MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 13: 357 369 (2007)

PRIMARY AND SECONDARY EFFECTS OF PARENTING AND STRESS MANAGEMENT INTERVENTIONS FOR PARENTS OF CHILDREN WITH DEVELOPMENTAL DISABILITIES: A META-ANALYSIS
George H.S. Singer,* Brandy L. Ethridge, and Sandra I. Aldana
Gevirtz Graduate School of Education, Department of Education, University of California, Santa Barbara, Santa Barbara, California

A meta-analysis of the group intervention research for parents of children with developmental disabilities was conducted in order to characterize the efficacy of treatments in reducing depressive symptoms and other forms of psychological distress associated with stress in parents of children with developmental disabilities. An extensive search led to the identification of 17 studies which were divided into three categories for comparative purposes: parenting education studies usually based on behavioral parent training, coping skills education studies based primarily on cognitive behavioral training, and studies that combined these methods along with other support services. Studies were rated for the quality of the research designs and of the reports. Consistent positive benefits were found in the form of reductions in parents distress, and these effects were comparable to those reported in other syntheses of parenting interventions for parents of children without disabilities. The studies were evaluated in order to assess whether or not they met standards for established evidence-based practices. On the basis of the quality and number of the randomized trials, we present evidence to support the claim that there are established evidence-based interventions for reducing psychological distress at least in middle-class mothers in the short term. The interventions for fathers are promising as are the data on somewhat longer-term effects. The need for replications with a more diverse group of parents and longer-term follow-up were discussed. Multiple component interventions addressing both parent well-being and behavioral parent training were significantly more effective than either behavioral parent ' 2007 Wiley-Liss, Inc. training or cognitive behavioral training along.
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Key Words: meta-analysis; developmental disability; treatment efficacy; parent training; stress management; evidence-based treatment

ontemporary scholarship on families of children with developmental disabilities has identified a wide range of variability in parent adaptation to family life with children with developmental disabilities [Glidden and Schoolcraft, 2003; Singer, 2006]. Formerly, researchers held the belief that there were inevitable and severe negative impacts on parents, including chronic sorrow [Olshansky, 1962]; increased mental and physical health problems [Wolfensberger, 1969; Witt et al., 2003]; increased divorce rates [Gath, 1977]; and elevated levels of psychosocial problems in siblings [Hannah

and Midlarsky, 1999]. However, recent meta-analyses and longitudinal studies show that these negative impacts are neither common nor as severe as once thought [Seltzer et al., 2001; Risdall and Singer, 2004; Glidden and Jobe, 2006; Singer, 2006]. Singer [2006] conducted a meta-analysis of 19 comparative studies of depressive symptoms in mothers of children with and without developmental disabilities. Roughly 70% of the mothers of children with disabilities did not have elevated symptoms. In addition, there is emerging evidence that many parents perceive long-term benefits and families are resilient over the long term. Data from the Wisconsin Longitudinal Study spanning a 35-year period found no significant differences between parents of adult children with and without mental retardation on measures of psychological well-being, depression, physical health, and divorce [Seltzer et al., 2001]. Further, an emerging literature indicates that many parents perceive benefits and positive contributions associated with loving and raising their children with developmental disabilities [Hastings and Taunt, 2002]. The accumulation of evidence suggesting family resilience, rather than family catastrophe, best characterizes these families and suggests that efforts to support and assist families should be designed to foster attitudes, skills, and resources that not only reduce distress but also buffer it as well, augment resilience, and promote positive outcomes. The cumulative weight of the more sanguine research indicates that it is realistic to aim for promotional as well as preventive and ameliorative outcomes. Despite long-term resilience, many parents of children with developmental disabilities experience unusual levels of stress along the way. Researchers have particularly focused on
*Correspondence to: George Singer, University of California, Santa Barbara, Department of Education, Gevirtz Graduate School of Education, Santa Barbara, California 93106-9490. E-mail: singer@education.ucsb.edu Received 20 August 2007; Accepted 22 August 2007 Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/mrdd.20175

' 2007 Wiley -Liss, Inc.

parents depressive symptoms as indicators of stress in these families [Singer, 2006]. For the sizable minority of parents who do experience unusual levels of psychological distress, there is a need for interventions leading to earlier resolution of depressive symptoms and fewer lifetime episodes of elevated levels of depression especially in mothers. In comparing studies of parents with and without children with developmental disabilities, Singer reported a small but consistent effect size difference in indicators of psychological distress in studies of mothers conducted over the past 25 years. He estimated an approximate 10% increase in the number of mothers with scores over clinical cutoff scores on standardized self-report, paper and pencil measures of depressive symptoms. Thus, roughly 3035% of the mothers of children with developmental disabilities in these studies had elevated levels of depressive symptoms. In their longitudinal research, Glidden and Jobe [2006] reported that parents of birth children with Down syndrome had higher levels of depressive symptoms compared to adoptive parents for the first 5 years following the birth with gradual improvement over this period of time. Over a 17-year period, early high levels of depressive symptoms predicted later emotional distress. Breslau et al. [1986] also found that although there was not a significant difference in the prevalence of Major Depression in this group of mothers compared to mothers of typically developing children, they did have significantly more lifetime episodes of depression, with the first occurrence at the time of their childrens original diagnoses. Stresses associated with caregiving for children with disabilities, particularly during periods marked by a pile-up of stressors from other sources, have the potential to generate psychological distress in both mothers and fathers [Quine and Pahl, 1987; Singer and Irvin, 1991; Hastings and Beck, 2004]. In the general population, twice as many women experience depression as men, although men are also vulnerable to psychological distress associated with chronic stress or a pile-up of stressors [Kessler et al., 1997]. Regardless of how it is measured, elevated depressive symptoms are very common in women, so that it is very likely that $20% of these mothers would experience psychological distress regardless of their childrens disability [Lin et al., 1986; Kessler et al., 1997; Glidden and Schoolcraft, 2003]. The terminology used to describe this psychological distress is important be358

cause there is some controversy over how to interpret information from written self-report measures of depression. Bailey et al. [2007] discuss the fact that elevated levels of depressive symptoms as measured with common selfreport instruments like the Beck Depression Inventory (BDI) [Beck et al., 1988] or the Center for Epidemiology Depression Scale (CES-D) [Radloff, 1977] are not accurate indicators of prevalence of the clinical condition, major depression, which can only be diagnosed by clinical interview with a trained diagnostician. It is for this reason that we refer to psychological distress as elevated levels of depression symptoms. Although self-report measures do not identify cases of clinical depression, there are important reasons for being concerned about individuals who express an elevated level of psychological distress on written self-report measures, even though they may not experience clinical depression. People with elevated depressive symptoms who do not have major depression have shown considerable limitation and distress in social, work, and physical functioning [Hays et al., 1995]. Hays et al. reported that subclinical levels of depressive symptoms were associated with lowered wellbeing, impaired role function, impaired social function, and poor general health. In their longitudinal study of 1,790 persons, they found that people with depressive symptoms but without current major depression had lower levels of functioning than individuals with chronic illnesses including diabetes and heart failure. Furthermore, elevated depressive symptoms have been associated with disrupted parenting interactions between mothers and their children [Downey and Coyne, 1990]. In direct observation studies comparing mothers with and without high levels of depressive symptoms, mothers in the former group interacted less with their children with disabilities, were less contingent in responding to them, were more irritable, had more negative affect, and were more likely to use explosive discipline than mothers without elevated depressive symptoms [Downey and Coyne, 1990]. In several of these studies, elevated depressive symptoms were measured by using self-report questionnaires. Thus, regardless of whether or not these measures indicate major depression, the psychological distress that they do measure is associated with problematic parentchild interactions. Further, in studies of parents of children with developmental disabilities,


research indicates that depressive symptoms are associated with problem behavior in children with developmental disabilities [Floyd and Phillippe, 1993; Baker et al., 2003; Hastings et al., 2006; Lecavalier et al., 2006]. The most prevalent theory of stress in the literature on families of children with developmental disabilities is a multivariate model, the double ABCX theory [McCubbin and Patterson, 1983; Bristol, 1987; Singer and Irvin, 1991]. It is a broad framework positing that outcomes from family encounters with stressful events are the product of an interaction of the nature of the stressor, the way family members appraise it, their resources including social support, and their coping skills. The theory recognizes that outcomes can be adaptive and indicative of resilience or they can be negative. Researchers have tested interventions aimed at addressing one or more of the elements in this model in order to support parents who are experiencing stress-related psychological distress. One specific stressor has been the focus of extensive researchchild problem behavior. Many studies have reported problem behavior to be a powerful predictor of parental distress. In their analysis of the literature on predictors of depression, Bailey et al. [2007] found that it was a significant correlate of depressive symptoms in nine out of nine studies. Parents have sought help for these problems and researchers have tested various forms of parenting education including, most commonly, methods based on social learning and applied behavior analysis theories [Lucyshyn et al., 2002]. Other researchers have focused on parenting coping skills education aimed at helping parents manage stress by teaching them techniques for both emotion focused and problemfocused coping [Hastings and Beck, 2004]. Most of these stress-management procedures are based on cognitive behavioral approaches to psychoeducation. The purpose of this meta-analysis is to determine how effective these behavioral and psychoeducational interventions have been in helping parents with stress and associated psychological distress, particularly with elevated levels of depressive symptoms and whether these interventions are most effective when delivered separately or in a multiple component model combining the two methods along with other forms of support. In addition, this research synthesis evaluates whether or not this body of research reasonably establishes the interventions as


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effective methods in keeping with recent professional and legal imperatives to use proven interventions in social, psychological, and educational services [Shavelson and Towne, 2001; Levant, 2005]. In order to make a claim that an intervention is evidence-based, two dimensions of the research literature need to be addressed: the efficacy of an intervention and its clinical utility [Levant, 2005]. In this study we are concerned about the first dimensiontreatment efficacy. In order to evaluate the efficacy of interventions for reducing distress in parents of children with developmental disabilities, we focus on randomized or quasi-randomized trials. Levant [2005] asserted, Randomized clinical trials and their logical equivalents are the standard for drawing causal inferences about the effects of interventions . . . (p. 8). In order to go beyond the claim that a treatment method is evidence-based, we also evaluate whether or not interventions can be considered to be well established, probably efficacious, or unproven.
For a treatment to be considered well established, two or more studies must show that it is superior to medication, placebo, or an alternative treatment or that it is equivalent to an already established treatment, or nine single-subject case studies must be conducted to establish its equivalence or superiority . . .. For an intervention to be considered probably efficacious, two or more studies must show it to be superior to a wait-list control condition or one experiment must meet the criteria for a well-established treatment, or three single-case studies must be conducted [Hoagwood et al., 2001, p. 1179].

parenting education has generalized benefits or contributes to family stress [Baker et al., 1991; Mahoney et al., 1999]. Parenting education has been criticized for a variety of reasons, including its demands on parents time, possible loss of self-efficacy related to professional dominance, and inadequate responsiveness to cultural differences [Winton et al., 1999]. In the following analysis, we look for evidence of increased emotional distress in parents who participated in different forms of parenting education. RESEARCH QUESTIONS AND HYPOTHESES In this meta-analysis we asked the following questions: 1. How effective have interventions for parents of children with developmental disabilities

probably efficacious or as yet unproven? METHODS Search Procedures Journals were searched electronically using the databases PsychINFO, PubMed, Social Science Citation Index, Social Science Research Database via CSA, ERIC, the Dissertation Abstracts International databases, the Sociological Abstracts and Social Services Abstracts databases. Articles were also identified from the Cochran Database [Barlow et al., 2003] and recent reviews of the literature on interventions for parents of children with developmental disabilities [Singer et al., 2002; Hastings and Beck, 2004]. The search was limited to studies published in English. Our working definition of developmental disability was a modification of the definition in the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (PL 106-42). Developmental disabilities were defined as occurring before age 22, likely to continue indefinitely, require professional services of lifelong duration, and result in functional limitations in at least three major areas of life activities. We narrowed this broad definition by including only those developmental disabilities associated with mental retardation or other cognitive disabilities and children with a combination of intellectual and physical impairments. That is, we excluded studies in which the children had physical disabilities and chronic illnesses that are not associated with cognitive disabilities. Thus, we excluded a group of studies focused on interventions for parents of children with ADHD and another of children with conduct disorders. Search terms for all databases included combinations of the terms disability, developmental disability, handicap, autism, mental retardation, cerebral palsy, traumatic brain injury and spina bifida with treatment, and intervention, depression, or distress with parents, mothers, fathers, and families. Databases were searched for all years available. After screening by reading titles and abstracts, all promising articles, dissertations, and book chapters were obtained and reviewed. References from these studies were searched, in turn, to identify other studies. References from reviews of the literature published as chapters in books were also searched [Singer and Irvin, 1991; Singer et al., 2002] Authors were contacted by letter or e-mail when further data were


Additionally, judgments about quality of research have been addressed from a variety of perspectives, but usually include commonly accepted elements of careful experimentation appearing in widely used graduate textbooks in psychology and education [Wortman, 1994; Shavelson and Towne, 2001; Levant, 2005]. Meta-analysis is a useful tool for examining the effectiveness of a variety of interventions drawn from differing theories and research traditions, because it creates one common metricthe effect sizeindicating the strength of each treatment as well as an overall indicator of the average efficacy in groups of research studies [Rosenthal et al., 2000]. Meta-analysis statistics can be readily compared to other areas of research in order to interpret the relative efficacy of interventions. This research synthesis also aims to help address a prominent debate in the fields of early intervention and family support, the question of whether or not

In this study, we are concerned about . . . treatment efficacy. In order to evaluate the efficacy of interventions for reducing distress in parents of children with developmental disabilities, we focus on randomized or quasirandomized trials.

been in reducing psychological distress in group comparison studies? 2. Are multicomponent training (MCT) interventions significantly more effective than either behavioral parent training (BPT) or cognitive behavioral, coping skills, training (CBT) alone? 3. Is there evidence to support the contention that parenting education or other forms of professionally-led psychoeducation increase stress? 4. Using APA guidelines, do these interventions meet criteria for evidence-based treatments or are they best considered as


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needed in order to determine an effect size or clarify information in the research reports. To be included in the meta-analysis, researchers had to have collected data on parental mental health using published standardized self-report measures with well-established psychometric properties. In order to be included, studies had to use random or quasirandom assignment to compare one or more interventions with a comparison group. Table 1 provides a summary of the dependent measures we chose to analyze in this study. Many of these studies included more than one dependent measure; however, we deliberately focused on measures of depressive symptoms or closely related measures of emotional distress assumed to be associated with caregiving. Table 1 lists these measures and shows that the majority of studies included widely used measures of depressive symptoms or general measures of emotional well-being. Statistical Analysis Effect sizes were calculated using a computer program, DSTAT [Johnson, 1993] and checked with another computer program, MetaWin [Rosenberg et al., 1999]. Hedges and Olkins [1985] d was used as the effect size statistic. It is calculated by subtracting the mean of the control or comparison group from the mean of the experimental or intervention group and dividing by the pooled standard deviation. In keeping with a common practice in meta-analyses, we calculated d based upon posttest means [Hedges and Olkin, 1985]. These are means at posttest and at follow-up. In the event that the groups had substantially different average scores on the dependent measures at pretest, we used an adjustment procedure recommended by Rosenthal [1994], in which change scores are used with adjusted standard deviations. When sufficient information about pre and posttest scores were not provided, effect sizes were calculated based on F or t values. Formulas for all analyses are available from the first author. Studies with larger samples are likely to produce more accurate results than those with smaller samples. Thus, individual effect size statistics needed to be refined by giving more weight to larger studies [Hedges and Olkin, 1985]. Further, as discussed later, studies with better design features and reporting of key variables are also likely to be more trustworthy. Based on a procedure recommended by Shadish and Haddock 360

[1994], a weighted effect size was calculated that took into account both sample size and quality. In order to account for sample size, each d was multiplied by a weight derived from the reciprocal of the variance. The logic of weighting by the inverse of the variance is that studies with larger sample sizes are assumed to more closely approximate the true effect size for the population of all similar studies. To analyze quality, we followed an approach recommended by Wortman [1994]. To determine whether or not all sample effect sizes were drawn from a common population of effect sizes with a shared mean, a test of homogeneity was performed. The Q statistic is tested via traditional inferential methods [Hedges and Olkin, 1985]. If this homogeneity test produces a result that is significant at the 0.05 level (of v2 at k-1 degrees of freedom), the individual studies are considered to be more variable than expected due to sampling error alone; thus, if the Q is significant (a 5 0.05), the variance associated with the effect sizes are heterogeneous and cannot be assumed to have been drawn from the same population of studies. If the variances are homogenous, then it is possible to combine studies and treat them as if they are one large study, provided that the dependent variables share an underlying construct. In this synthesis, we combined measures under the broad construct of parental distress related to environmental stress. Planned comparison Rosenthal et al. [2000] presented a procedure for conducting planned comparisons in meta-analysis in order to identify significant moderating variables. It is based on traditional ANOVA with an adjustment in the calculation of variances and the use of weightings for planned comparisons. We conducted one comparison based on the ABCX theory and previous research findings. We investigated whether multicomponent training interventions, which focused on both parenting behavior and parent cognitive behavior coping skills, were more effective than either presented alone. Fail-safe statistic A potential threat to the validity of a meta-analysis is the possibility that there are unpublished studies unavailable to the researchers and that the published research is biased toward results with higher effect sizes in order to meet common publication standards for statistical significance. As a way to assess the likeli

hood of there being enough contradictory studies to undermine confidence in an overall effect size, a fail-safe statistic was calculated [Hedges and Olkin, 1985]. The formula used to calculate the fail-safe d number is k0 k dc =dc , in which k0 is the number of studies with null results needed to render the average effect as negligible, k the number of studies in the synd thesis,  the overall average effect size, and dc is the effect size at a negligible level, where in this analysis it was set at 0.01 [Hedges and Olkin, 1985]. DSTAT and MetaWin do not include the procedure for calculating the planned comparison statistics, therefore quality-weighted effect size, and so an Excel program developed by the first author was used based on formulas provided by Shadish and Haddock [1994]. Similarly, an Excel program developed by the first author was used to calculate the planned comparison statistics using formulas presented by Rosenthal et al. [2000]. Weighting effect sizes for quality of research studies and their reports To address the variability in the quality of studies and their reports, they were assigned quality weightings. These weightings form an index of the confidence that can reasonably be placed in the findings from each study and from the overall synthesis [Orwin, 1994; Wortman, 1994]. Several major design variables were given the weight of either 1 or 0 based on (a) whether or not the study used random assignment to treatment and comparison groups, (b) whether or not the study included follow-up data, (c) whether or not the study included evidence for fidelity of treatment, (d) whether demographic differences between groups were tested and differences controlled statistically, (e) whether or not the treatment was based on a manual, and (f ) whether or not the psychometric properties of the dependent measures have been established. All of the studies used psychometrically mature instruments and were assigned a weight of 1 on this dimension. In addition to the design features of the studies, we also evaluated the extent of the information included in the research reports. Parent descriptive data was coded with a 1 or a 0 for each of the following bits of information: (a) primary caregivers ages, (b) primary caregivers highest levels of education attained in years, (c) marital status, (d) family income or employment category, and (e) and parents ethnicity or race. The following descriptive variables for


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Table 1. Summary Data for Meta-Analysis of Group Comparison Studies of Interventions to Reduce Psychological Distress in Mothers and Fathers of Children with Developmental Disabilities
Author Publication Date; Primary Disability Bristol et al., 1993; Autism Chadwick et al., 2001; ID Drew et al., 2002; Autism Feldman and Werner, 2002; DD Gammon and Rose, 1991; DD N Intervention Type MCT BPT BPT BPT CBT Measure CES-D Post Follow-up PSI Post Follow-up PSI Post Follow-up BDI Post Follow-up POMS (DepressionDejection Scale) Post Follow-up DASS (Stress Subscale) Post Follow-up BDI Post Follow-up CES-D Post Follow-up CES-D Post Follow-up BDI Post Follow-up Quebec Health and Social Survey Emotional Distress Indexd Mothers Post Follow-up Fathers Post Follow-up PSI (Parental Distress Scale) Post Follow-up General Health Questionnaire Mothers Post Follow-up Fathers Post Follow-up BDI Mothers Post Follow-up Fathers Post Follow-up BDI Post Follow-up BDI Mothers Post Follow-uph Fathers Post Follow-uph Intervention 14 14 38 31 10 18 24 39b 25 143 49 21 12 3 18 Comparison 14 14 24 18 10 18 18 26 72 27 23 5 16 Mean (SD) Intervention 12.9 (10.5) 9.7 (7.1) 31.30 (9.8) 31.6a (9.3) 104.3 (20.0) 7.2 (5.9) 22.2 9.2 6.6 (5.8) 7.1 (5.9)* 14.7 (11.2) 10.6 (7.1) Comparison 16.6 (13.5) 16.7 (10.2) 33.6 (11.2) 31.1 (12.1) 112.1 (20.1) 8.3 (7.8) 20.6 15.1 6.8 7.8 (7.0) 9.9 (8.5) 13.4 (7.6) 13.6 (8.7) Effect Size 0.30 0.77 0.47 0.05 0.37 0.16 0.13 0.60 0.20 0.39 20.13 0.40c 0.37

Hudson et al., 2003; ID Kirkham, 1993; DD McIntyre, 2007; DD Niccols and Mohamed, 2000; DD Nixon and Singer, 1993; DD Pelchat et al., 1999; DS

MCT CBT BPT BPT CBT FSI

17 17 17 17 12

14 14 14 14 5

4.4 (2.7)* 3.6 (1.2)* 2.9 (1.6)* 2.8 (1.4)* 63.4 (28.8)

5.1 (2.2) 4.5 (2.5) 3.5 (2.1) 3.4 (2.7) 52.20 (36.9)

0.30 0.45 0.32 0.29 1.97e

Salt et al., 2002; Autism Schultz et al., 1993; ID

MCT CBT

15 15

39 39

15.7 (9.2)* 16.3 (8.3)*

21.3 (13.5) 20.2 (13.0)

0.44 0.32

Singer et al., 1994; TBI

CBT

4 3f 18g

6 2 18

7.7 (6.8)* 7.4 (5.9)*

13.88 (10.8) 9.0 (6.1)

0.63

Singer et al., 1988; DD Singer et al., 1989; DD

CBT MCT

0.27

19 15 9 8

13 8

5.7 (5.5)*** 6.4 (7.1) 5.3 (5.8)** 6.0 (6.9)

12.5 (12.7) 8.9 (9.9)

0.72 0.45

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Table 1. (continued)
Author Publication Date; Primary Disability Tonge et al., 2006; Autism N Intervention Type MCT Measure General Health Questionnaire Posti Follow-up Intervention 35 35 Comparison 35 35 Mean (SD) Intervention 18.0 (13.6) 17.1 (7.6) Comparison 21.7 (10.2) 21.5 (11.9) Effect Size 0.31 0.43

Note. Dashes indicate the data were not available. DD, developmental disabilities; ID, intellectual disability; TBI, traumatic brain injury; BPT, behavioral parent training; CBT, cognitive behavioral training; FSI, family systems intervention; MCT, multiple component treatments; BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies; DASS, Depression Anxiety and Stress Scale; PMI, Perception of Mood Inventory; PSI, Parent Stress Inventory. a Mean of two intervention groups: individual and group training. b Three intervention groups combined: group support, telephone support, and self-directed support. Effect size calculated from F value. c No scores provided, only an average d across three different measures including the CES-D, PSI, and Parenting Sense of Competence Scale. d French adaptation of the Psychiatric Symptoms Index [Ilfeld, 1976]. e Change score from pre to post with d calculated from N and P value. f Mothers and fathers BDI scores were combined for analysis. g Mothers and fathers data combined. h Follow-up data for intervention group only. i Only four fathers participated in the study, thus group assignment was not indicated. *P < 0.05; ** P < 0.001; *** P < 0.01.

children were also rated with a 1 if reported and a 0 if not: (a) childs age, (b) childs primary diagnosis, and (c) a measure or indication of the severity of the childs disability. Detailed tables summarizing the parent and child demographic variables are available from the first author. Reliability To determine interobserver agreement on quality weightings, a second reader coded 100% of the studies. Percentage of interobserver agreement was calculated by dividing the total number of agreements by agreements plus disagreements and multiplying by 100. In instances of disagreement, the author and the observer discussed and reviewed the texts and arrived at an agreed upon correct data point. RESULTS A first order search of the PsychInfo and PubMed databases using the terms, parent, disability, and intervention yielded a total of 124 and 150 studies, respectively. Review of abstracts and articles led to inclusion of a total of 22 studies retrieved from the databases and published literature reviews. Two studies were dropped because of insufficient data and three other studies were not included because they did not measure parental stress or emotional distress as outcome variables. Thus, 17 studies met the inclusion criteria for this synthesis. We sorted the studies into four logically determined categories based on the treatment methods evaluated: (a) behavioral parent training (BPT), (b) cognitive behavioral treatment (CBT), (c) multiple component treatment (MCT), and (d) family systems intervention (FSI). Table 1 presents basic information 362

about the studies. It includes the authors and years of publication, the treatment categories, the dependent measures, the numbers of subjects in each group, the means and standard deviations, and posttest and follow-up (when available) on the dependent measures selected for inclusion in the analysis, and their effect sizes. Demographic Data Most of the parents in these studies, with a few exceptions, were White and middle class with high school or some college as their highest level of educational attainment. Several studies included single parents, usually mothers, and small numbers of people with relatively low incomes. The numbers of parents of color or from recent immigrant populations were very small. The great majority of subjects were mothers, with only three studies reporting outcomes for fathers. The ages of the children ranged from an average of 6 months to $14 years old. Eight of the studies served parents of children with an average age of 6 months to 6 years, and therefore may be classified as early intervention research. Four of the studies targeted parents of children with autism, with the other 13 aimed at parents of children with a variety of developmental disabilities as well as autism. Detailed tables summarizing parent and child characteristics are available from the first author. Dependent Measures and Homogeneity of Variance It is common in meta-analyses to combine effects based on a variety of logically related dependent measures, provided they measure the same general construct and that the data is character

ized by homogeneity of variance [Hall et al., 1994]. In this meta-analytic synthesis, we focused on the impact of interventions on parental stress and emotional distress. The most common dependent variables in these studies were depressive symptoms. Whenever it was necessary to choose one effect size from others in any given study, we calculated effect sizes based on measures of depressive symptoms. Eleven of the studies reported outcomes on commonly used measures of depressive symptoms, including the BDI [Beck et al., 1988]; the CES-D [Radloff, 1977]; and the Depression Anxiety and Stress Scale [Lovibond and Lovibond, 1995]. In one study we analyzed a subscale for depression from the Depression/Dejection Scale of the Profile of Mood States [McNair et al., 1971]. Three studies employed broader measures of stress and emotional distress. Pelchat et al. [1999] used the Emotional Distress Index from the Quebec Health and Social Survey [Pre ville et al., 1992], which is a French version of the Psychiatric Symptom Index [Ilfeld, 1976], a general measure of psychological distress with scales for depression, cognitive disturbance, anxiety, and anger. Schultz et al. [1993] and Tonge et al. [2002] used the General Health Questionnaire [Goldberg and Hillier, 1979], which measures four factors: insomnia, somatic symptoms, anxiety, and severe depression. Three studies used either total or subscale scores from the Parent Stress Inventory [Abidin, 1995], a widely used measure of perceived stress in the family. The underlying construct which provides the rationale for combining these various measures is parental psychological responses to stress.


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The Q test for homogeneity of variance was nonsignificant, indicating that the studies shared a common variance, a necessary condition for combining studies with diverse measures and intervention (Q 5 7.41, P 5 0.917). Interventions Five studies had a primary focus on interventions designed to teach parents skills for interacting effectively with their children in order to improve childrens problem behavior, increase their skills, or promote a secure attachment, and therefore categorized as behavioral parent training interventions [Niccols and Mohamed, 2000; Chadwick et al., 2001; Drew et al., 2002; Feldman and Werner, 2002; McIntyre, submitted for publication, 2007]. In these studies, measures of parental depressive symptoms were secondary measures meant to assess the indirect emanative effects of BPT. The studies tested various forms of BPT, with an emphasis on positive parenting. The specific behavioral techniques included in these studies varied and are reported in Table 2. One study in the BPT category used an intervention based on attachment theory, although it focused on changing parents responsiveness to their infants with disabilities by teaching parents to change their own behavior [Niccols and Mohamed, 2000]. McIntryre [2007] implemented a developmental and behavioral intervention, an adaptation for parents of children with autism of the Incredible Years Parent Training Series [Webster-Stratton, 2000]. Because our analysis of these studies is focused on the collateral effects on parents, we do not report on child behavior change, although in every instance there was significant improvement in adaptive behavior or decreases in problem behavior. Six studies were categorized as using cognitive behavioral training to teach coping skills to parents to directly reduce psychological distress associated with stress. In these studies, the interventions were directly aimed at supporting parents to learn and use skills that would reduce the impact of daily stress [Singer et al., 1988, 1994; Gammon and Rose, 1991; Kirkham, 1993; Nixon and Singer, 1993; Schultz et al., 1993]. Table 2 presents a list of the major cognitive behavioral skills that were taught to parents. Five studies had interventions that were categorized as multiple component treatments, which included BPT and either CBT and/or other support serv-

ices [Singer et al., 1989; Bristol et al., 1993; Salt et al., 2002; Hudson et al., 2003; Tonge et al., 2006]. One intervention was based on family systems theory [Pelchat et al., 1999] and was categorized as an FSI. Table 2 presents brief descriptions of the main treatment elements, along with information about the number of sessions or amount of time involved in the group meetings. How Effective Were These Interventions? The average unweighted effect size for the participants at posttest for the 17 studies was d 5 0.49, with a 95% confidence interval of 0.27/ 0.7. A total of 920 parents participated in these studies. When weighted by the inverse of the variances and quality indices, the overall effect size was reduced to d 5 0.29. It is the weighted effect size that most accurately reflects the overall efficacy in these studies. We made one notable statistical decision in calculating these effect sizes. We used follow-up rather than posttest data for three studies, because there was evidence of a delayed effect [Bristol et al., 1993; Pelchat et al., 1999; Tonge et al., 2006] with unweighted effect sizes changing from posttest to followup from 0.30 to 0.77, 0.30 to 0.45, and 0.29 to 0.43, respectively. In these three studies the number of subjects remained constant from posttest to follow-up, whereas the other studies with followup data suffered from participant attrition. We believe that these data more accurately represent the efficacy in these three studies than the posttest scores and so they were used to calculate their effect sizes. Data from the three studies that included separate posttest data for fathers [Schultz et al., 1993; Pelchat et al., 1999; Singer et al., 1989] yielded an average posttest unweighted effect size of d 5 0.36, with a 95% confidence interval of 0.27/0.44 and a weighted effect size of 0.37 for a total of 102 fathers. When Grouped by Type of Treatment What Were the Effect Sizes? The average posttest unweighted effect sizes for the five BPT studies was 0.25. The six studies had an average unweighted effect size of d 5 0.34. The five multiple component intervention studies, which combined elements of


BPT, CBT, and, in some cases, other forms of support services, had an average effect size of d 5 0.90 [Singer et al., 1989; Bristol et al., 1993; Salt et al, 2002; Hudson et al., 2003; Tonge et al., 2006]. The single study of the impact of a FSI [Pelchat et al., 1999] yielded an unweighted average effect size, with mother and father effect sizes averaged, of d 5 0.37 at follow-up. Were Multicomponent Interventions More Effective Than Treatments Which Focused Solely on Either BPT or CBT? There was a significantly higher average effect size from the multiplecomponent studies compared to either the BPT or the CBT interventions alone (F1,14) 5 6.53, P < 0.025. The FSI was not included in the analysis, because there was only one study using this method. Quality Rating All studies were rated for quality using commonly accepted standards for group comparison research methods. The purpose of these ratings was to create indicators of the overall confidence that can reasonably be placed in the studies. The quality ratings ranged from a low rating of 4.7 to a high rating of 9.7. The average quality rating was 7.04 with a median rating of 6.75 out of a possible score of 10. The most common design deficiencies were lack of methods for assuring fidelity of implementation (12 of 16), lack of treatment manuals (9 of 16 without), and lack of follow-up data (9 of 16). Several studies failed to report important descriptive data on the parents and children. Is There Evidence to Support the Contention That Parenting Education Causes Increased Stress? The evidence reported here leads us to reject this contention. Assuming that depressive symptoms reflect stress, there is little or no evidence that parenting education or coping skills education causes an increase in distress related to stress in parents. To the contrary, in all but one study, parents who participated in these interventions benefited by experiencing reductions in distress. There was one exception: a study by McIntyre [submitted for publication, 2007] had a negative unweighted effect size of d 5 20.13, but we believe it should be considered an outlier given the outcomes in the other studies. Further, McIntyre [submitted for publication,


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Table 2. Descriptions of Interventions for Parents of Children with Developmental Disabilities

Author, Publication date; Intervention Type Bristol et al., 1993; MCT

Treatment Description Counseling and Treatment and Education of Autistic and related Communication-Handicapped Children (TEACCH) Parent-asCotherapist treatment program services are comprised of (a) child behavior management, (b) parent attitude adaptation and home environmental management, and (c) implementation and evaluation of special education procedures and behavior modification techniques through one-to-one modeling, reinforcement, and guided feedback (p. 5). Individual coaching and counseling provided as needed. Individual and group parent training is comprised of (a) range, causes, consequences and possible functions of their childs challenging behavior, (b) teaching appropriate behaviors and reducing or weakening unwanted behaviors . . . importance of applying these techniques consistently over time and across a range of situations,(c) awareness of more general factors influencing the childs behavior,(d) developing focused behavior therapy programmes using the other training components, and (e) acknowledgement and addressing obstacles to implementation of behavior programmes, such as expectations and beliefs or practical, family, and social factors (p. 155). Social-pragmatic joint attention focused parent training programme, is comprised of (a) behavioral management and compliance promotion, (b) development of early precursors to social and communicative competence. It aimed to promote joint action routines, the explicit teaching of joint attention behavior, (c) shared meaning establishment in joint action routines, and following the developmental sequence of responding to, maintaining and then initiating, (d) support wholistic language learning, and (e) program integration into everyday routines (p. 268). Behavioral parent training is comprised of (a) changing/removing setting events and antecedents, (b) replacement skill training . . . noncontingent and differential reinforcement, and errorless procedure . . ., and occasionally (c) extinction, response interruption and redirection, or response cost (p. 80). Coping skills training program (CSTP) is comprised of . . . cognitive restructuring, interpersonal skills training, problem solving, individual goal attainment, and group treatment (p. 247). Signposts for building better behavior . . . parent materials consist of eight information booklets, a videotape and a workbook and is comprised of (a) child behavior measurement, (b) systematic use of everyday interactions,(c) replacing difficult behavior with useful behavior, (d) better behavior planning, (e) teaching children new skills, (f ) stress management, and (g) family as a team (p. 241).

Duration of Training Total hours of training unknown: in general, biweekly with length of time unknown for 18 months

Chadwick et al, 2001; BPT

7.510 hr of training: 1.52 hr for 5 weeks

Drew et al., 2002; BPT

24 hr of training: 3 hr every 6 weeks for 12 months

Feldman and Werner, 2002; BPT

1248 hr of training: 12 hr for 36 months

Gammon and Rose, 1991; CBT Hudson et al., 2003; MCT

20 hr of training: 2 hr for 10 weeks Total hours of intervention varies by mode of intervention: each mode was delivered over the course of 3 months, where (a) group mode was 12 hr of training: 2 hr six times on a fortnightly basis, (b) telephone-support mode had no training, but $1.3 hr of contact: $20 min of therapist contact on a fortnightly basis, (c) self-directed had no training or therapist contact. Hours of training unknown: duration and number unknown for 9 weeks

Kirkham, 1993; CBT

McIntyre (submitted for publication, 2007); BPT

Niccols and Mohamed, 2000; BPT Nixon and Singer, 1993; CBT

Life skills-training is comprised of . . . coping and communication skills, problem-solving and decision-making techniques, and skills to manage and control their social network. In addition, each group applied the newly learned skills to resolve a problem in their community that they shared . . .. Techniques used in the skills-training program included didactics, homework assignments, modeling, and peer leadership (pp. 510511). Incredible Years Parent Training (IYPT) program with modifications for children with developmental disabilities (IYTP-DD) included the topics of: play, praise, rewards, limit setting, and handling challenging behavior . . .. [Using the Incredible Years Parent Training manual for toddlers was used with modifications for children with developmental disabilities] this treatment program utilizes group discussion, viewing videotape vignettes of parentchild interactions, role-playing, didactics, and weekly homework[s] (p. 10). Skill building group is comprised of (a) attachment security, (b) parentchild interaction, (c) child and parent personality,(d) disengage cues, (e) engage cues, and (f) children as leaders where parents learn how to follow . . . in play (p. 142). Cognitive behavioral parent training is comprised of (a) cognitive model of emotions introduction, (b) strategies to change cognitive distortions and automatic thoughts, (c) control-based cognitive distortions, (d) misattributions around the explanation of events, and parental schema-related cognitive distortions and misattributions (p. 334).

20 hr of training: 2.5 hr for 12 weeks

16 hr of training: 2 hr for 8 weeks

10 hr of training: 2 hr for 5 weeks

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Table 2. (continued)
Author, Publication date; Intervention Type Pelchat et al, 1999; FSI

Treatment Description Programme dIntervention Familiale (PRIFAM) is comprised of five family subsystems and their associated program objectives: (a) individual, focused on identification of parental perceptions and beliefs related to the situation; to change those that are detrimental and to reinforce those promoting adaptation, and assisting parents gaining of a realistic understanding of the situation and to help them grieve their dream of a perfect child, (b) conjugal, focused on helping spouses understand the experience of each other and support each other in the grieving process, (c) parental, focused on promotion of a trusting relationship between the parents and the child and to encourage the development of attachment, (d) family, focused on fostering exchanges within the family concerning the perception of the situation and to acknowledge the role of each in the adaptation process, and (c) social, focused on helping parents keep significant relationships with others and use in the most efficient way the available resource and the help from health care professionals (p. 468). Scottish Centre for Autism (SCA) is comprised of (a) take the lead from the child, (b) interpret every behavior as a potential interaction, (c) shape the childs interactions, (d) introduce adult lead activities with time, (e) maintain balance between intrusion and distress, (f ) use imitation to access the childs world, (g) use language contingent on activities, (h) use the childs objects to create exchanges, (i) use pausing effectively, (j) introduce flexibility, Parent support groups offered every 2 weeks. Caring for Parent Caregivers (CPC) is a three-tiered approach to developing personal coping skills and social supports through awareness and a problem-solving orientation . . .. Topics covered include family dynamics, loss and grief, communication and conflict-resolution skills, networking and resource utilization, stress management, and relaxation skills (p. 207). Stress management classes are designed to combine two approaches to helping: psychoeducational instruction of coping skills and parent-toparent self-help and social support (p. 42) where homework assignments included (a) daily logging of stressful events and coping responses, (b) practicing progressive muscle relaxation (PMR) . . ., (c) practicing short forms of relaxation in stressful events, (d) monitoring self-talk in stressful events, and (e) keeping track of helpful social contacts (p. 43) Stress management training is comprised of (a) stressful event and physiological reaction self-monitoring, (b) muscle relaxation skills, and (c) modification of cognitions associated with distress (p. 272). Community-based intensive support is comprised of (a) identifying stressors and stress reactions with self-monitoring, (b) progressive muscle relation long and short forms, (c) self-monitoring and brief relaxation in home and community, (d) modification of negative thoughts through self-coaching, (e) covert rehearsal for difficult situations, (f ) techniques for managing worries and obsessive thoughts, and (g) strengthening social support networks, utilizing respite, and advocacy (p. 315) Parent education and behavior management (PEBM) skills training is comprised of (a) education about autism, (b) features of communication, social, play, and behavioral impairments, (c) behavior management and change principles (d) teaching new skills, (e) social interaction and communication improvement, (f ) services available, (g) managing parental stress, grief and mental health problems, and (h) sibling, family, and community responses to autism (p. 563).

Duration of Training Hours of training unknown: 68 meetings over 6 months, duration unknown

Salt et al., 2002; MCT

176 of training: 8 hr fortnightly for 11 months

Schultz et al., 1993; CBT

12 hr of training: 2 hr for 6 weeks

Singer et al., 1994; CBT

18 hr of training: 2 hr for 9 weeks

Singer et al., 1988; CBT Singer et al., 1989; MCT

16 hr of training: 2 hr for 8 weeks 32 hr of training: 2 hr for 16 weeks

Tonge et al., 2006; MCT

25 hr of training: ten 90-min small group sessions alternated with ten 60-min individual family sessions over 20 weeks

BPT, behavioral parent training; CBT, cognitive behavioral training; FSI, family systems intervention; MCT, multiple component treatments.

2007] reported significant reductions in the primary target of the intervention, problem, and adaptive behavior in young children with autism. A notable finding was that in studies that compared skills based educational interventions to support groups, the parents in the noneducational groups did not improve on measures of psychological distress.

How Many Unpublished Studies Would Need to Exist to Invalidate These Findings? The fail-safe statistic for the 17 studies yielded an estimate of 544, suggesting that a large number of unpublished studies with effect sizes of 0.01 or less would need to be extant, but not retrieved for this synthesis, to reduce the overall effect size to a negligible level.


How Many Studies Compared an Intervention with Either an Attention-Only Placebo Group or an Alternative Treatment? Drew et al. [2002] compared an intensive behavioral intervention for children with autism with a group that received local services consisting of home visiting based on the Portage Project model. They randomly assigned


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parents to the two groups and found significant reduction in parental distress in the BPT group. Cognitive behavioral training interventions were also compared to other forms of parent support. Kirkham [1993] randomly assigned parents to either a coping skills educational group or a support group, which did not include skills training. Similarly, Singer et al. [1994] randomly assigned parents to either a multiple component treatment or an informational support group that met for the same amount of time as the coping skills group, but received only didactic information. Two multicomponent interventions also used alternative treatment comparison groups with random assignment. Tonge et al. [2006] used a design that allowed examination of the value added through individual coaching of parents. They compared a group that received emotional group support, and only the informational content of their combined BPT and CBT intervention but without direct coaching of parenting skills versus a group that received the full intervention, including not only didactic presentations but also coaching of skills in home settings. For parents who entered the study with elevated depressive symptoms, both groups were beneficial compared with the no treatment control. Singer et al. [1989] used random assignment to compare a group receiving intensive BPT and CBT plus case management and respite care with a group that received only case management and respite. The intensive support group had significantly lower depressive symptom scores at posttest than the comparison group, and these changes maintained in the intensive treatment group at a 1-year follow-up. DISCUSSION Parents of children with developmental disabilities on average experience more stress than comparative families of typically developing children [Hastings and Beck, 2004]. Elevated levels of depressive symptoms in mothers are associated with this stress [Singer, 2006]. Over the past three decades, several researchers have studied interventions designed either directly or indirectly to reduce depressive symptoms and improve well being. When viewed as a whole, these studies consistently demonstrated benefits. This evidence is encouraging and is a clear indicator that the problems of some parents of children with developmental disabilities are 366

responsive to supportive interventions at least in the short term. The benefits have primarily been demonstrated with mothers, although the three studies including fathers as participants also provided evidence of efficacy. Six of the studies reviewed here primarily aimed at training parents to manage their childrens problem behavior and, in some cases, to increase childrens skills. It is important to note that all of the BPT studies reported improvements in childrens behavior associated with the interventions, although we did not attempt to characterize the quality of this evidence for child behavior change. We asked a different question: Can BPT be used as a way to help parents with stress-related emotional distress? There were consistent findings of collateral benefits of parent behavioral training in reducing depressive symptoms in mothers, although the effect sizes were small. Childrens problem behaviors and pa-

Cognitive behavioral training was also consistently effective in six studies reviewed in this synthesis.
rental depressive symptoms have been shown to covary in a bidirectional fashion over a 1-year period [Hastings et al., 2006]. It is likely that reduction in problem behavior is both, in part, a cause and an effect of improvement in parental affect. The average weighted effect size for reductions in depressive symptoms was d 5 0.25, which approaches the 0.26 effect size derived from nine studies that measured depressive symptoms in a recent Barlow et al. [2003] meta-analysis of the collateral benefits of several theoretical approaches to parent training for parents of children without disabilities. We believe that there is sufficient evidence to warrant the claim that these treatments are evidence-based as ways to help parents with stress-related distress, particularly depressive symptoms, at least for the short term for middle class White American mothers. The evidence suggests that BPT may not only change parenting behavior, but also it has small but consistent collateral benefits.


Cognitive behavioral training was also consistently effective in six studies reviewed in this synthesis. Unlike the BPT studies, reductions in parental distress were the primary target of these interventions. CBT was used to provide parents with coping skills for reducing or preventing the effects of environmental stress associated with parenting children with developmental disabilities. Rather than attempting to effect parentchild behavior change, these interventions were designed for parents to learn and support the use of self-management skills that would directly impact their own well being. When CBT was the sole treatment approach, the average unweighted effect size was d 5 0.34, evidence for relatively small but consistent benefits. These interventions for the most part were transferred from stress management and psychotherapy treatments for people in the general population. There is sufficient evidence also to believe that these approaches can be considered to be evidence-based with the same caveats as for the BPT results. Given the evidence for bidirectional effects of depressive symptoms and child problem behaviors, a reasonable hypothesis in future research would be that childrens problem behavior and well being would improve as a result of their parents achieving greater well being by using CBT coping skills. None of the counseling and stress-management interventions in this review asked whether there were collateral positive changes in childrens behavior associated with improvement in parental depressive symptoms, a potentially useful question to address in future research. Multiple component interventions were clearly more effective than BPT or CBT alone. This finding is consistent with Folkman and Lazarus [1980] theory of stress, understood to be the product of a complex interaction between cognitive appraisal, family resources, and instrumental behavior. The multicomponent interventions also meet standards for evidence-based treatments at least in middle class mothers and in the short term. One intervention was designed based on family systems theory [Pelchat et al., 1999]. It was the only study in this synthesis that attempted to address some of the needs of siblings and other family members while primarily focusing on the parents of infants. When more complex intervention methods were presented to parents over a relatively longer period of time than in the single component studies, there were substantial reductions


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in parental distress. The five studies with multiple component interventions had an average unweighted effect size of d 5 0.90 is very close to the average effect sizes for studies in the general psychotherapy literature when treatment groups were compared to no-treatment comparison groups (d 5 0.82) and exceeds the average effect size when treatments were compared with a placebo (d 5 0.48) [Wampold et al., 1997]. This finding is very encouraging and suggests that the stresses many parents of children with developmental disabilities experience and the resulting distress are amenable. A second generation of studies is warranted by extensive changes in our understanding of adaptation in families of children with developmental disabilities. We would hope that future studies include all family members, measure family quality of life as well as empowerment, parenting selfefficacy, and perceptions of the positive contributions that children with disabilities make to their families. These studies were primarily concerned with decreasing distress, but recent research indicates that it is realistic to aim not only for reduced family problems but also for positive adaptation in which the benefits of intervention include meaningful improvements in positive well being and quality of life. Several methodological and measurement issues should be addressed in future studies. Efforts should be made to expand the use of direct observation in assessing the impact of treatments aimed at the whole family as a unit. The recipients of future supportive interventions should include as many coresident family members as possible. Fathers, with separate complete posttest data and analyses, were included in only three of the studies and comprised 11% of the total sample. None of the studies looked at the emanative effects of supporting parents on siblings without disabilities. An analysis of the quality of these studies suggests that there is considerable room for improvement in the design, conduct, and reporting of intervention research. Studies with larger sample sizes are needed, and threats to internal and external validity need to be better controlled in future research. It was encouraging to find several studies using random assignment, standardized measures with mature psychometric properties, and treatment manuals with adequate reporting of the important details of the study. It is hoped that future studies will also provide effect sizes and sufficiently report on the char-

acteristics of the children and parents, so that evidence for external validity can be evaluated better. An area that deserves much more research attention is the question of the efficacy of these treatments for parents from the many ethnic and linguistic minority families in the contemporary US. Several of the studies did include some parents with low incomes and most included single mothers, who on average are more vulnerable to economic insecurity. However, the number of parents from traditionally underserved groups in the US was vanishingly small in these studies. It is hoped that researchers will turn their attention to finding and evaluating effective methods of supporting these families. A logical place to begin would be to evaluate the efficacy of the most effective treatments in this literature when provided to different populations

When more complex intervention methods were presented to parents over a relatively longer period of time than in the single component studies, there were substantial reductions in parental distress.
of parents and when specific accommodations in the treatment methods are made to reflect cultural and/or social class differences. Longer term follow-up data is needed. On the basis of our experience with families, we believe that a comprehensive system of family support would make interventions available on an as-needed basis, as family circumstances change over the life cycle. Common events such as divorce, moving to a new home or neighborhood, young adult children leaving home, and changes in the needs of children with disabilities over time need to be reflected in the support services available to these families. Research has not yet begun to look at the longitudinal needs for and benefits of supportive interventions. It is hoped that future research will build an evidence base for support through the life cycle. Clinical utility in part is a matter of evidence for external validity. Three


of the studies reported here were evaluations of interventions that were implemented as part of public social service programs, suggesting that parenting education can be delivered on a larger scale [Feldman and Werner, 2002; Salt et al, 2002; Hudson et al., 2003]. Similarly, Kirkham [1993] implemented a CBT intervention with a relatively large number of parents and Singer et al. [1993] included a replication of their combined intervention by a group other than the originators of the intervention. These findings begin to build a case for clinical utility but they are only the beginning. There is much work yet to be done before it can be said that these methods are proven to be effective across the full range of ethnic, linguistic, and socioeconomic groups in the US and over longer periods of time. The results of this meta-analysis suggest that researchers now have a solid foundation of evidence on which to build future forms of family support. n

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