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Documenti di Professioni
Documenti di Cultura
3, 1999
Parental engagement in the treatment process is influenced by parents' beliefs about the
cause of their children's problems, perceptions about their ability to handle such problems,
and expectations about the ability of therapy to help them. This paper examines the role of
parental cognitions related to attributions and expectations in relation to engagement in
child mental health treatment. Reviewed studies indicate that parental attributions and
expectations influence three aspects of treatment: help seeking, engagement and retention,
and outcome. This paper integrates findings from developmental and clinical research, highlights gaps in the literature, presents the beginnings of a model regarding the parental
attributional process as it relates to engagement in treatment, recommends future research
directions, and discusses clinical implications.
KEY WORDS: Parenting; family intervention; engagement; children and adolescents; parental cognitions; parental attributions.
INTRODUCTION
and other caregivers is viewed as essential to therapeutic success and is recommended for both the planning and treatment phases of therapy (Henggeler,
1994). Successful treatment of child and adolescent
mental health problems, then, relies heavily on the
motivation of parents not only to bring their children
consistently to therapy, but also to participate fully
in the treatment process. However, many parents
are reluctant to initiate treatment as evidenced by a
15-35% no-show rate to first appointments following
an initial telephone request for services (Ewalt, Cohen, & Harmatz, 1972; Kourany, Garber, & Tornusciolo, 1990). Furthermore, parents who initiate treatment have been shown to drop out prematurely from
child and family treatment at a rate as high as 60%
(Armbruster & Fallon, 1994; Gould, Shaffer, &
Kaplan, 1985; Pekarik & Stephenson, 1988; Weisz,
Weiss, & Langmeyer, 1987).
Attrition from therapy is a significant challenge
that impacts the effectiveness and cost of services,
the strain on an overburdened service delivery
system, and the growing rate of untreated mental
health problems among youth (Armbruster & Kazdin, 1994; Prinz & Miller, 1996; Weisz et al., 1987).
Further, only a small percentage of families seek
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1096-4037/99/0900-0183$16.00/0 1999 Plenum Publishing Corporation
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help for childhood psychological problems (Costello
et al., 1988; Stouthamer-Loeber, Loeber, & Thomas,
1992). Therefore, when families reach out for mental
health treatment, it is imperative that clinicians and
service systems foster and secure the engagement
of these families in the treatment process.
Although factors related to attrition have been
widely studied in adult populations, fewer studies
have focused on attrition in child treatment (Armbruster & Kazdin, 1994; Pekarik & Stephenson,
1988). The available research does suggest, however,
that the factors related to attrition in adult populations (i.e., therapist-client match, treatment modality, problem severity, distance from the clinic, age
and gender of client) do not account for attrition in
child treatment (Armbruster & Kazdin, 1994; Armbruster & Fallon, 1994; Gaines & Steadman, 1981;
Kazdin & Mazurick, 1994; Kazdin, Mazurick, & Bass,
1993; McMahon, Forehand, Griest, & Wells, 1981;
Pekarik & Stephenson, 1988; Weisz et al., 1987). In
contrast, some family demographic charcteristics
such as family composition, socioeconomic status,
and minority status have yielded moderate, but inconsistent, associations (Armbruster & Fallon, 1994;
Frankel & Simmons, 1992; Gaines & Stedman, 1981;
Gould et al., 1985; Kazdin et al., 1993; Kazdin &
Mazurick, 1994; Kazdin, Stolar, & Marciano, 1995;
Pekarik & Stephenson, 1988; Viale-Val, Rosenthal,
Curtiss, & Marohn, 1984; Weisz et al., 1987). Studies
that support the influence of socioeconomic status
(SES) and minority status on engagement suggest
that the mechanism by which these variables operate
is related to different class-linked or culturally linked
beliefs and expectations for treatment. These, in turn,
may influence a parent's decision to pursue or terminate treatment (Armbruster & Fallon, 1994;
Gaines & Stedman, 1981; Gould et al., 1985; Kazdin
et al., 1993; Kazdin & Mazurick, 1994; Kazdin et al.,
1995; Pekarik & Stephenson, 1988).
Child, therapist, and treatment characteristics
do not seem to account for attrition, while cultural
and SES variables seem to have some association
with attrition. That cultural and SES variables may
infleunce parental beliefs and expecatations has led
to a focus on potential contributions parents might
make to attrition from child mental health treatment
(Armbruster & Kazdin, 1994). In fact, Pekarik and
Stephenson (1988) argued that the only reliable
finding in the child dropout literature pertains to
parental characteristics. A focus on parents seems
appropriate given that they are often the primary
decision-maker regarding when to pursue and termi-
nate treatment (Pekarik & Stephenson, 1988). Several studies investigating the role of parental characteristics on attrition in child treatment suggest that
parents who were uncooperative, negative, or had
no desire to make change in themselves were more
likely to have their children dropout of treatment
(Frankel & Simmons, 1992; Gould et al., 1985).
One of the most important factors influencing retention or continuation in child treatment appears
to be the parents' positive attitude toward, and
motivation for, participation in child treatment
(Ewalt et al., 1972; Pekarik & Stephenson, 1988;
Singh, Janes, & Schechtman, 1982; Viale-Val et
al., 1984).
Normative-developmental and clinical research
both underscore the importance of cognitions and
attributions on parental behavior, which in turn has
implications for understanding treatment engagement. For example, the attributions parents make
about their children influence parenting behaviors
such as disciplinary actions (Bugental & Shennum,
1984; Janssens, 1994) and communication style (Bugental & Shennum, 1984). Parental attributions have
also been implicated in the adverse reactions that
some parents show when faced with challenging
child problems. Parents who perceive their children
as deviant tend to develop a pessimistic attributional
style that is related to parental stress (Mouton &
Tuma, 1988), perceived parental incompetence (Baden & Howe, 1992; Day, Factor, & Szkiba-Day,
1994; Johnston, 1996; Mash & Johnston, 1983; Sobol,
Ashbourne, Earn, & Cunningham, 1989), and psychological maladjustment (Griest, Wells, & Forehand, 1979; Griest & Wells, 1983). Attributions that
mediate parental behavior might also play a role
in the treatment process. Parents who believe, for
example, that they are ineffective caregivers, that
nothing they try works, or that their child's behavior
is unchangeable, might not engage easily in treatment. We suggest that parental cognition may be
a critical variable in determining engagement in
child and adolescent treatment. In considering the
topic of parental cognitions, the purposes of this
review are as follows: (1) to establish the roles of
attributions in parental reactions to child misbehavior; (2) to examine the roles of parental perceptions,
attributions, and expectations in the child treatment
process; (3) to present a framework for understanding the parental attribution process as it relates to
treatment engagement; and (4) to identify potentially fruitful research directions and treatment applications.
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tional bias when observing their children. In other
words, prosocial behavior is perceived by most parents as stable and dispositional, and negative behavior is viewed as temporary and situational (Dix &
Grusec, 1985; Dix et al., 1986; Goodnow, Knight, &
Cashmore, 1986; Gretarsson & Gelfand, 1988). Such
a positive perception of child behavior facilitates the
maintenance of parental perceptions of worth and
competence and results in parental responses that are
potentially more consistent, confident, and effective
(Goodnow, 1985; Sameroff & Feil, 1985). However,
studies of mothers rearing children with behavioral
problems show that mothers respond in the opposite
directionthat is, they tend to attribute the cause
of their child's negative behavior to stable and dispositional qualities within the child (Compas, Adelman,
Freundl, Nelson, & Taylor, 1982). Such mothers have
also been shown to place less emphasis on the importance of parental practices in child outcomes
(Himelstein, Graham, & Weiner, 1991). It appears
that when child behavior is perceived as more negative, parents view the problem as solely a function
of child factors, and almost in a protective stance
minimize their own responsibility for child misconduct. Such attributions that a child's behavior is unchangeable and uncontrollable may serve to protect
parental self-esteem, but could result in lower participation by parents in the treatment process.
Parental Attributions in Clinical Samples
Consistent with the developmental literature on
problematic child behavior, clinical studies have also
shown that parents of children with psychological
disorders tend to attribute their children's negative
behavior to factors external to themselves and outside their control. The literature in this area, focusing
primarily on parents of children with disruptive behavior disorders, illustrates the influence of parental
attributions on perpetuating child problems, decreasing perceived parental competence, and increasing
parental distress.
Mouton and Tuma (1988), using the Parental
Locus of Control Scale (PLOC; Campis et al., 1986),
found that mothers referred to a mental health clinic
had higher external locus of control scores than nonreferred mothers. Similarly, studies of community
samples have shown that most parents reflect an internal locus of control (Janssens, 1994). Clinical research has shown that parents of childen with hyperactive (Sobol et al., 1989), oppositional (Johnston &
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Phase 2: Treatment Engagement
Out of those families who have sought help and
initiated the treatment process, between 28 and 60%
never completed treatment (Gould et al., 1985;
Prinz & Miller, 1996). Some families who remain in
treatment may exhibit other indicators of low engagement, such as sporadic attendance, missed and late
appointments, failure to complete homework assignments, and minimal participation in sessions (Prinz &
Miller, 1996). This section considers the possible role
of parental cognitions in relation to engagement during treatment.
Parental Perceptions of Barriers to Engagement
and Treatment
Kazdin, Holland, and Crowley (1997) observed
that a parental perception of barriers to treatment
predicted premature termination in a sample of 242
referred families seeking services for children with
disruptive behavior problems. Perceived barriers to
treatment contributed uniquely to dropout even
when other familial, parental, and child variables
were controlled (e.g., family composition, SES). Examples of perceived barriers included stressors and
obstacles that competed with treatment, perceived
treatment demands, perceived irrelevance of treatment, and problematic relationship with the therapist. When each of these domains was analyzed separately, perceived irrelevance of treatment best
discriminated dropouts from completers. Thus, parental perception of the importance and relevance
of treatment has been established as an important
variable related to engagement.
Parental Expectations and Treatment Engagement
The expectations that a parent holds regarding
treatment can play a role in a parent's willingness to
participate. For example, parents who believe treatment should focus solely on the identified child may
be reluctant to take part in assessment and treatment
(Furey & Basili, 1988). Burck (1975) found that 7 of
10 randomly selected families attending a child clinic
had expectations that were mismatched with the
treatment process, such as that the parent would not
need to participate or that treatment success would
be reached in one or two sessions. These dissonant
expectations related to missed appointments and dis-
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190
Parental Perceptions of Child Deviancy and
Treatment Outcome
Parental perceptions of child deviancy can affect
outcome, as demonstrated by Furey and Basili
(1988), who examined parental satisfaction with a
program designed to help parents of noncompliant
children. Furey and Basili (1988) found that while
parents who were satisfied with the outcome of training viewed their children's behavior as significantly
improved after treatment, the parents who were dissatisfied with treatment outcome continued to view
their child's behavior as problematic despite objective reports of child improvement and parental use of
effective parenting strategies. Although the learned
parenting behaviors had effectively reduced child behavior problems, parental cognitions were not sufficiently modified in the dissatisfied parents. Parental
satisfaction was unrelated to the severity of child
deviant behavior, but was related to pretreatment
levels of parental depression. Depression was highest
in those mothers who dropped out, second highest
in the dissatisfied mothers that completed treatment,
and lowest in mothers who were satisfied with treatment outcome. Therefore, this study confirms that
depressed mothers may be at risk for inaccurate perceptions of treatment gains and for treatment drop
out. Furey and Basili (1988) recommend that treatment programs continue to follow parents for longer
posttreatment intervals and suggest the use of
booster sessions to help sustain positive changes in
parenting skills and parental perceptions.
Dumas (1984) did not find support for a relationship between parental perception of child deviance
at intake and subsequent treatment outcome. Rather,
successful treatment outcome depended primarily on
the level of family functioning. That is, when maternal psychopathology, marital conflict, and maternal
social isolation were low, the child had a better
chance of benefiting from treatment. In examining
the role of parental perceptions of child problems on
treatment outcome, Dumas (1986) found that parental perceptions of child problems were influenced
both by child level of functioning and by parental
level of distress. However, similar to Dumas (1984),
yet contrary to other studies (Furey & Basili, 1988),
the best fit model did not demonstrate a causal relationship between parental perceptions of child behavior and treatment outcome. Further, the model
suggested that treatment involvement and outcome
may be solely determined by socioeconomic variables. This finding is in contrast to other parent train-
191
a little different because there are two players, parent
and child, rather than just one. Weiner's model has
been applied specifically to personal "failures," such
as alcoholism (McHugh, Beckman, & Frieze, 1979),
crime (Carroll, 1978), and domestic violence (Frieze,
1979), but the model is relevant to parenting if we
view parenting as an achievement process. Similarly,
child outcomes might also be judged as "successes"
and "failures." Furthermore, motivation is an important factor in treatment engagement (Miller, 1985),
and so an attributional model such as Weiner's that
focuses on motivation seems appropriate to use in
child and adolescent treatment process research.
As shown in Fig. 1, the proposed model of the
parental attribution process with respect to engagement in child mental health treatment is adapted
from Weiner's model to allow for both child-referent
and self-referent attributions. The model suggests
that parents who are ineffective at modifying their
child's behavior will spontaneously make both childreferent and parent-referent attributions that influence their affective response, expectancy for future
success, and subsequent behavior.
The model is consistent with both the developmental and clinical literatures reviewed in this paper.
For example, the parental self-referent pathway demonstrates that experiences with failure often lead parents to make attributions that the locus for such
events is caused by reasons outside themselves, that
they have no control over correcting the situation,
and that failure is certain in the future. Such attributions have also been supported in the clinical literature showing that parents of children with behavioral
disorders, who report increased difficulties in controlling their child, report an external locus of control
(Baden & Howe, 1992; Johnston & Patenaude, 1994;
Roberts et al., 1992; Sobol et al., 1989). The model
then suggests that parents using such pessimistic attributions would have feelings of apathy, helplessness,
and hopelessness. Such affect is consistent with findings show that parents of deviant children report decreased parental competence (Baden & Howe, 1992;
Day et al., 1994; Johnston, 1996; Mash & Johnston,
1983; Sobol et al., 1989), and increased stress (Mouton & Tuma, 1988; Mash & Johnston, 1983; Patterson,
1982), and depression (Griest et al., 1979; Griest &
Wells, 1983; Patterson, 1980). Barlow (1988) has emphasized that uncontrollability and unpredictability
are central to theories of anxiety, thus again directing
a focus at the role of attributions in mediating parental adjustment.
The implications of such cognitions and emo-
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193
were longitudinal in structure. Longitudinal studies
with community populations could help establish a
greater understanding of the normative patterns of
parental attributions. Similarly, longitudinal studies
with clinical populations could contribute to an understanding of how parental attributions change over
time, taking into account therapeutic intervention,
and might include long-term treatment follow-up to
determine the endurance of modifications to parental
attributions and the relationship of attributions to relapse.
Future research should focus on the development of models and measures that better capture the
complexity of relationships among child behavior,
parental cognitions, parenting behavior, and treatment engagement. Researchers may need to move
beyond linear models to more transactional ones that
reflect the interplay between parent and child, factoring in cognitions, affect, and behavior (Bugental
et al., 1998; Slep & O'Leary, 1998). The complexity
of parent-child relationships and the influence of
spontaneous attributions on behavior, provide a case
for conceptualizations of a more systems or relational
perspective, with a shift in methodology to analyzing
the transactional nature of parent-child relationships
in more naturalistic settings (Bugental et al., 1998;
McHale & Fivaz-Depeursinge, 1999; Slep &
O'Leary, 1998).
Parental cognitions are related to treatment engagement, and many parents at risk for early drop
out can be identified at their first contact with the
treatment setting. Previous research has begun to
establish that parental attributions and expectations
can indeed be modified (Alexander et al., 1989; Roberts et al., 1992; Slep & O'Leary, 1998), and that
explicitly preparing families for treatment can lead to
improved expectations and engagement (Bonner &
Everett, 1986; Day & Reiznikoff, 1980). Future research should continue to identify strategies to be
used to modify parental cognitions both prior to and
during treatment.
Research Directions
This area of work can be improved methodologically through (1) consistent use of standardized measures of attributions, (2) assessment via multiple informants (including assessment of fathers), (3)
attention to measurement bias (blind conditions),
and (4) enhancement of external validity by studying
demographically diverse samples that are found in
clinical settings.
Of the studies reviewed in this article, few if any
Clinical Recommendations
Several previous articles have described successful intervention strategies designed to improve initial
follow-through and sustained treatment engagement
with the use of letter writing (Lown & Britton, 1991),
intensive telephone contact (McKay, McCadam, &
Gonzales, 1996), parent orientation meetings (Wenning & King, 1995), modifying treatment to address
194
by adapting strategies used in motivational interviewing (Miller & Rollnick, 1991; Walitzer, Dermen, & Connors, 1999) Solution-Focused Therapy
(Selekman, 1997), engagement-focused dialogue
(Liddle, 1995), or interventions based on the Stages
of Change theory that aim to foster the initiation and
maintenance of healthy behaviors (Fairhurst, 1996;
Prochaska, DiClemente, & Norcross, 1992), or from
strategies used in recruiting and retaining families in
prevention research (Spoth, Goldberg, & Redmond,
1999). When teaching behavioral management skills
to parents, the modification of parental behaviors
may be facilitated by focusing on emotional arousal
and attributions (Smith & O'Leary, 1995). Bloomquist (1996) also more directly targets parental cognitions by preparing parents for change through a discussion of both unhelpful and helpful parental
cognitions that may affect the treatment process.
Such a direct discussion and modification of parental
cognitions will surely help facilitate the parent's continued involvement in the child and adolescent treatment process.
Given that depressed parents may be at higher
risk for treatment dropout and for underestimate of
treatment gains (Furey & Basili, 1988), interventions
that pay particular attention to parental cognitions
in this population may be especially important. Assessing parental attributions and expectations
throughout the treatment process could facilitate
identification of parents at risk for attrition. Interventions with depressed parents can be informed by the
cognitive therapy literature (Beck, 1995; Burns,
1989). Perhaps the modification of parental cognitions throughout treatment might be facilitated by
combining Bloomquist's (1996) list of unhelpful parental cognitions with interventions designed to identify and modify "faulty" cognitions or negative automatic thoughts. Depressed parents can be educated
about the potential role of depression in perpetuating
child problems and increasing parental perceived
stress, and can be encouraged to seek treatment to
directly address their depression. Finally, Furey and
Basili (1988) recommend that treatment programs
continue to follow parents for longer posttreatment
intervals, and suggest the use of booster sessions to
help sustain positive changes in parenting skills and
parental cognitions.
Conclusion
This paper has examined the role of parental
attributions and expectations on the child and adoles-
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