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Caregivers of children with health problems have been demonstrated to show poorer physical and psychological health than caregivers of healthy children. It has been suggested that child behavioural problems are key and account for a large proportion of the variance in caregiver health. Currently, the relation between behaviour problems and caregiver health remains unclear. We conducted a meta-analysis and a secondary data analysis using national data to describe and compare the associations between internalizing and externalizing behaviour problems and caregiver health. Meta-analytical results suggest an association between child behaviour problems and parental stress, depression, and presence of psychiatric symptoms. National data analyses suggested an important association between child behaviour problems, particularly externalizing behaviour problems, and caregiver physical and psychological health when accounting for socioeconomic variables. Results suggest mothers may be more impacted than fathers, and that externalizing behaviour problems may contribute to bigger caregiver health effects than internalizing behaviour problems.

Background: Conduct problems (CPs), a persistent pattern of challenging, oppositional, defiant or aggressive behaviour are a significant concern to educators, families and other professionals. CPs in preschool children are related to poorer educational and social outcomes in addition to a range of behavioural and emotional difficulties. Although there is evidence for hereditary and temperamental influences, parental factors are widely considered to be significant in the development of CPs. Parents experiencing psychological or social distress are considered to be at risk for challenging behaviour in their children. Psychologists and other theorists have suggested several possible reasons for this association. Firstly, it is possible that parents in distress have difficulty managing stress and as a result use harsh, inconsistent or coercive approaches to parenting. Secondly, parents with children who have CPs may be low in parental self efficacy, a consistent belief in their capacity to parent, which leads them to parent ineffectively and inconsistently. A third possibility is that parents in distress struggle to form stable attachments with their children which can lead to later behavioural difficulties. Finally, it is possible that parent’s distress is influenced by external contextual factors which also influence children such as family or social conflict. Studies suggest that training programmes for the parents of preschool children are effective in reducing child behaviour problems. Training approaches are influenced by a combination of psychological theories including behaviourist, social-cognitive, attachment and ecosystemic approaches. There have been many quantitative evaluations supporting the use of parent training programmes (PTPs). However, there has been limited inquiry into the process of PTPs from the perspective of those who attend them. Aims: The first part of this study was designed to evaluate vulnerability factors related to conduct problems; parental self efficacy, stress and child behaviour problems over the course of a community parent training programme designed to help participants to understand and manage the behaviour of young children. The overall research aim was to evaluate the outcomes and process, using different methodologies to address several questions. A realist methodology was applied to evaluating: 1. was there an association between parental stress, parental self efficacy and child behaviour problems at the start of the programme consistent with the established theory? 2. Did the parents attending the course experience higher than expected levels of stress and child behaviour problems? 3. Did quantitative and qualitative data indicate that these vulnerability factors changed over the duration of the course? Finally, an interpretivist methodology was used to explore how parents of young children evaluated as at risk of challenging behaviour described the experience of learning in the programme. Methods: The study utilised a pragmatic approach to evaluation with mixed methods and differing methodologies. At the start of the programme, a cohort of 38 parents agreed to participate in the study prior to the programme and completed self report measures related to parental stress and parental self efficacy. Parents with concerns about the behaviour of a child aged over three also completed a questionnaire relating to child behaviour problems. Of the original cohort, 27 completed self report measures at the end of the programme. 17 parents completed the same measures at a follow up meeting at the Children’s Centre, five to six weeks after the programme was completed. At this meeting 16 parents were interviewed to discuss their experience of the programme and any subsequent changes which had occurred. Results The results of the first part of the evaluation suggested a significant relationship between parental self-efficacy and stress and between stress and child behaviour problems. However, there was no statistical association between self-efficacy and child behaviour problems, as expected. This tentatively indicates that parental self-efficacy is less important in the development of child behaviour problems than has been previously suggested. The analysis of stress data at the start of the programme indicated that the frequency of parents reporting moderate to extremely severe stress was 4.42 times that which would be expected in a typical British cohort. At the start of the programme, frequency of child behaviour problems in the cohort were 5.9 times higher with conduct problems being 9 times what would be expected based on British norms. This suggests that the programme is being accessed by parents whose children are evidencing behaviour problems and, in particular, conduct problems. However, methodological issues are likely to have led to a slight overestimate of relative prevalence of child CPs in the cohort. Results indicated that parents reported significantly increased self efficacy, significantly reduced stress and child behaviour problems, including conduct problems, between the start and end of the programme. Thematic analysis and subsequent content analysis of outcome themes from interviews suggested that the majority of parents interviewed identified changes in parenting behaviour, knowledge, confidence, reduced stress and improved child behaviour as outcomes from the programme. However, changes in the quantitative data were not observed as frequently, reliably or to the same extent in the interview subgroup as they were in the main cohort, suggesting a sampling bias or a discrepancy in findings between methods. The self report data and interviews for all interviewees were then reviewed and interviews with six parents evaluated as having moderate to high stress, social or psychological difficulties and possible child behaviour problems were sampled. These were then re-analysed using a rigorous inductive approach to Thematic Analysis to identify emergent themes relating to the experience of participating and learning through the programme. Six themes emerged from analysis including; Understanding Difficulties, Identifying and Connecting, New Knowledge, Stopping and Thinking, Approach and Interaction and Reconstructing. The Understanding Difficulties theme described the different ways in which parents understood of their difficulties relating to themselves, their children and others which motivated them to attend the programme. The Identifying and Connecting theme described the importance to parents of personal identification with several aspects of the programme in terms of “being understood” in addition to identifying connections with established support, learning objectives and personal development goals. New Knowledge was categorised into three sub-themes of theoretical, practical and contextual. Contextual knowledge was constructed as understanding the experience of other parents, for example, identifying that other parents had similar difficulties. Theoretical knowledge about child behaviour and development encouraged parents to “stop and think” about the reasons for their children’s behaviour. Practical knowledge was constructed as parenting strategies which, when used, helped parents to feel more confident in themselves, more relaxed and more in control. The Stopping and Thinking theme described parents withholding action and considering the motivations for their children’s behaviour or the best approach to interacting with them. Approach and Interaction described changes to the way parents interacted with their children. The parents in question described changed or reconstructed understandings of their children, themselves and their difficulties as a result of participating in the programme. The theoretical implications of analysing the learning experience are that it highlights the importance of personal identification with the course objectives and experience.

This thesis presents a program of research evaluating the implementation of a primary care intervention program for disruptive child behaviour, and the process of dissemination of the intervention to primary care staff. The specific aims were to: 1) evaluate the effectiveness and acceptability of a brief, preventive behavioural family intervention (BFI) administered by primary care staff in improving parenting skills and confidence and reducing targeted child behaviour problems; 2) assess the process of disseminating the intervention to primary care professionals by evaluating aids and obstacles for program implementation in the workplace; and 3) provide recommendations for future dissemination of psychological interventions. Childhood disruptive behaviour problems are becoming increasingly prevalent and are associated with significant personal and societal costs. Much is now known about the development of such problems, including individual, family and social risk and protective factors. There is considerable evidence that BFI programs are effective in reducing child behaviour problems and the family risk factors associated with the development and maintenance of these problems. Unfortunately, many evaluated programs have not been disseminated effectively, and have primarily been provided to clinical or high-risk populations in efficacy trials. Primary care settings have been increasingly identified as ideal settings for detection and early intervention for child mental health problems. However, there is limited research in the area of primary care BFI. While dissemination of psychological innovation to psychologists has historically been poor, with little impact on the professional practices of practitioners in the field, documentation of dissemination of these interventions to non-psychologists is rare. Although dissemination and diffusion theory have expanded, there is little controlled research evaluating the necessary or optimal conditions for the adoption and ongoing implementation of evidence-based programs. To address the problem of poor dissemination and limited access to evidence-based parenting programs in the community, a multilevel parenting and family support initiative, the Triple P-Positive Parenting Program, has been developed at the University of Queensland. One level of this system, Primary Care Triple P, encompasses a preventively oriented, early intervention program that aims to promote positive, caring relationships between parents and their children and to help parents develop effective management strategies for a variety of common behavioural and developmental issues. This primary care intervention was trialled and disseminated in the current research. Study 1 examined the effectiveness of Primary Care Triple P implemented by child health nurses with clients requesting help for child behaviour problems. A randomised group methodology was employed, comparing the intervention with a waitlist control condition. Assessments were completed at pre, post and 6-month follow-up. Data are presented for 26 families. In comparison to the waitlist condition, families receiving the intervention showed a significant reduction in targeted child behaviour problem/s according to monitoring and mother-report. Mothers receiving the intervention also reported significantly reduced dysfunctional parenting practices, greater satisfaction with their parenting role, and decreased anxiety and stress following the intervention in comparison to waitlist mothers. No group differences were found for observed parent-child interaction. However, rates of observed disruptive child behaviour and aversive parent behaviour were low from the outset. Consumer satisfaction with the program was high, and intervention gains were primarily maintained at 6-month follow-up. These results provide some of the first effectiveness outcomes from a randomised controlled trial of BFI in a primary care setting, and establish the effectiveness and acceptability of Primary Care Triple P conducted by child health nurses as part of usual practice. Study 2 examined the implementation of Primary Care Triple P following professional training in the program. Results of a survey of 1078 professionals are presented. A model of the personal, program, training and workplace factors influencing program implementation was tested. Structured equation modelling confirmed that practitioner self-efficacy mediated the relationship between program characteristics and program implementation. Prior professional experience and satisfaction with training did not predict self-efficacy or uptake. Workplace support was also directly associated with program implementation. These results advance our knowledge of the aids and obstacles faced by practitioners in implementing a new program in the workplace. This research provides important new knowledge in relation to improving early access to empirically-supported intervention services and has implications for the potential scope of service delivery in primary care settings. It also advances our understanding of the factors influencing a professional’s ability to implement a new intervention program following training. This information may inform the development of future dissemination efforts, allowing them to address necessary program, personal and workplace supports, and optimise program implementation following training.

This thesis presents a program of research evaluating the implementation of a primary care intervention program for disruptive child behaviour, and the process of dissemination of the intervention to primary care staff. The specific aims were to: 1) evaluate the effectiveness and acceptability of a brief, preventive behavioural family intervention (BFI) administered by primary care staff in improving parenting skills and confidence and reducing targeted child behaviour problems; 2) assess the process of disseminating the intervention to primary care professionals by evaluating aids and obstacles for program implementation in the workplace; and 3) provide recommendations for future dissemination of psychological interventions. Childhood disruptive behaviour problems are becoming increasingly prevalent and are associated with significant personal and societal costs. Much is now known about the development of such problems, including individual, family and social risk and protective factors. There is considerable evidence that BFI programs are effective in reducing child behaviour problems and the family risk factors associated with the development and maintenance of these problems. Unfortunately, many evaluated programs have not been disseminated effectively, and have primarily been provided to clinical or high-risk populations in efficacy trials. Primary care settings have been increasingly identified as ideal settings for detection and early intervention for child mental health problems. However, there is limited research in the area of primary care BFI. While dissemination of psychological innovation to psychologists has historically been poor, with little impact on the professional practices of practitioners in the field, documentation of dissemination of these interventions to non-psychologists is rare. Although dissemination and diffusion theory have expanded, there is little controlled research evaluating the necessary or optimal conditions for the adoption and ongoing implementation of evidence-based programs. To address the problem of poor dissemination and limited access to evidence-based parenting programs in the community, a multilevel parenting and family support initiative, the Triple P-Positive Parenting Program, has been developed at the University of Queensland. One level of this system, Primary Care Triple P, encompasses a preventively oriented, early intervention program that aims to promote positive, caring relationships between parents and their children and to help parents develop effective management strategies for a variety of common behavioural and developmental issues. This primary care intervention was trialled and disseminated in the current research. Study 1 examined the effectiveness of Primary Care Triple P implemented by child health nurses with clients requesting help for child behaviour problems. A randomised group methodology was employed, comparing the intervention with a waitlist control condition. Assessments were completed at pre, post and 6-month follow-up. Data are presented for 26 families. In comparison to the waitlist condition, families receiving the intervention showed a significant reduction in targeted child behaviour problem/s according to monitoring and mother-report. Mothers receiving the intervention also reported significantly reduced dysfunctional parenting practices, greater satisfaction with their parenting role, and decreased anxiety and stress following the intervention in comparison to waitlist mothers. No group differences were found for observed parent-child interaction. However, rates of observed disruptive child behaviour and aversive parent behaviour were low from the outset. Consumer satisfaction with the program was high, and intervention gains were primarily maintained at 6-month follow-up. These results provide some of the first effectiveness outcomes from a randomised controlled trial of BFI in a primary care setting, and establish the effectiveness and acceptability of Primary Care Triple P conducted by child health nurses as part of usual practice. Study 2 examined the implementation of Primary Care Triple P following professional training in the program. Results of a survey of 1078 professionals are presented. A model of the personal, program, training and workplace factors influencing program implementation was tested. Structured equation modelling confirmed that practitioner self-efficacy mediated the relationship between program characteristics and program implementation. Prior professional experience and satisfaction with training did not predict self-efficacy or uptake. Workplace support was also directly associated with program implementation. These results advance our knowledge of the aids and obstacles faced by practitioners in implementing a new program in the workplace. This research provides important new knowledge in relation to improving early access to empirically-supported intervention services and has implications for the potential scope of service delivery in primary care settings. It also advances our understanding of the factors influencing a professional’s ability to implement a new intervention program following training. This information may inform the development of future dissemination efforts, allowing them to address necessary program, personal and workplace supports, and optimise program implementation following training.