychology, RMCH, Hospital Road, Pendlebury, Manchester M27 4HA, UK. E-mail: chrissie.verduyn{at}cmmc.nhs.uk
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ABSTRACT |
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Aims To evaluate the effect of group cognitivebehavioural therapy (CBT) on child behaviour problems and maternal depression in a group of women with young children.
Method An assessor-masked, randomised placebo-controlled trial compared three treatments: CBT for depression and parenting skills enhancement; a mothers support group; and no intervention. An epidemiological (general population) sample was recruited.
Results Analysis showed no significant difference between the groups. Within-group comparison suggested that at the end of treatment and at 6-month and 12-month follow-up, child problems and maternal depression had improved significantly in the CBT group.
Conclusions There was no statistically significant difference between groups. Both contact interventions seemed to provide some benefits to mothers with depression, with a possibly improved outcome resulting from CBT for children with behavioural problems. The results must be treated with caution.
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INTRODUCTION |
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Few studies have focused on both mothers and childrens problems (Puckering et al, 1994; Gelfand et al, 1996; Cooper & Murray, 1997; Sanders & McFarland, 2000); none used group interventions. The study reported here evaluated a cognitivebehavioural programme addressing maternal and child psychopathology, considering evidence of good outcome for cognitive therapy for depression (Jacobson et al, 1996) and for parenting skills groups (Webster-Stratton, 1991).
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METHOD |
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Overview
The study was an assessor-masked, randomised controlled trial using an
epidemiological sample that is, the sample was derived from the total
population of mothers and children within a geographical area in which the
children fell within a targeted age range. The study was not based upon a
clinically referred sample. A community was screened to identify
motherchild dyads where the mother and the child scored highly on
standardised measures. Mothers identified as being clinically depressed from
interview were randomly allocated to CBT, placebo contact (mother and toddler
groups) or no treatment groups.
The project was conducted in the Wythenshawe, Withington and Burnage areas of south Manchester, UK, areas with high levels of socio-economic deprivation. The population is predominantly White and is composed of a high proportion of mothers with young children. Two large, centrally located modern health centres with child-friendly facilities were used. Ethical approval was obtained from South Manchester Ethics Committee. Consent for participation was obtained before screening and before trial entry.
Screening
All mothers with children aged between 2 years 6 months and 4 years
(pre-school age) were identified using the Community Child Health Register
and, subject to consent, were asked to complete the Beck Depression Inventory
(BDI; Beck et al,
1961) and, by postal questionnaire, the Preschool Behaviour
Checklist (PBCL; Richman et al,
1982) or, by interview, the Behaviour Screening Questionnaire
(BSQ; Richman & Graham,
1971). Mothers were contacted first by post; those who did not
respond were visited at home. Women were excluded if their child was not
living with them, if their first language was not English, if they were
suffering from a major psychiatric disorder other than depression, or if their
child had a major developmental disability. Women who fulfilled the screening
criteria both for depression (BDI score 15) and child problems (BSQ score
8) were entered into the study, using the multiple criterion screen
methodology of Nicol et al
(1993).
Sample size
In calculating the sample size, a moderately large effect size (0.6) was
assumed on the primary outcome of child behaviour problems with the Child
Behavior Checklist (CBCL; Achenbach &
Edelbrock, 1983). To have an 80% chance of detecting that size
difference between the CBT and the control groups, using a two-tailed test, a
sample of 45 per condition was required (significance level of 0.5).
Procedure
Randomisation to the three groups was concealed, and was performed by an
independent statistician using sealed envelopes and stratified by gender of
child. No blocking was used. Slowness in initial recruitment meant that an
inadequate number of participants were available for three-way allocation at
first randomisation. Because it was essential for the groups to start on time,
the first randomisation was to the groups only CBT or mother and
toddler group resulting in a smaller number being allocated to the
no treatment group (Fig.
1).
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Assessment points
Assessments were made by research assistants masked to group allocation at
the following time points: pre-intervention, immediately post-intervention,
6-month follow-up, and 12-month follow-up. Masking was maintained by
separating the assessors administratively from the therapist and requesting
participants not to discuss any details of treatment with them.
Measures
The primary outcome measures of the study were assessments of the behaviour
problems of the children. Assessments of maternal depression were secondary
outcomes. In choosing the primary measures of outcome, two issues were taken
into account: first, the possibility that the mothers mental state
would influence her rating of the childs behaviour; and second, the
requirement that, as far as was possible, outcome measures were made masked to
treatment status. These were resolved by obtaining child outcome measures from
a number of sources (including direct observations), and by employing an
independent assessor (the assistant clinical psychologist) kept masked to
treatment status by exclusion from access to records and discussion regarding
intervention.
Assessment of children
The mothers were asked to complete the CBCL a well-validated
checklist for parents reports of childrens competencies and
problems, yielding scores for internalising and externalising problems and a
total score. This measure is in widespread research use, and norms are
available for clinic-referred and non-referred populations
(Achenbach & Edelbrock,
1983). Mothers also completed the Eyberg Child Behaviour Inventory
(ECBI; Robinson et al,
1980), a 36-item inventory of child conduct problem behaviours,
standardised on children 27 years old and with acceptable validity and
reliability. The ECBI is used frequently in evaluation of the effectiveness of
parent training groups. In addition, a brief developmental assessment of the
child investigated areas of vocabulary, verbal comprehension, digit recall and
basic number skills, yielding scores for individual scales as well as overall
IQ (British Ability Scales short form;
Elliott, 1987), and a
structured interview was used to obtain demographic details, family and
psychosocial information, and details of the childs development.
For children attending nursery or school, teachers were asked to complete the teacher equivalent of the parent measures, the Preschool Behaviour Checklist (McGuire & Richman, 1988) and CBCL. Small numbers attending nursery and a high attrition rate precluded further analysis of these measures.
Assessment of mothers
A standardised psychiatric interview, the Structured Clinical Interview for
DSMIV Non-Patient edition (SCIDNP;
Spitzer et al, 1994),
was used to assess the adult participants mental state, with the
Hamilton Rating Scale for Depression (HRSD;
Hamilton, 1967) for rating the
severity of depressive symptoms. The participants also completed the BDI, an
18-item standardised self-report measure of clinical depression including
suicidal risk which is in widespread research and clinical use in the UK
(severity score range 063), and a self-report checklist of history and
treatment of depression. The measures used at screening were repeated at the
completion of treatment and at 6-month and 12-month follow-up.
Intervention
Women assessed as having a DSMIV diagnosis of depression
(American Psychiatric Association,
1994) and who accepted an offer of intervention were randomly
allocated to one of the three groups. During the course of the intervention,
group therapists used a strategy of assertive outreach to optimise attendance
and minimise the numbers leaving the study. Transport was provided to all
groups if required by participants. Follow-up contacts and telephone reminders
were made prior to treatment sessions and after any missed sessions. The
social aspects of the groups were emphasised to enhance adherence and
participation.
Group 1 cognitivebehavioural therapy
Group 1 (47 motherchild pairs) was assigned to receive CBT in the
form of 16 group sessions. These sessions for 68 motherchild
pairs were held weekly and were run by two clinical psychologists with support
from two nursery nurses qualified in child care. Four experienced clinical
psychologists qualified for a minimum of 5 years were involved in
treatment.
The mothers group and the childrens play sessions were separate and ran in parallel for 90 min. The mothers group applied:
The focus of cognitive therapy was on aspects of cognition and problem-solving that relate most directly to parenting, where possible. This included how depression could cause problems in parenting: for instance, effects of irritability on childrens behaviour, and low mood leading to lack of confidence as a parent. There was a shift in focus as sessions progressed, with less time devoted to coping with depression and more to developing positive parenting skills (further information available from the author upon request). The parenting sessions included education about normal developmental problems and childrens understanding, enhancing the motherchild relationship through child-centred play, dealing with negative behaviour (ignoring and time out), reinforcing positive behaviours, praise and attention. Mothers identified problems that they wished to work on and developed action plans, keeping a diary between sessions. Cognitive therapy sessions included education about depression from a cognitive perspective, development of a problem formulation for each woman, activity scheduling, problem-solving and cognitive restructuring.
Quality and fidelity of therapy was ensured by weekly supervision from one of three clinical psychologists experienced in CBT supervision.
Group 2 mother and toddler groups
Group 2 (44 motherchild pairs) attended mother and toddler groups
run by a health visitor together with an experienced clinical psychologist.
These sessions were designed as an attention placebo and ran at the same
frequency as the active treatment groups, using the same staffing ratio. They
had the same facilities available and included informal, non-directed group
discussion of problems raised by the mothers and separate play opportunities
for the children. The format was similar to many community-based support
groups for mothers with young children, but no advice was given on parenting
or other problems.
Group 3 no treatment
Group 3 (28 motherchild pairs) received no intervention, and these
mothers and children were assessed by home visit only. Routine services were
accessible as usual to these participants, and service uptake was
recorded.
Analysis
Data were analysed using the Statistical Package for the Social Sciences
version 10.1 for Windows. Analyses were conducted on an intention-to-treat
basis that is, all participants who had been randomised to a treatment
group were included in the analyses irrespective of the actual treatment
received. Parametric statistics were used throughout since all variables
conformed to the assumptions underlying such analyses, including normality of
distributions. Between-group differences on continuous measures for children
and mothers were analysed through multivariate analyses of variance with
repeated measures on the time factor. For assessing the outcomes over multiple
time points (post-treatment, 6-month and 12-month follow-up) repeated-measures
analysis of covariance (ANCOVA) was employed, again using pre-treatment scores
as the covariate. To compare the effects within the treatment groups on the
outcome measures before and after treatment, a series of paired-sample
t-tests were used.
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RESULTS |
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Between-group analysis
Repeated-measures ANCOVA with pre-treatment scores as the covariate
revealed no significant difference between the three groups at post-treatment
assessment and follow-up on either the primary outcome measures of child
problem or the secondary outcome measures of maternal depression (Tables
3 and
4). In an attempt to ascertain
whether the two contact groups (groups 1 and 2) differed from group 3 (no
treatment), these two groups were combined and compared with group 3. Again,
repeated-measures ANCOVAs revealed no significant difference between the two
contact groups combined and group 3 on any of the primary or secondary outcome
measures.
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Within-group analysis
To determine whether there were any changes over treatment and at follow-up
a series of post hoc within-group analyses were performed separately
for each of the three treatment groups.
Primary outcome: child behaviour
There were significant differences in the primary outcome of child
behaviour pre-test to post-test (t=3.54, d.f.=31, P <
0.001), pre-test to 6-month follow-up (t=2.95, d.f.=27,
P=0.006) and to 12-month follow-up (t=2.98, d.f.=30,
P=0.006) on CBCL total scores for the CBT group but not for the two
control groups. The CBT group also displayed an improvement in ECBI problem
scores from pre-test to 6-month follow-up (t=2.66, d.f.=31,
P=0.01) and to 12-month follow-up (t=2.88, d.f.=33,
P=0.007), whereas the two control groups did not.
Secondary outcome: maternal depression
Paired-sample t-tests were used to assess any differences in
pre-intervention and post-intervention scores. At the end of the intervention,
womens depression (as measured by the BDI) showed significant
improvement in both group 1 (t=3.90, d.f.=34, P<0.001)
and group 2 (t=2.30, d.f.=31, P<0.03). In contrast, there
was no difference in the no treatment group (t=1.58,
d.f.=20, P=0.13). The improvement experienced by the two contact
groups was maintained at the 12-month follow-up (group 1: t=4.41,
d.f.=39, P<0.001; group 2: t=4.36, d.f.=30,
P<0.001). The HRSD scores showed a similar pattern: group 1 had
improved significantly after the intervention (t=5.18, d.f.=35,
P<0.001), as had group 2 (t=4.23, d.f.=31,
P<0.001). In contrast, the no treatment group did not improve on
this measure. The improvements in groups 1 and 2 were maintained at 12-month
follow-up (group 1: t=4.01, d.f.=39, P<0.001; group 2:
t=3.67, d.f.=30, P=0.001).
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DISCUSSION |
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There were important differences between this study and previous ones. The programme was targeted at severe and persistent maternal depression in women with children of pre-school age, in contrast to earlier studies which targeted either post-natal depression or less severe maternal depression. Additionally, the study overcame some methodological deficiencies of previous work by employing a design that controlled for the non-specific aspects of therapy (including social support), ensured masked and independent assessment of treatment outcomes, and had a sample drawn from an epidemiological cohort.
Outcome
The study did not demonstrate statistically significant differences between
the three treatment groups on either the primary outcome of child behaviour or
the secondary outcome of maternal depression. This was disappointing because
there was a strong clinical impression and anecdotal feedback from the
participants that the CBT groups were beneficial and well accepted. Thus, the
principal analysis did not reveal significant group differences between the
treatment groups.
Post hoc within-group analyses were promising. These indicated that the CBT group alone showed statistically significant improvement at the post-treatment assessment on the child behaviour measures. In addition, both the groups that involved contact (groups 1 and 2) showed significant improvements in maternal depression scores, which were maintained over the 12-month follow-up period, in contrast to women in the untreated control group, who did not improve. There are no clear group differences, although within-group analyses suggest that there are benefits for both child and mother from participation in CBT groups. The non-specific effects of mother and toddler groups may also reduce maternal depression although they have less effect on the problems of the child. These results must be treated with caution, and this study treated as a preliminary test of feasibility from which to generate further research, rather than as a definitive answer.
Recruitment and study design
The problems with slow recruitment at the beginning of the study meant that
the non-intervention control group was restricted to 28 motherchild
pairs, which reduced the power of the study to show statistically significant
differences. A potential strength of the study was its use of an
epidemiological cohort, using a community sample to avoid the selection and
referral biases that dogged early studies of the impact of maternal depression
(Downey & Coyne, 1990).
However, this methodology presented difficulties in conducting the study.
Women who had not sought help were approached to attend groups; this was
likely to have affected successful recruitment and might have resulted in
inclusion of a smaller sample than would have been possible with recruitment
from clinic attenders. Recruitment into therapy groups, which is
conventionally expected to be about 50% with clinically referred populations,
was 37% in this study. For testing study hypotheses this figure is problematic
although clinically not unusual. Once recruited into the study, 39% of women
completed a substantial number of sessions. It proved possible to design an
attention placebo group sufficiently attractive to maintain similar attendance
rates. Unfortunately, the level of attrition in the study was high, which
means that the results need to be interpreted with caution.
The nature of the sample presented significant problems in assessing participants, as there were high levels of mobility and life crises. Encouraging attendance at follow-up assessments, particularly by participants who had not been offered intervention, proved difficult.
Clinical issues
Previous research has not used comparable populations or interventions, or
targeted the problems of both mothers and children. The study suggests that
the highly structured format of CBT was helpful, but completing the course in
16 weeks to adhere to the treatment manual was challenging to therapists. A
key problem was persuading women to attend the groups consistently and
regularly to protocol. Considerable effort was expended in attempting to
achieve this, including arranging transport if required. Once attendance was
established, retention was generally good but was sometimes interrupted by
life events, most often episodes of difficulties with partners. For some
women, a longer and more flexible intervention might have been more useful and
in tune with their lifestyle.
In clinical practice, where referral increases the likelihood of successful engagement into groups, the treatment programme as it stands might be more effective than under research constraints. It appeared that the therapeutic approach was helpful to some mothers and their children. The group nature of the intervention was effective in promoting social support, to the extent that several of the groups continued to meet.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication May 22, 2002. Revision received May 28, 2003. Accepted for publication June 12, 2003.
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