6. Behavioral Outcomes of Parent of Parent-Child Interaction Therapy

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    Behavioral Outcomes of Parent-Child InteractionTherapyand Triple PPositive Parenting Program: ARevie and!eta-Analysis

    Rae Thomas " !elanie #$ %immer-&em'ec( )*++,

    A'stract We conducted a review and meta-analyses of 24 studies to evaluate andcompare the outcomes of two widely disseminated parenting interventionsParent-ChildInteractionTherapy and Triple P-Positive Parenting Program. Participantsin all studies were caregivers and - to !2-year-oldchildren. In general" our analyses revealed positive e#ects

    of $oth interventions" $ut e#ects varied depending on interventionlength" components" and source of outcome data.%oth interventions reduced parent-reported child $ehaviorand parenting pro$lems. The e#ect si&es for PCIT werelarge when outcomes of child and parent $ehaviors wereassessed with parent-report" with the e'clusion of ($$reviatedPCIT" which had moderate e#ect si&es. (ll forms ofTriple P had moderate to large e#ects when outcomes wereparent-reported child $ehaviors and parenting" with the e'ceptionof )edia Triple P" which had small e#ects. PCITand an enhanced version of Triple P were associated withimprovements in o$served child $ehaviors. These *ndingsprovide information a$out the relative e+cacy of two programs

    that have received su$stantial funding in the ,( and(ustralia" and *ndings should assist in maing decisionsa$out allocations of funding and dissemination of these parentinginterventions in the future.

    %ehavioral parent training interventions are widely used $ecausethe evidence shows they are e+cacious /eretich 01umas" !3. (lthough parenting interventions focusing onchild $ehavior management are widespread there are a varietyof theoretical foundations and delivery formats for theseinterventions /5umpfer 0 (lvarado" 266. 7evertheless"$ehavioral parent training" where parents participate in sillstraining" is included in many interventions with demonstrated

    e+cacy /eretich 0 1umas" !3. 8ften" $ehavioral parenttraining involves discussing di#erential reinforcementand timeout procedures" and an emphasis is placed on therole the parent plays in the development and maintenance ofchild pro$lem $ehaviors /9ollenstein" :ranic" toolmiller"0 nyder" 2664. ;et" interventions might only include parents"might involve family sills training" where the parentsand children are taught sills and have time to practice thesetogether with a therapist" or interventions may involve familytherapy in which the family unit receives intervention withless of the content directed at sill development.Clinical $ene*ts of $ehavioral parent training interventions

    were descri$ed in one meta-analysis of 23 pu$lishedstudies /ereetich 0 1umas" !3. In another systematicreview /%arlow 0 tewart-%rown" 2666" !3 randomi&ed

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    controlled trials of group parenting interventions were determinedto $e e+cacious for improving child $ehavior whencompared to waitlists or other comparison groups. In thisreview" however" the heterogeneity of the interventions andstudy designs" and the di+culties in generali&ing the *ndingswere emphasi&ed. There have $een few reviews that have

    systematically compared the e+cacy or e#ectiveness of parentinginterventions that have di#erent primary methodologies.9ence" the evidence of e+cacy of parent interventionspertains to the $road category of $ehavioral parent trainingrather than particular intervention types. In past reviews"summaries included one or two pu$lished controlled trialsto represent each of a range of studies that used di#eringtraining methodologies.amily-focused prevention interventions werecited as" in general" producing moderate to very large e#ectsi&es" whereas child only interventions often producedvery small e#ects. (lthough this paper was not a systematicreview of interventions" the distinction $etween interventionmethodologies and their di#ering e#ect on familyfunctioning highlights the importance of e'amining the e+cacyof speci*c types of parenting interventions" and thepotential importance of such *ndings for governmental policyand decision-maing with respect to dissemination ofinterventions.Parent-Child Interaction Therapy /PCIT and TriplePPositive Parenting Program /Triple P are two parentinginterventions descri$ed as $ehavioral parent training interventions"$ut PCIT and Triple P rely on di#erent deliveryformats" and Triple P also uses a range of delivery formats"including using the media" individual" and group intervention.The current reviewsummari&es what is nown a$out thee+cacy of PCIT and Triple P" and their su$types" for threeprimary reasons. >irst" in a previous review" an emphasiswas placed upon descri$ing and attending to actual interventioncontent and delivery formats in future meta-analyses/:eeraert" ?an den 7oortgate" :rietens" 0 8nghena" 2664.9ence" we descri$ed PCIT and Triple P content and delivery

    formats here" and used meta-analytic techni@ues to assesswhat is currently nown a$out the e+cacy of these two interventions"which are $oth founded in social learning theory"$ut have di#erent modes of service delivery. (lthough usingmeta-analysis to summari&e the *ndings from trials of PCITand trials of Triple P is not a direct comparison of deliveryformat" as other di#erences $etween the two types ofinterventions and each trial were not controlled" we electedto analy&e trials of PCIT and Triple P $ecause of the cleardi#erences in delivery formats and the potential importanceof such information for future research and intervention implementation.econd" the num$er of trials of PCIT and Triple P hasreached a level that maes them amena$le to summari&ation

    separate from other parenting interventions. We alsoe'pected that these *ndings would $e of importance to families"

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    communities" and policymaers" $ecause these two interventionshave $een /and are continuing to $e widely disseminatedand funded in $oth the ,( and (ustralia. PCITand Triple P have $ecome popular in (ustralia in recentyears" and $oth have $een used widely or are $eing disseminatedin the ,(. Triple P has seen widespread growth in

    (ustralia" with recent dissemination to the ,( /Prin& 0anders" 2664. PCIT is used widely in the ,(" with morerecent dissemination to (ustralia /7i'on" 266!. PCIT andTriple P have attracted government funding in $oth countriesto support their implementation.Conclusions a$out the e#ectiveness of PCIT and TripleP for improving parenting $ehaviors and reducing child $ehaviorpro$lems have $een made in some previous literaturereviews. In one review" PCIT was descri$ed as a pro$a$lye+cacious treatment for children with e'ternali&ing and antisocial$ehavior /%restan 0 Ay$erg" !B" whereas 7i'on/2662 cited $oth PCIT and Triple P as parent training interventionswith demonstrated e+cacy $ased upon numerous

    studies with rigorous methodologies. We$ster-trattonand Taylor /266! cited $oth intervention types as empiricallysupported for the reduction of child antisocial $ehavior.9owever" a third reason for conducting the meta-analyses reportedhere was that none of these reviews were systematicreviews of all pu$lished evaluation studies of $oth PCIT andTriple P" and there was no use of @uantitative meta-analyticmethods to summari&e *ndings from all studies. %ased onthe conclusions of these narrative reviews and others /e.g.">oote" chuhmann" ones" 0 Ay$erg" !B= anders" Cann"0 )arie-1adds" 266 and the e'pectation that servicesprovide interventions that are Devidence-$ased"E Triple Pand PCIT have attracted signi*cant funding in the ,( and(ustralia. (s such" the evidence of e+cacy and impact ofdi#ering methodology of $oth Triple P and PCIT warranteda more detailed e'amination. In the current study" we completeda review and meta-analyses of all trials of Triple P andPCIT dated $etween !B6 and 2664.Theoretical foundations of PCIT and Triple PPCIT and Triple P have $een derived from social and developmentaltheories. >irst" some PCIT and Triple P interventioncomponents have a foundation in the propositions ofsocial learning theory />oote" Ay$erg" 0 chuhmann" !B=anders et al." 266. >or e'ample" a social learning frameworhas $een employed to direct attention to the interactions

    $etween family mem$ers as the source of di+culty" ratherthan implying that the child or the parent is independentlyresponsi$le for all pro$lems. >or minor child mis$ehaviordi#erential reinforcement is the primary positive parentingstrategy taught in $oth interventions. 1i#erential reinforcementis a planned $ehavior management strategy of positivelyrewarding a childFs prosocial $ehavior whilst providingminimal attention to a childFs inappropriate $ehavior. Inaddition to di#erential reinforcement" $oth PCIT and TripleP focus on appropriate conse@uences for child mis$ehavior.Positive reinforcement of the parent during interactionswith the child is also used in PCIT" $ut this is not directlyintegrated into Triple P.

    econd" applied $ehavior analysis" developmental modelsof social competence" and developmental psychopathology

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    are theories descri$ed as foundations for Triple P /anderset al." 266" and attachment theory has $een descri$ed as afoundation of PCIT /9erschell" Cal&ada" Ay$erg" 0)c7eil"2662. (lthough PCIT and Triple P share theoretical underpinnings"there are often di#erences in intervention length"service delivery components" and how the intervention format

    met their speci*ed goals.Triple PPositive Parenting ProgramTriple P was designed to promote positive parenting andcaring relationships $etween parents and children aged $etween2 and !3 years /anders et al." 266. Triple Phas $een descri$ed as a %ehavioral >amily Intervention/e.g." anders 0 )c>arland" 2666 with a multi-tieredcontinuum of service intervention /anders et al." 266.>amilies are o#ered information on parenting and $ehaviormanagement strategies through a variety of interventionstructures that reGect the di#ering needs of parents.The Triple P service modality is structured to ena$le parentsto access information from a variety of sources includingmulti-

    media" professional consultations and self-directedmodules. 1istinct tiers of Triple P are availa$le /httpHwww.triplep.net*lespdfTripleP )odel Ta$ole.pdf. These includetandard" :roup" Anhanced" elf-1irected" and )edia/i.e." one version of ,niversal Triple P. ( child mean age of*ve years was found in the Triple P evaluations included inthe current study.)any of the pu$lished articles on the e+cacy of Triple Pare $ased on tandard Triple P" :roup Triple P or AnhancedTriple P. tandard Triple P wors with single families" whilegroup sessions are conducted within :roup Triple P. %othof these types of Triple P emphasi&e the role of parents inthe development and maintenance of child mis$ehavior $yassisting parents to identify possi$le causes and esta$lishinggoals for $ehavior change /Turner" )arie-1adds" 0anders" !B. Through didactic presentations" individualor small group activities and homewor" parents use di#erentialreinforcement" communication sills" e#ective conse@uencesfor mis$ehavior" and planned activity scheduling/Turner et al." !B. (ppro'imately !6 sessions are availa$lefor tandard Triple P" whereas" it is usual to o#er *vegroup sessions and three telephone consultations to :roupTriple P participants.In Anhanced Triple P" three adJunct modules" tailoredto the parentsF individual needs" are added to tandard

    Triple P. )odules listed on the Triple P we$ site/httpHwww!.triplep.net and in the PractitionerFs )anualfor Anhanced Triple P /anders" )arie-1adds" 0 Turner"!B are Practice" Coping ills" and Partner upport. Inthe Practice module" the goals are to identify and resolvepro$lems with implementing new parenting strategies. Inthe Coping ills module" parents are assisted with personalissues" such as depression and an'iety. In the Partner upportmodule" dual parent families who are e'periencing di+cultiesin communication" relationships andor co-parenting areo#ered support /anders et al." !B.The *nal two interventions of Triple P are elf-1irectedand )edia. elf-1irected Triple P participants are supplied

    with a te't and a self-help manual and provided with!6 wees of structured learning tass and do not have contact

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    with a professional /anders" )arie-1adds" Tully" 0 %or"2666. ills taught in elf-1irected Triple P are similar tothose taught in tandard Triple P and weely telephone consultationswith a professional can $e arranged. )edia TripleP is descri$ed as !2 episodes of an DinfotainmentE televisionintervention /anders" )ontgomery"0%rechman-Toussaint"

    2666. :oals of the intervention are descri$ed as providingparents with parenting strategies" to normali&e the challengeof parenting and to increase community awareness of familyrelationships /anders" )ontgomery et al." 2666.Parent-Child Interaction Therapy /PCITPCIT is an individuali&ed intervention developed for caregiversand their 4- to K-year-old children with e'ternali&ing$ehavior /9em$ree-5igin 0 )c7eil" !L. Therapeuticoutcomes of PCIT have $een descri$ed as $eing guided$y o$served changes in parent-child interactions" rather thanself-report changes in the childFs $ehavior only. ( parent isassisted to alter herhis $ehavior via direct coaching strategies.In turn" this change in parent $ehavior is e'pected to

    improve the childFs pro$lem $ehaviors" and increase positiveinteractions within the parent-child dyad. (lthough thea$ove is a shared principle of $ehavioral parent training" theuse of direct" in vivo coaching of parental $ehaviors di#erentiatesPCIT from most other $ehavior parent traininginterventions" including Triple P. In the reviewed studies ofPCIT" the average length of treatment was $etween !2 and!4 wees.There are two phases in PCIT" which are la$eled Child1irected Interaction and Parent 1irected Interaction. Progressionfrom one phase to the ne't is predominantly dependenton attaining prescri$ed levels of speci*c sills nownas mastery criteria /9em$ree-5igin 0 )c7eil" !L. 9owever"in the studies reviewed here" PCIT was often limitedto a speci*c num$er of sessions /e.g." !2 sessions. PCITsills are taught via didactic presentations to parents" and directcoaching of parents while they are interacting with theirchildren. In didactic sessions /usually two sessions" the focusis on teaching the parent speci*c sills related to eachphase of the therapy and these sessions are conducted priorto the direct coaching sessions. The remainder of PCIT /usuallya$out !6M!2 sessions in the studies reviewed involvesdirect coaching sessions. These sessions are conducted withthe parent and child in a play therapy room with the therapistin another room $ehind a one-way mirror. The therapist and

    the parent communicate through a D$ug-in-the-earE device.This device permits the therapist to provide direct coachingof parental communication and $ehavior management sills"immediate feed$ac and social reinforcement of the parent.Parents are e'pected to practice the sills at home.(s in Triple P" there are variants of the standard PCITintervention. (lthough PCIT was descri$ed as a !2-wee interventionin most studies" 7i'on et al. /266" 2664 used ana$$reviated version of PCIT that followed the same guidelinesas tandard PCIT /i.e." two phases of treatment" howeverthe two didactic sessions were replaced with videosfor home viewing. In addition" instead of the standard !6M!2 PCIT direct coaching sessions" a$$reviated PCIT o#ered

    *ve in-vivo coaching sessions" which alternated with *ve6-minute telephone consultations.

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    (nother variant of PCIT adds a 3-session motivationcomponent /PCIT N motivation. This delivery format wasused in a randomi&ed controlled trial of PCIT with familieswho had a history of physically maltreating their children/Cha+n et al." 2664. The motivation sessions includedvideotaped testimonials from previous participants" psychoeducation"

    decision maing e'ercises" self-motivationalcognitions" self-e+cacy" and an understanding of theconse@uences of child maltreatment. %efore proceeding totandard PCIT" participants su$mitted personal statementsregarding parental $eliefs" practices and goals for therapy.(fter PCIT" a 4-wee group intervention was implementedin order to improve generali&ation and maintenance of sills.(lso" Cha+n et al. /2664 implemented a second version ofAnhanced PCIT. In this version" participants were providedwith PCIT plus the motivational component" as well asindividual counseling sessions for depression" marital issuesor su$stance a$use" and home visits.The delivery formats and speci*c intervention

    strategies of Triple P and PCIT(ccording to alas and Cannon-%owers /266!" Triple P andPCIT employ strategies that have $een found to $e e#ectiverelevant information is presented to parents and parentingconcepts are demonstrated through role-play in $oth TripleP and PCIT. 7evertheless" there are at least three ey interventionstrategies that di#er $etween PCIT and Triple P.ummari&ing the e#ects of these programs was e'pectedto provide important information a$out the relative e+cacyof di#erent intervention components. >irst" a colla$orativelearning model is inherent in Triple P group interventionswhere group interactions assist in the learning process. Colla$orativelearning has demonstrated e+cacy and reducestherapist time and resources /he$ilse" ordan" :oettl" 0Paulus" !B. PCIT does not have a group version. econd"although parents in Triple P are encouraged to conduct homewortass and discuss these with the therapist" o$servedpractice of parents interacting with children and managingchallenging child $ehaviors does not usually occur as part ofthe intervention design. tandard Individual and AnhancedTriple P have the provisions for child involvement" $ut childinvolvement was not descri$ed in the reviewed studies. Incontrast to Triple P" the use of coaching strategies that includeparents interacting with their children in PCIT is a eyintervention strategy and provides opportunities for parents

    to practice new sills and get immediate feed$ac a$out performancefrom interventionists. %ecause the parent might $eprovided with direct remediation of incorrect implementationof sills and practice with implementation that worsfor the parent and the child" and $ecause the overlearningprinciples of PCIT evident in the O)astery CriteriaF allowfor repeated practice of sills and increases retention rates ofnewly ac@uired sills /1risell"Willis" 0 Copper" !2" thedirect coaching strategies in PCIT might yield larger e#ectson $oth parent and child outcomes. Third" although restricted$y a small num$er of pu$lished studies" comparing the e#ectivenessof standard PCIT and Triple P to interventionsthat have $een enhanced with additional services and other

    components was e'pected to add important information forfuture intervention design and research.

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    The current studyIn the current study" our aim was to provide a comprehensiveassessment of the state of the evidence to guide decisionsa$out the implementation and continued dissemination ofTriple P and PCIT in (ustralia and the ,(" and to determinewhether summari&ing the e+cacy of PCIT and Triple

    P allowed for conclusions a$out e#ective intervention deliveryformat. To do this" we identi*ed all randomi&ed controlledtrials and single group follow-up studies of TripleP and PCIT dated $etween !B6 and 2664. We a$stracteddata from all identi*ed studies" and used standard reviewand meta-analysis techni@ues to draw conclusions a$out thecapacity of each type of intervention to improve parent andchild $ehaviors. We provided speci*c analyses of each su$typeof Triple P and PCIT that has $een investigated andsummari&ed the e+cacy of each type of intervention.We reportede#ects si&es from independent group pre-treatmentpost-treatment /I:PP studies and single group pre-treatmentpost-treatment /:PP" and e#ect si&es $ased upon di#erent

    sources of information /e.g." parent-report" o$servation"and compared e#ect si&es found in tandard PCIT to e#ectsi&es found for Triple P.!ethodifth" our searches included $oo chapters andattempts to o$tain unpu$lished trials from nown authors ofpu$lished trials of PCIT and Triple P" $ut no additional trialswere identi*ed and retrieved.Included and e'cluded studiestudies reported $etween !B6 and 2664 were included in

    the meta-analysis if they met three criteriaH These criteriaincluded a focus on the e+cacy of either Triple P or PCIT"the inclusion of at least one parent or child behavior problemsoutcomemeasure" and the inclusion of empirical data neededfor meta-analysis.Thirty-two studies of PCIT were retrieved" and we included! studies from B cohorts and research groups/Cha+n M ! cohort" Ay$erg)c7eil M 3 cohorts" 7i'on M! cohort= see Ta$le !. even studies reported only means ordid not include needed information for meta-analysis" ninestudies were not e#ectiveness studies" one study consideredthe e#ectiveness of PCIT within the classroom setting withthe teacher coached in PCIT sills /i.e." parents were not

    included in the intervention" and one study was a duplicateof results reported in an included study.! 8ne further study

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    met most of the inclusion criteria" however" it was not included$ecause three treatment groups with di#erent levelsof father involvement were compared and total e#ects for allparticipants were not reported /%agner 0 Ay$erg" 266.We retrieved 2B studies of Triple P /or earlier versionsof this intervention. Aleven studies $ased on !6 cohorts

    from ! research group /anders were included in metaanalyses/see Ta$le !. Twelve studies did not include enoughinformation to $e included in meta-analysis. >our studies were e'cluded as they focusedon child outcomes other thanchild $ehavior pro$lems /e.g." $ed-wetting or pain.! 8nestudy metmost inclusion criteria" $ut results were reported $ysu$groups in order to e'aminemartial discord as a moderatorof treatment e#ectiveness" and total results for all participantswere not reported /1adds" chwart&" 0 anders" !BK.1ata a$straction and coding>rom each study" we a$stracted study and intervention characteristics/see Ta$le !. Aach author a$stracted informationindependently and results were compared to correct inconsistencies.

    (ll discrepancies were due to misreading articlecontent or data entry errors $y one author. 9ence" to correctdisagreements" the original reference was consulted and thediscrepancies were easily recti*ed. Intervention characteristicsthat were e'tracted included the length of time in treatment"the treatment components /e.g." additional individualsessions for depression" psychoeducational informationon (191" marital relationship enhancement" etc." and" forTriple P" whether the interventionwas administered to groupsor individual parentsfamilies. 8ther a$stracted data werecharacteristics of participants" study design" and outcomes.When availa$le" parent and child characteristics includedchild gender" parent gender" raceethnicity" and child age.tudy design factors included an indicator of randomi&ationversus matchedother comparison group" type of comparisongroup" time in treatment" time to follow-up assessments" si&eof treatment and comparison groups and attrition rate.8utcome measures used in each study were classi*ed asnegative or positive measures. With the e'ception of positiveand negative $ehavioral o$servations" scores on positivemeasures were reversed so that higher scores always reGectedmore negative parent and child $ehaviors.PCIT study outcomesThe outcomes varia$les measured in studies of PCIT includedchild pro$lem $ehaviors as measured $y parent- or

    teacher-report" clinic or classroom o$servation" and parentstress and $ehavior as measured $y parent-report. Child pro$lem$ehavior was assessed with parent-report @uestionnairesin all ! PCIT studies" while teacher reports were gatheredin two pu$lished studies from a single cohort. The mostcommonly used measures were the Ay$erg Child %ehaviorInventory /AC%I" Ay$erg 0 Pincus" !" mother report"the Parenting tress Inventory /PI" ($idin" !6" motherreport" and the1yadic Parent-Child Interaction Coding ystem/1PIC"

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    included only measures of child outcomes.

    Ta$el

    child and parent outcomes" while studies from 2 cohortsincluded only measures of child outcomes.Triple P study outcomesThe outcome measures in studies of Triple P included childpro$lem $ehaviors as measured $y parent- or teacher-reportand clinic o$servation" while parenting stress and $ehaviorwas measured $y parent-report. Child and parent $ehaviorswere measured $y parent-report @uestionnaires in all !! studiesof Triple P. The most common parent-report measuresfor child $ehavior outcomes included the AC%I and Parent1aily

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    != 9ood 0 Ay$erg" 266= )c7eil" Ay$erg" Aisenstadt"7ewcom$" 0 >under$ur" !!= chuhmann et al." !B.In two other Triple P studies parentsF maJor psychiatric diagnosiswas an e'clusionary criterion /anders 0 )c>arland"2666= Qeung et al." 266.ome studies speci*ed inclusionary criteria. In studies

    of Triple P" these included parental depression /anders")arie-1adds et al." 2666" marital conGict /Ireland"anders" 0 )arie-1adds" 266= anders )arie-1addset al." 2666" minimum 26 hwee employment /)artin0 anders" 266" and parental noti*cation of child maltreatment/not necessarily con*rmed or elevated scoreson three su$scales of the tate-Trait (nger A'pression Inventory/anders et al." 2664. 8ne study of PCIT speci*edthe re@uirements of a con*rmed noti*cation of childphysical maltreatment /Cha+n et al." 2664. The other!2 PCIT studies did not specify inclusionary criteria forparents.Computation and analyses of e#ect si&es

    We computed single group e#ects from pre-treatmentto post-treatment /:PP and pre-treatment to followup/4 months to one year after treatment completion=:P>.We also analy&ed independent groups pre-treatmentpost-treatment /I:PP and independent groups pretreatmentfollow-up /I:P> e#ects. In the following sections"we refer to treatment versus DcomparisonE groups inthe I:PP and I:P> analyses. Comparison groups includedrandomi&ed waitlists" matched control groups" and alternativecommunity intervention or social validation /DnormalcommunityE groups /see Ta$le !.SGPP and SGPF eect sizesThe formula used to calculate a single group e#ect si&e/:PP or :P> was the followingHdsg /Mpost R MpreSDprewhere"dsg was the single group e#ect si&e /:PP or :P> reportedin Ta$les"Mpost was the mean value at post-treatment or at follow-up"Mpre was the mean value at pre-treatment" and"SDpre was the standard deviation at pre-treatment.

    In one single group study" means and standard deviationswere not reported" so paired t-test values were used to calculatee#ect si&es.

    IGPP and IGPF eect sizes(s suggested $y %ecer /!BB and )orris 0 1ehon/2662" the *nal I:PP and I:P> e#ect si&es used in analyseswere calculated as the di#erence $etween the treatmentand comparison single group e#ects. The three formulasused to calculate I:PP e#ect si&es and I:P> e#ect si&eswereHdt /Mt-post R Mt- preSDt-predc /Mc-post R Mc-preSDc-predig dt -dcwhere"dt was the e#ect si&e for the treatment group"dc was the e#ect si&e for the comparison group"

    dig was the *nal I:PP or I:P> e#ect si&e reported in theTa$les and >igures"

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    Mt-post and Mc-post were the mean values for the treatmentgroup /t-post or the comparison group /c-post at posttestor at follow-up"Mt-pre and Mc-pre were the mean values for the treatmentgroup /t-pre or the comparison group /c-pre at pre-test"SDc-pre and SDc-pre were the standard deviations at pretest.

    9ence" dig was the treatment e#ect si&e net of the comparisongroup e#ect si&e. When dig was positive this indicateda larger e#ect in the treatment group than in the comparisongroup. When dig was negative this indicated a larger e#ectin the comparison group than in the treatment group.We used pre-test SDs for all calculations" as suggested$y %ecer /!BB" $ecause pre-test SDs are often moreconsistent across studies than post-test SDs. The use of pretestSDs to estimate e#ect si&es" therefore" results in estimatesthat are more compara$le across di#erent e'perimentalmanipulations /in this case" $etween studies of PCIT andTriple P. Post-test SDs have $een found to $e less consistentthan pre-test SDs as a result of di#erent e'perimental

    manipulations. We ept single group e#ect si&es separatefrom independent group e#ect si&es" $ecause there is continuingde$ate a$out when these can $e com$ined" and $ecausesingle group e#ect si&es are often larger than independentgroup e#ect si&es /see Carlson 0 chmidt" != )orris 01ehon" 2662. (lthough there are many reasons that singlegroup and independent group e#ect si&es might di#er and$oth study designs can have their own $iases" one reasonsingle group e#ect si&es often are larger is $ecause they donot tae into account the time e#ect /e.g." history or maturatione#ect that can $e partly accounted for $y a comparisongroup /)orris 0 1ehon" 2662.PCIT eect sizesThirteen studies were included in calculations of :PP e#ectsi&es= eight studies were included in calculations of I:PPe#ect si&es. >our studies were availa$le for calculations of:P> and I:P> e#ects.We calculated the following for child$ehavioral outcomesH 3L :PP e#ects" 6 :P> /4 month to! year after treatment e#ects" 4 I:PP e#ect si&es" and !4I:P> e#ect si&es. >or parenting $ehaviors" we calculated 4K:PP e#ects" !4 :P> /4 month to ! year after treatmente#ects" L4 I:PP e#ects" and !3 I:P> e#ects.Triple P eect sizesAleven studies were included in the calculations of :PP=whereas seven studies were included in calculations of I:PP

    There were no studies with comparison groups that includeda follow-up assessment.We calculated the following for child$ehavioral outcomesH KB :PP e#ects" 2K :P> /4 month to! year after treatment e#ects" and L I:PP e#ects. >or parenting$ehaviors" we calculated KK :PP e#ects" LL :P> /4month to ! year after treatment e#ects" and L6 I:PP e#ects.!eduction of eect sizes and "nal analysisA#ect si&es were categori&ed $y purpose of the measure /toassess child or parent" method /@uestionnaire versus o$servationand reporter /mother" father" teacher. In some cases"e#ect si&es in the same category within a study were averagedafter accounting for repetition from multiple studiesfrom the same sample. This averaging was done to reduce

    $ias that might $e introduced from studies that used moremeasures" and *ndings reported in more than one pu$lication

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    were included only once. In sum" we report one e#ectsi&e per study sample for /a child $ehavior $y method andreporter and /$ parenting $y method and reporter. A#ectsi&es were analy&ed with 1T(T /ohnson" !B to compute$ias-corrected summary e#ect si&es" con*dence intervals"r values" to e'amine homogeneity of e#ect si&es and

    outliers" and to compare e#ect si&es for PCIT to those forTriple P. ince there was homogeneity of e#ect si&es in allanalyses" we did not e'amine correlates of e#ect si&es.)ost o$servational and survey measures used within trialsof PCIT and Triple P were for the assessment of negativechild or negative parenting $ehaviors. 9ence" e'ceptin the cases of observations of positive child or parent $ehavior"negative e#ect si&es were e'pected as they wouldindicate declines in pro$lem $ehaviors from pre-treatmentto later assessments in studies with single group repeated measurement designs" andgreater declines in the treatmentgroup compared to the comparison group in studies with independentgroups repeated measurement designs. With the

    e'ception of one PCIT study /Ay$erg 0

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    in PCIT compared to a normal comparison group. A#ectsi&es ranged from an a$solute value of !.2!M!.LK. Whencompared to a deviant community group" teachers reportedgreater improvements in negative $ehaviors of children inPCIT d R!.!3 however there were no signi*cant e#ectsfor o$servations of positive $ehavior in the classroom.

    #bbreviated PCIT7o signi*cant e#ects of ($$reviated PCIT were foundwhen child $ehaviors were compared to waitlist comparisongroups /see Ta$le 2. When ($$reviated PCIT participantswere compared to a normal community comparison group"there was no signi*cant e#ect on o$served positive child$ehavior" $ut there was signi*cant improvement for PCITparticipants when child $ehaviors were assessedwith motherreport" d R!.LK.$nhanced PCIT7o comparisons of Anhanced PCIT /PCIT N motivation orPCIT N motivation N individual versus waitlist comparisongroups were conducted. Instead" in one study" parents

    with a history of maltreating their children were assigned toPCIT N motivation or a community group didactic intervention.In this study" parent-reports of child $ehavior werecollected" and the e#ect of PCIT was large" d R.B /seeTa$le 2. ( large e#ect on mother-reported child $ehaviorpro$lems also was found for a PCIT N motivation N individualintervention when compared to a community groupdidactic intervention" d R2.!3.Parent change during treatmentH ingle grouptreatment e#ectsThere were signi*cant changes in parenting outcomes pretreatmentto post-treatment"with e#ect si&es for negative andpositive parenting ranging from an a$solute value of !.!!M.!! /see Ta$le . The only e'ception was a nonsigni*cante#ect si&e found for father-reported negative $ehaviors inone small study of !2 fathers" d R.3B.)edium to large e#ectswere found for clinic o$servationsof negative parent $ehaviors and parent-report measures ofnegative parent factors from pre-treatment to follow-up. A#ectsi&es ranged from an a$solute value of .3! to .4.ParentingH Treatment versus comparison groupsStandard PCITThere was more improvement in parent $ehavior and functioningamong parents in PCIT than those in a waitlist. (lle#ect si&es e'cept one /o$servations of fathersF negative

    $ehaviors in one small study of 22 fathers were signi*cantand usually large in magnitude" d ranged from an a$solutevalue of .K3 to L.3K /see Ta$le . imilar large e#ects ofPCIT were found for o$servations of mothers" d R!.6"and mother-reports of their parenting" d R!.L" whencompared to mothers in a normal community comparisongroup.

    Ta$elll

    #bbreviated PCITCompared towaitlist" medium or large e#ects of($$reviated

    PCIT were found for o$served changes in positive" d .2"$ut not negative" parenting $ehavior and mother-reports of

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    their parenting" d R.K4 /see Ta$le . When negativeparenting $ehaviors of participants in ($$reviated PCITwere compared to a normal community group" there weremoderate to large e#ects on clinic o$servation of negativeparental $ehavior" d R.B2" and mother reports of their$ehaviors" d R.KL.

    ta$el

    $nhanced PCITThere was a large e#ect when Anhanced PCIT N motivationwas compared to a community group didactic interventionfavoring Anhanced PCIT on all parent measures"d ranged from an a$solute value of !.!L to !.3L /seeTa$le . Anhanced PCIT N motivation N individual alsowas compared to a community group didactic interventionon all parent measures. Qarge e#ect si&es ranging from ana$solute value of .B3 to 4.K favoring Anhanced PCIT Nmotivation N individual also were found for o$served negative

    and positive parent $ehavior and negative parenting$ased on self-report.Results: Triple PChild $ehavior change during treatmentH ingle grouptreatment e#ects>or Triple P" small and medium e#ects were found forsingle group pre- to post-treatment child $ehavior /seeTa$le 4. Clinic o$served negative child $ehavior" negativechild $ehavior measured $y $oth mother and father reportsand stepparent reports of negative child $ehavior improved.A#ect si&es ranged from an a$solute value of .! to .K.9owever" a small study of children with teacher reports of child $ehavior did not yield asigni*cant e#ect si&e. (nalysesof single group pre-to follow-up data on child $ehaviorresulted in small and medium e#ect si&es for all measures" dranged from an a$solute value of .3 to .K6 /see Ta$le 4.

    Ta$ell

    Child $ehaviorH Treatment versus comparison groupsStandard Individual Triple P)edium e#ects were found in favor of tandard IndividualTriple P when compared to waitlist comparison group when

    child negative $ehavior was reported $y mothers /or mi'edmothersfathers" d R.3 or $y fathers" d R.36 /seeTa$le 4. This did not hold for clinic o$servations of negativechild $ehavior and one study including reports from 42stepparents.Group Triple PWhen compared to a waitlist control" a medium e#ect wasfound for tandard :roup Triple P when $ased on mother/or mi'ed motherfather report" d R.3K /see Ta$le 4.7o studies used o$servational methods or collected reportsfrom individuals other than parents.$nhanced Triple PWhen Anhanced Triple P was compared to waitlist" medium

    and large e#ect si&es favoring Anhanced Triple P were foundfor clinic o$servations of negative child $ehavior and father

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    and mother reports of negative child $ehavior. A#ect si&esranged from an a$solute value of .43 to .3 /see Ta$le 4. Ina small study of 26 teachers" there was no signi*cant e#ect of Triple P when negativechild $ehavior was compared to awaitlist comparison group.Self%directed Triple P

    )others in elf-1irected Triple P reported moderate improvements"d R.L!" while fathers reported large improvementsin their childrenFs $ehavior" d R!.23" comparedto waitlistmothers and fathers /see Ta$le 4. 7o signi*cante#ect on clinic o$servations of child negative $ehaviorwas found.Media Triple PCompared to waitlist" )edia Triple P had a large e#ect onchild $ehaviors as reported $y parents" d R.K.Parent change during treatmentH ingle grouptreatment e#ectsmall and medium e#ects on parenting $ehaviors werefound in analyses of single group pre-to post-treatment data"

    d R.K6 for mother report and d R.B for father report/see Ta$le L. Therewas no signi*cant e#ect for o$servationsof negative parent $ehavior. mall and medium e#ects werefound for pre-to follow-up changes in parenting self-reportmeasures for mother report and father report and o$servednegative parent $ehavior ranging from an a$solute value of.2B to .3.ParentingH Treatment versus comparison groupsStandard Individual Triple PWhen compared to waitlist" tandard Individual Triple Phad a large e#ect favoring the Triple P intervention when$ased on mother /or mi'ed motherfather reports of parenting"d R!.6K" and a medium e#ect $ased on fatherreports of parenting" d R.46 /see Ta$le L. 9owever"this did not hold for clinic o$served negative parent$ehaviors.Group Triple PCompared to a waitlist comparison group" a medium e#ectsi&e was found in favor of tandard :roup Triple P when $ased on mother /or mi'edmotherfather reports of theirparenting" d R.3 /see Ta$le L.

    Ta$ell

    $nhanced Triple PWhen comparing Anhanced Triple Pwithwaitlist" therewerestatistically signi*cant e#ects favoring Anhanced Triple Pfor measures of negative parent factors as reported $y mothers/or mi'ed motherfather= large e#ect" d R.B andfathers" d R.43 /medium e#ect" see Ta$le L. Thisdid not hold for clinic o$servations of negative parent$ehaviors.Self%directed Triple PWhen we analy&ed *ndings comparing elf-1irected TripleP to waitlist" large and small e#ects favoring elf-1irected Triple P were found $ased on mother /or mi'edmotherfather report" d R!.44" and father report"

    d R.3" respectively /see Ta$le L. This did not holdfor o$served negative parent $ehavior.

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    MediaThere was no signi*cant e#ect of )edia Triple P on parenting$ased on self-report @uestionnaire.Results: Comparison of PCIT and Triple PWe used categorical modeling to compare the e#ect si&esfor PCIT and Triple P /ohnson" !B. We conducted analyses

    to compare :PP e#ect si&es" and compared I:PP fortandard PCIT /compared to waitlist to the multiple formsof Triple P /compared to waitlist.ingle group pre-treatmentpost-treatment /:PPe#ect si&es>or :PP" PCIT had larger e#ects of parent report of childnegative $ehaviors" $ut not when e#ect si&es were $asedon o$served child $ehaviors. )ore speci*cally" there wasa larger improvement for study families in PCIT than inTriple P for parent-report of child $ehavior pro$lems" R!.!vs. R.K"p&.66! /seeTa$les 2ML. 9owever" there was nodi#erence in :PP e#ect si&e for o$served child negative$ehavior" R.L4 vs. R.!"p .2K.

    >indings when comparing :PP for parenting pro$lemsshowed that PCIT had larger e#ects for $oth parent reportand o$served parent negative $ehaviors. There was a largerimprovement for study families in PCIT than in Triple Pwhen outcomes were $ased on parent report of parentingpro$lems" R!.!! vs. R.K6"p&.66!. There also was a largerimprovement in o$served parent negative $ehavior for PCITthan Triple P" R!.43 vs. R.!"p&.66!.Independent groups pre-treatmentpost-treatment/I:PP e#ect si&esChild ne'ative behaviors>igure ! shows I:PP e#ect si&es and con*dence intervalsfor the four forms of PCIT and *ve forms of Triple P whencompared to waitlist. The e#ects in >ig. ! are $ased onparent-reports of child negative $ehavior. (s shown" therewere large e#ect si&es for child negative $ehavior in all formsof PCIT" e'cept the ($$reviated version" which did not havea signi*cant e#ect on child negative $ehavior. There weremedium to large e#ects for all forms of Triple P.(s can $e seen $y comparing the con*dence intervals in>ig. !" results of our analyses that compared tandard PCITto multiple forms of Triple P showed di#erences in PCIT andsome forms of Triple P for parent report of child negative$ehaviors. The e#ect si&e for PCIT" R!.4L"was signi*cantlylarger than the e#ect si&es for elf-directed" R.L!"p&.66!"

    :roup" R.3K"p&.6!" and Individual Triple P" R.3"p&.6!"$ut the PCIT e#ect si&e was not larger than the e#ect si&efor Anhanced" R.3" or )edia Triple P" R.K. 9owever" incontrast to these *ndings" for I:PP $ased on o$served childnegative $ehaviors" there were no di#erences in the e#ectsi&e for tandard PCIT" .!!" compared to Triple P in theelf-directed" R.62" Individual" R.22" and Anhanced" R.43"forms /*gure not provided.Parent ne'ative behaviors>igure 2 summari&es I:PP e#ect si&es $ased on parent reportsof parent negative $ehavior" and illustrates that all formsof PCIT and Triple P" e'cept )edia Triple P" had medium orlarge e#ects. )edia Triple P did not have a signi*cant e#ect

    on self-reported negative parent $ehavior. (ll other interventionsreduced negative parenting of those in treatment

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    when compared to waitlist. 8f these e#ective interventions"($$reviated PCIT and :roup Triple P had the most modeste#ects on parenting" $ut e#ect si&es were still medium in si&eand @uite similar to other" often more intensive and longerforms of these interventions /i.e." all con*dence intervals hada range of values in common.

    When we statistically compared tandard PCIT to formsof Triple P" PCIT had a larger e#ect when compared to)edia Triple P" $ut not when compared to other forms ofTriple P= the e#ect si&e for tandard PCIT" R!.!3" was notdi#erent when compared to elf-directed" R!.44" :roup"R.3" Individual" R!.6K" and Anhanced Triple P" R.B. ;et"PCIT did have a larger e#ect on parent report of parentingpro$lems than media Triple P" R.4L"p&.6L. 9owever" for I:PP of o$served parentnegative $ehaviors" tandard PCIThad a larger e#ect si&e" R.K3" than Triple P in the elfdirected".6K"p&.6!" Individual" .!4"p&.6!" and Anhanced"R.!!"p&.6L" forms /*gure not provided.

    :am$arrr

    .iscussion%ehavioral parent training is a popular form of parentingintervention /)c)ahon 0 >orehand 266= 7i'on" 2662=anders et al." 266= We$ster-tratton 0 Taylor 266!and has $een descri$ed as e+cacious in previous metaanalyticand reviewarticles /%arlow0tewart-%rown" 2666=eretich 0 1umas !3. In an attempt to go $eyond statementspertaining to the e+cacy of $ehavioral parent trainingas a $road category" our review and meta-analyses descri$edthe reported e+cacy of two parenting interventions withnown $ehavioral parent training origins. The interventionswere chosen for this review due to their similar theoreticalfoundations" and their wide-spread dissemination" popularityand signi*cant level of government funding in $oth the,( and (ustralia" $ut their di#ering modes of delivery.

    :am$arrr

    We analy&ed 24 evaluations of Parent-Child InteractionTherapy /PCIT and Triple P-Positive Parenting Program.>indings revealed that these interventions improve parenting"such as improving parental warmth" decreasing parental hostility"increasing parental self-e+cacy" and reducing parental

    stress. )ost versions of these interventions also reduce negativechild $ehaviors" such as aggression and e'treme tantrumsand opposition. These results put numerical weight $ehindprevious narrative reviews in which authors have concludedthat interventions are e#ective when they include $ehavioralparent training /7i'on" 2662= We$ster-tratton 0 Taylor"266!= Weis&" 9awley" 0 ensen 1oss" 2664.Participation in PCIT and Triple P results in improvementsin child $ehavior and parenting from pre- to post-treatment/i.e." short-term improvements in $ehavior. In addition"although few studies included follow-up $eyond immediatepost-treatment" there was some support from prospectiveassessment of treatment participants for continued positive

    e#ects of these interventions up to months after interventioncompletion. 9owever" conclusions regarding long-term

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    e#ectiveness of either intervention must remain tentative.>ollow-up data collected from treatment participants werenever compared to waitlist or alternative treatment groups.)ore speci*cally" follow-up data were not collected fromwaitlist participants for any of the Triple P studies and followupdata only were collected from a social validation group

    in only one series of PCIT studies in (ustralia /7i'on et al."266" 2664.>indings show that the strength of the e#ects of PCITand Triple P" and conclusions a$out which intervention mayresult in greater improvements in parenting and family functioning"depended on the measures used to assess outcomesand the su$type of each intervention. (lthough *ndings werenot without e'ception" tandard PCIT tended to have largere#ects than Triple P when compared to waitlist and whenoutcomes were $ased on parent report of child negative $ehaviorsand o$served parent negative $ehaviors. In contrast"there was no e#ect si&e di#erence when *ndings were $asedon o$served child $ehaviors and only one di#erence /tandard

    PCIT vs. )edia Triple P for parent report of parenting.In addition" tandard PCIT did not have a larger e#ect thanAnhanced Triple P" e'cept when comparing o$served parentnegative $ehavior.>or some intervention types and when o$servational measureswere used" e#ects were not consistently found to $edi#erent from 6 /i.e." e#ectswere not signi*cant. igni*canttreatment e#ects on children(s behaviors were found for $othTriple P and PCIT interventions when outcomes were assessedvia female caregiver /or com$ined femalemale caregiverreports or o$servation. A#ects were generally mediumfor Triple P and large for PCIT. The e'ceptions were a largee#ect si&e for Anhanced Triple P and a small and nonsigni*cante#ect si&e for ($$reviated PCIT. A#ect si&es $asedon teacher reports were calculated on single studies withsmall samples" and were rarely as large as those $ased onfemale caregiver report or o$servation and often did notshow signi*cant improvements in childrenFs $ehaviors" $utimprovements among PCIT participants were greater thanwaitlist comparison groups />under$ur et al." !B= 9oath0 anders" 2662= )c7eil et al." !!. Qarge e#ect si&eswere found for father reports of child $ehavior and parentingwhen PCIT was compared to a waitlist /%restan et al."!K= 7i'on et al." 266" 2664= chuhmann et al." !B andsmall to large e#ects were found with the same measures

    for Anhanced Triple P and elf-1irected Triple P /Connellet al." !K= anders" )arie-1adds et al." 2666. Parentingduring elf-1irected Triple P did not signi*cantly improvewhen father reported $ehaviors.Considerations for the generali&ation of study *ndingsThere are three ey issues to consider when generali&ing theresults of the current meta-analyses. (ll issues come fromthe sampling details included in studies and the measurementstrategies used. >irst" the demographic characteristicsof families included in many of the studies were unclear ormay have $een limited to moderate or higher income families.8nly two of the Triple P studies had participants withinthe lower socio-economic status /A group and with low

    parent education /9oath 0 anders" 2662= anders et al."2664. anders and )c>arland /2666 reported participants

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    in the low A range" however failed to report parental education.(lthough sometimes unclear" all other participants inTriple P studies appeared to have $een from middle class orhigher A groups and" with the e'ception of one study /%or"anders" 0 )arie-1adds" 2662" middle or higher levels ofparental education. 1ue to the high num$er of Triple P studies

    in the meta-analysis with middle or higher A" it is notcertain that *ndings can $e generali&ed to low income orhigh ris groups at this time.With the e'ception of three studies from one study group/7i'on" 266!= 7i'on et al." 266= 7i'on et al." 2664" participantdemographic data were not consistently reportedin studies of PCIT. When income or educational informationwasreported" participantswere low-to-mid A /Ay$erget al." 266!=9ood0Ay$erg" 266=7i'on" 266!=7i'on et al."266" 2664= )c7eil et al." !!= chuhmann et al." !B.In the cases when education was reported" PCIT participantshad moderate levels of education /%restan et al." !K=Ay$erg 0

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    of child $ehaviors" there were some di#erences in the o$servationalmeasures of children and parents" and measuresthat assessed parenting" and we cannot rule out the possi$ilitythat di#erences are due to the use of di#erent measures.>or e'ample" 1PIC /amily 8$servation chedule" anders etal." !3" cited in anders" )arie-1adds et al." 2666 wasused to assess o$served $ehaviors of children and parents.(lthough the >8 was developed to assess the aims of TripleP it does not directly follow treatment activity nor is progressionof treatment relative to this measure" whereas coachingof PCIT sills is directly lined to the 1PIC. >urther" families

    are repeatedly videotaped and coded for o$served $ehaviors/using 1PIC results throughout PCIT sessions toguide intervention strategies and this is not done in TripleP. These di#erences may have made it more liely to *ndo$served improvements in child and parent $ehaviors amongfamilies in PCIT /Weis&" Weiss" 9an" :ranger" 0 )orton"!L. 8verall" including o$servational measures in additionto parent report measures is recommended for future studies"and the *nding of more signi*cant e#ect si&es in PCIT thanin Triple P when using o$servational measures may showthat it is advantageous" $oth for intervention developmentand outcome studies" to develop o$servational measures thatare designed to test speci*c intervention aims /as has $eendone in PCIT.Implications for clinical practice and interventiondisseminationTriple P and PCIT $oth have $een designed to provide participantswith a range of intervention options. >or e'ample"therapist contact time and length of service delivery variesfor Triple P - from )edia Triple P and elf-1irected TripleP with minimal therapist involvement" to :roup Triple Pand tandard Individual Triple P. Anhanced Triple P alsois availa$le" which is administered individually and includesadditional sessions on coping sills and partner support. 1ueto the limited num$er of comparison studies of various intervention

    types" it is di+cult to determine the $ene*ts ofthe enhanced intervention versions. Currently the *ndingsdo not clearly support the additional $ene*ts of concurrenttreatment options for families" such as those provided in AnhancedTriple P and Anhanced PCIT. When compared to awaitlist control" elf-1irected Triple P /with minimal therapistcontact produced similar e#ect si&es when compared toAnhanced Triple P. Qarger e#ects were found for PCIT withthe addition of a motivational enhancement and individualservices /PCITN)AN I when compared to ($$reviatedPCIT. 9owever" these large e#ect si&es for PCITN)ANIwere liely inGuenced $y the structure of the intervention.Cha+n et al. /2664 reported that participants were re@uired

    to succeed in the motivational component prior to commencingPCIT. This re@uirement may have inGated e#ect si&es"

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    $ecause participants who entered and completed PCIT hadalready completed a 3-wee motivational course and" althoughretention rates for the motivation course were reported"the overall attrition rate was unclear. These mi'ed*ndings are consistent with

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    treatment.EWe were precluded from descri$ing Triple P as awell-esta$lished treatment" $ecause our search revealed thatTriple P evaluations have not yet $een conducted $y twoindependent investigators or investigatory teams. :iven theneed to mae choices a$out how resources are allocated for arange of interventions" independent trials of PCIT and Triple

    Pwith longer-term follow-up and cost-e#ectiveness analysesshould $e conducted.amily Interaction