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Clinician-Identified Factors in Success of Parent-Directed Behavioral Therapy for Children’s Tantrums

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Abstract

Disruptive behavior disorders (DBD) are the most common behavioral health problems in young American children. When not well-managed in early childhood, DBD can progress to lifetime mental health problems with personal, economic, as well as societal impacts. The evidence-based intervention of choice for DBD is outpatient parent-directed behavioral therapy (PDT). However, little is known about clinicians’ perspectives on the factors influencing PDT’s effectiveness in routine care. The current study directly assesses clinicians’ perspectives on factors they believe impact PDT’s success for disruptive behavior problems, in particular tantrums, at two outpatient behavioral therapy clinics specializing in PDT. In-depth interviews with 19 clinicians across three experience levels (doctoral intern, post-doctoral, licensed staff psychologist) were conducted and analyzed using qualitative methods. Two major themes were identified as enabling and limiting treatment success: (1) appointment attendance, (2) primary caregiver buy-in to treatment approach. Additional identified factors include caregiver’s familial and social support, caregiver’s physical and emotional capacities, complexity of the child’s behavior problems, the extent to which the home environment can support positive changes, competing family/home demands, and care coordination among hospital programs. The primary factors identified by clinicians highlight the importance of fostering appointment attendance and parental psychoeducation that can be addressed by implementing multi-level administrative, training, and clinical initiatives to improve PDT’s real-world effectiveness for DBD.

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Acknowledgements

We thank the clinicians and clinical leadership at two outpatient behavioral therapy clinics at the Kennedy Krieger Institute for their commitment to treatment quality and participating as key informants in this study. We acknowledge the foundational efforts of the Director of the Department of Behavioral Psychology, Dr. Michael Cataldo, PhD, who supported and initially guided the investments to create the treatment accountability infrastructure within the outpatient behavioral psychology clinics. We also acknowledge Brittany Comunale and Leslie Wang, graduate students from the Johns Hopkins Bloomberg School of Public Health, who assisted in literature reviews.

Funding

The research outlined here was supported by the Kennedy Krieger Institute’s Department of Behavioral Psychology as part of routine treatment accountability practices in their outpatient programs.

Author information

Author notes

  1. Helen Fan Yu-Lefler

    Present address: Bureau of Primary Health Care, Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD, 20852, USA

Authors and Affiliations

  1. Department of Behavioral Psychology, Kennedy Krieger Institute, Baltimore, MD, USA

    Helen Fan Yu-Lefler & Steven Lindauer

  2. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Helen Fan Yu-Lefler & Anne W. Riley

  3. Johns Hopkins School of Medicine, Baltimore, MD, USA

    Steven Lindauer & Anne W. Riley

Authors
  1. Helen Fan Yu-Lefler
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  2. Steven Lindauer
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  3. Anne W. Riley
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and initial coding were performed by HY-L. SL and AWR reviewed the raw data and coding and assisted in finalizing the results. The first draft of the manuscript was written by HY-L and all authors contributed to subsequent versions of the manuscript, and read and approved the final manuscript.

Corresponding author

Correspondence to Helen Fan Yu-Lefler.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

This is a qualitative study using key informants. The Johns Hopkins Bloomberg School of Public Health Institutional Review Board determined the study as Not Human Subjects Research and exempt from review. All procedures involving human participants were in accordance with the ethical standards of the Kennedy Krieger Institute, Johns Hopkins Bloomberg School of Public Health and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

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This manuscript was prepared using the EQUATOR Network’s SRQR guidelines for qualitative research.

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Appendices

Appendix: Semi-structured Interview Sheet

Clinician-Identified Factors Influencing Treatment Effectiveness for Tantrums

Semi-Structured Interview Sheet

figure a

Target Patient Population: Patient cases in Clinic 1 and Clinic 2 who have tantrums as their primary (or one of their primary treatment targets), attended at least an initial evaluation (IE) + 1 follow-up appointment prior to inactivity/discharge.

Directions: Conduct a 30-min interview with Clinic 1 and Clinic 2 clinicians who had at least 1 year of clinical experience with patient cases with tantrums. Ideally, interviews ought to be conducted with 3 interns, 3 post-docs, and 3 licensed psychologists. On the network, the interviewer should pull up an electronic copy of this interview sheet saved under the clinician’s name and the Header section filled out with the clinician’s information. Please also audio-record on Voice Recorder and save to same folder on network as the interview sheet. During the interview, the interviewer will type in freestyle answers provided by the clinician under the respective questions below. If the clinician has trouble answering the questions, the interview may use some of the factor categories to help promote discussion.

Introduction: Thank you for speaking with me today. One of the things the Clinical Outcomes team is helping to do is identify factors impacting treatment success for patients with tantrums. I need your help to identify these factors. What I will do today is ask you some questions, and to write down your responses. Your answers will be kept confidential and will aid in a qualitative analysis on common factors impacting treatment for tantrums.

Questions: Think back to the patient cases you’ve had over your time in Clinic 1/Clinic 2.

  1. 1.

    For cases that had successful treatment of tantrums, what were aspects of the case and/or of the family that made treatment successful? <Type in freestyle what the clinician says> 

  2. 2.

    Please think about a very recent parent and child who had successful treatment for tantrums. Can you tell me what factors you think contributed to this outcome?

  3. 3.

    For cases that weren’t so successful in treating tantrums, what were aspects of the case and/or of the family that limited treatment success? <Type in freestyle what the clinician says> 

  4. 4.

    Please think about a very recent parent and child who didn’t have successful treatment for tantrums.

    • How much progress do you think was made?

    • Can you tell me what factors you think contributed to this outcome?

Thank you so much for all your assistance! If you have any questions or think of anything to add, feel free to contact me at [HY-L email].

Factor categories

Child/Family Attributes

Factors Influencing Appointment Attendance

Factors Influencing Family/Child’s Engagement in Treatment

Factors Influencing Treatment Effectiveness before Inactivity/Discharge

Factors Influencing Treatment Effectiveness after Inactivity/Discharge

(examples below)

– Child age

– Child diagnosis

– Function of tantrums (and/or any other associated behavior)

– Level/Severity of behavior problem prior to therapy

– Level of parent education

– Number of other children in household

– Etc…

(examples below)

– Distance

– Overall cost of OBP services to family (with or without insurance)

– Change/lapse in healthcare insurance to cover for behavioral therapy

– Scheduling conflicts

– Other family life events that take precedence over behavioral therapy (sickness, changing jobs/schools, relocation)

– Parent ability to keep a schedule

– Etc…

(examples below)

– Commitment from primary caregiver(s) and child to get behavioral therapy

– Prior experience with therapy

– Support/agreement from other family members for child to get behavioral therapy

– School/teacher support/agreement for child to get behavioral therapy

– Rapport between clinician and child/caregivers

– Etc…

(examples below)

– Accurate understanding by caregiver(s) of development for child

– Reasonable expectations for treatment

– Treatment plan accurately diagnoses function behind behavior problem, and provides adequate strategies to reduce the problem

– Caregiver skill acquisition

– Child receives concurrent care from other developmental and/or mental healthcare professionals

– Etc…

(examples below)

– Continual usage of treatment strategies by caregiver(s) and/or child

– Child has other problems that arise’

– Child receives care from other developmental and/or mental healthcare professionals after inactivity/discharge

– Etc…

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Yu-Lefler, H.F., Lindauer, S. & Riley, A.W. Clinician-Identified Factors in Success of Parent-Directed Behavioral Therapy for Children’s Tantrums. Adm Policy Ment Health 49, 168–181 (2022). https://doi.org/10.1007/s10488-021-01155-1

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