"Recruiting the right people"

by Gonnie Albrecht (Psychologist, PMTO Program Leader, Netherlands). 

Becoming a certified PMTO therapist is a long, intensive trajectory for therapists. The efforts and costs spent on it should be well used. In an attempt to maximize the number of successful trajectories and minimize the number of drop-outs during the process of education and certification, a recruitment and selection procedure for future PMTO therapists was developed. Both research findings and clinical expertise provided input for building and tailoring these procedures. In a brief overview both the development and the procedures themselves are shared.

"Engaging and training supervisors"

by Anett Apeland (Psychologist, Assistant Clinical Director, The Norwegian Center for Child Development) and Mona Duckert (Psychologist, Regional PMTO Coordinator, The Norwegian Center for Child Development). 

The PMTO therapists in Norway have been required to participate in maintenance supervision groups 8 days annually to keep up their certification, some have participated for nearly 10 years. All supervisors are certified PMTO therapists, and have received follow-up from the regional coordinators and one annually 2 days workshop at The Norwegian Center for Child Development. As the need to reorganize the supervision system emerged, a formal training program for PMTO supervisors was developed to meet the need for more systematic supervision in a shorter period of time. The training program consist of 4 workshops (2 days each) and 3 home assignments. All the workshops consist of short presentations, demonstrations and exercises and the content is based on two different sources of knowledge: 1) supervision theory and elaborated experience with training supervisors and 2) clinical experiences from certifying more than 300 Norwegian PMTO therapists. The program is recently completed in all the five regions of Norway. The training program describes a model for PMTO supervision.The model includes: therapeutic development, assessment and feedback based on FIMP, problemsolving and skilltraining. These elements are based on the foundation pilars: leadership/structure, encouragement/support, observation and roleplays. The second subject is based on clinical experiences from certifying PMTO therapists. From this experience we have extracted four topics that therapists may need to elaborate; 1) how to use roleplay for different aims in the therapy sessions, 2) sophisticating process skills, 3) adjusting PMTO components to the families in accordance with the basic theoretical principles, and 4) use of the FIMP dimensions for self evaluation.

"Establishing system-wide infrastructure"

by Laura Rains (Director of Implementation and Training, ISII, USA) and Luann Gray (Michigan PMTO State Coordinator, USA).

The map for large scale implementation of PMTO is paved with multiple perspectives, brilliant gold mines, and hidden traps. Essential tools for the journey include engagement and buy-in at all levels for short- and long-term vision, as well as clear expectations, collaboration, communication and consistency amongst stakeholders. Engagement occurs through meetings, phone and videoconference calls, documentation exchanges, etc., and is vital to assuring that everyone is on the same page. In this session we will briefly discuss the Michigan experience. Everyone agreed that a vital component of the infrastructure needed to be the assurance of sustained fidelity. This was achieved through the clarification of roles and responsibilities necessary to successfully carry out the evidence-based practice. Presenters will briefly discuss the document used in Michigan to promote cohesion and sustainability: PMTO Requirements to Ensure Sustainable Fidelity and Quality (Gray, Rains & Forgatch, 2009). The short working title is “The Matrix.” Administrators at the state and local levels, purveyors, PMTO participants and community stakeholders now share a common view of all levels: clinician, coach, FIMPer, trainer, and consultant. The Matrix is an essential tool to achieve the shared goal of skilled therapists, parents, and children.

"Cultural adaptation of PMTO for ethnicity and language"

by Melanie M. Domenech Rodríguez (PhD, Associate Professor, Utah State University, USA) and Nancy G. Amador Buenabad (Research Scientist, Instituto Nacional de Psiquiatría, México). 

Criando con Amor: Promoviendo Armonía y Superación is a culturally adapted PMTO manual. It was developed in Logan, UT and then further refined for use in Mexico City. A recent meta-analysis of culturally adapted treatments for US-based ethnic minorities showed a significant improvement in outcomes for adapted versus non-adapted interventions. The authors will present the systematic and theory-based cultural adaptation process utilized to tailor the manual for use with Spanish-speaking Latinos in the U.S. and in Mexico. Examples of specific cultural adaptations made will be shown. Evidence of treatment acceptability on the part of participating families at both sites will be presented. Additionally evidence of treatment outcomes in the Mexico sample will be presented. The authors will discuss significant differences in implementation practices at each site. These will be discussed to highlight the importance of adhering to fidelity of implementation when transporting the intervention across national and cultural groups. Specifically, the presentation will underscore the importance of training procedures for interventionists in achieving desired outcomes.

"Adapting for culture and context with risk populations"

by Ragnhild Pettersen (Psychologist, Regional PMTO Coordinator, The Norwegian Center for Child Development) and Abigail Gewirtz (PhD, Assistant Professor, University of Minnesota, USA).

Refugee parents face many challenges as they acculturate into new societies, among them, parenting and managing children’s behavior in a context of new expectations, and against a backdrop of significant adversity and trauma. The two projects presented review efforts to implement PMTO among Somali and Pakistani refugee populations in Norway, and Minnesota, USA. Gewirtz reviews an ongoing project in Minnesota, USA., home to the largest population of Somalis outside Somalia. The project was initiated following discussions with the Minneapolis Public School System, which was facing challenges with regard to managing the behavior of refugee children, and involving parents as partners. Three pilot Parenting Through Change groups have been implemented, each with 8-12 mothers. Cultural modifications to the PTC curriculum include additional content focused on the unique needs of this highly stressed and traumatized population, as well as modifications to program delivery (e.g. longer sessions, use of pictures rather than words, etc). Focus groups were conducted with mothers following group completion, yielding valuable information about parenting values, expectations, and utility of PTC with this population. Focus group, satisfaction and participation data are presented to highlight key issues in the implementation of PMTO with this population.

"Military adaptation of PMTO"

by Abigail Gewirtz.

The protracted conflicts in Afghanistan and Iraq have resulted in unprecedented deployments of US military personnel, and among them large numbers of Reserve and National Guard soldiers. The latter – ‘civilian soldiers’ – tend to be older, partnered and parenting, and at higher risk than regular (‘active duty’) soldiers for posttraumatic stress disorder, substance use, and related psychopathology. Emerging data indicates the impact of these and other deployment-related challenges on the family – and on parenting in particular. This presentation reviews data indicating associations among parenting, and posttraumatic stress symptoms among soldiers returning from war, and presents the rationale for the modification of PMTO for military families. The PMTO program – After Deployment, Adaptive Parenting Tools –ADAPT – incorporates new delivery methods (online material) as well as contextual adaptations, and will be tested in a large-scale randomized effectiveness trial with 400 families of the Minnesota Army National Guard and Reserves. The study design and curriculum is presented, and issues related to military adaptations of PMTO, and recruitment of military families to PMTO are discussed.

"Intervention intensity: Prevention to treatment"

by Roar Solholm (Psychologist, Senior Advisor, The Norwegian Center for Child Development)

The task of implementing  Parent Management Training – Oregon model (PMTO) in Norway was given to The Norwegian Center for Behavior Development by the government in form of a twofold mandate: First to strengthen the competence in the specialist treatment services for young children with conduct problems (3-12 years of age) at the county level (i.e. child mental health and child welfare services) through a nationwide implementation of PMTO, and second to make the evidence based knowledge and principles behind PMTO available in various settings and arenas in the municipality based services for children. The mandate strongly emphasized the preventive perspective of the implementation. This presentation will focus on the second part of the mandate. Children with conduct problems represent a broad range of “acting out behavior”, from minor oppositional behavior to more serious forms of antisocial behavior. Different developmental trajectories (“early and late starters”) and several important risk factors, both in and outside the family, have been identified. The individual child shows symptoms that vary across age and settings and the symptoms also vary in their intensity, magnitude and combinations.  Experience with conduct disorder, intervention competence, understanding and terminology varies both between and in the services for children, and there is often a lack of systematic cooperation that hampers effective interventions for these children and their families. Consequently some children with conduct problems run the risk of being identified (too) late and that the type, extent and quality of the interventions are (too) limited and vary according to where and by whom the problem first was identified. TIBIR (a Norwegian acronym for “early initiatives for children at risk”) is a municipality wide program that addresses the second part of the mandate, building on the general knowledge of conduct problems, prevention, and the rationale, principles, strategies and techniques of PMTO. The program is designed with the aim to systematically identify children at risk as early as possible, both in terms of children’s age and severity of symptoms, and to offer tailored interventions (or combinations of interventions) targeting different risk factors, problem arenas and groups of significant others. The program also aims at increasing the likelihood of rapid initiation of intervention and to facilitate the cooperation between the child services in the municipality. TIBIR consist of six modules: a multiple gate assessment tool for early identification and five interventions. Three modules target parent: PMTO, PMTO Parent Group and Brief Parent Training. One module, Teacher Consultation, focuses on other significant adults in important arenas such as schools and kindergartens while one module, Child Social Skills Training, is designed to improve the child’s social skills. The modules in TIBIR are intended to be both supplementary and compensatory to each other, and some form of parent training will always be part of the “intervention package”. Each module consists of 1) training of key personnel in the regular services (teaching and case supervision), 2) training and intervention manuals and other teaching materials, and 3) the actual intervention.

"RCTs to demonstrate that adaptations retain effectiveness"

by John Kjøbli (PhD, Researcher, The Norwegian Center for Child Development).

Following the implementation of PMTO and the randomized effectiveness trial with Norwegian families showing encouraging results (Amlund-Hagen, Ogden & Bjørnebekk, 2011; Ogden & Amlund-Hagen, 2008), several adaptations of the program were initiated. The overarching model is called “Early Intervention for Children at Risk” (Norwegian acronym: TIBIR); a community (municipality) wide model for preventing and treating conduct problems among children and is based on the SIL model as well as on the PMTO principles. In order to empirically evaluate and ensure model adherence, the six interventions in TIBIR will be tested in separate RCTs.  By so doing, the TIBIR interventions are tested in real world settings, rather than under optimal conditions (as in efficacy studies). In addition to point at essential factors for successful implementation of effectiveness trials, findings from the current trials are presented. Furthermore, future research that may increase our knowledge about how to sustain the effectiveness and increase the reach of the TIBIR interventions will be discussed.

"Addressing the challenges in conducting an RCT in a large scale implementation"

by Margrét Sigmarsdóttir (Psychologist, PMTO Program Leader, Iceland).

The Icelandic treatment effectiveness study of Parent Management Training – the Oregon model (PMTO) is a randomized control trial (RCT) that started in May 2007. The sample was recruited from five municipalities throughout Iceland and consists of families of 102 children, 28 girls (27.5%) and 74 boys (72.5%), age 5-12 (M = 8.02, SD = 1.91) with behavior problems (mean CBCL Total Problem scale T score was 64.95, SD = 7.70).  Cases were referred to treatment by professionals in the communities. Following the assessment of set of two cases, they were randomly assigned to either PMTO or treatment as usually offered in each community. Assessment points in the study are pre-, post (9 months later) - and 9 months follow up. Follow up assessments have been collected for approximately 30% of the sample at this time; all measures will be finished by the end of 2011. This presentation will focus on the child outcome at post measures where 95% of the sample was retained. This is the second effectiveness study (RCT) of PMTO outside the United State where the Norwegians are the pioneers. This is also the first RCT of a treatment model to treat behaviour problems in Iceland. The implementation of PMTO in Iceland is being conducted with minimal resources. The program started in one community and has spread steadily to other communities. Main challenges over the research period have been the following: convincing leaders to invest money and time on the project, motivating professionals in the field to send referrals to the RCT, motivating therapists to participate in the study and getting families in for later measurements.

"Starting and restarting a large scale RCT" 

by Gøye Thorn Svendsen (Psychologist, PMTO & PALS Program Leader, Denmark). 

The implementation of PMTO in Denmark started in 2004. The Governmental foundation included foundation for an RCT trial. This RCT was meant to be the first RCT evaluating the effects of a family intervention for children in severe social problems in Denmark. The presentation will give an overview of important issues in the failed process: Stakeholders, Design, Methods, Measures, Challenges and How the Challenges where meet. Learning points and some of the conditions for research in the beginning of an implementation process will be discussed. Some important questions for the research process in evidence based programs will be raised. Is it possible or even desirable to reach the golden standard for researchers understood as keeping total independence of the program facilitators in the first phases of the implementation process or do we by this miss an important opportunity combining clinical research with the effectiveness evaluation?