Effectiveness of a multidisciplinary parent training program for children with developmental disabilities: A single-blind randomized waitlist controlled trial

Abstract

This study aimed to evaluate the effectiveness of a multidisciplinary parent training program, Promoting Holistic Development of Young Kids (Poly Kids), using a single-blind randomized waitlist controlled design. The participants included 218 parents of children with developmental disabilities (DD) (intervention group = 107 and waitlist control group = 111). The primary outcomes were child learning, expressive language, fine and gross motor skills (based on individual assessment by respective blinded professionals), and parental reports of child behavior problems. The parents in the intervention group reported significantly lower child behavior problems (d = .34), higher child task motivation (d = .63), and lower parenting stress post-intervention (d = .25), while the children in the intervention group produced significantly more words post-intervention (d = .82). McNemar test results were significant for movement out of the clinical range in child behavior problems and cognitive skills in the intervention group, but not the control group. The results provided initial evidence on the effectiveness of this train-the-trainer program in supporting families with preschool children with DD in terms of child behavior problems, expressive language, cognitive skills, task motivation, and parenting stress.

Keywords

Developmental disability multidisciplinary parent training

Introduction

Young children learn best through daily interaction with adults in a familiar setting; hence, family members play a vital role in their development (Early Childhood Intervention Australia, 2016). Parental involvement has been a significant area in interventions for children with developmental disabilities (DD) (Matson et al., 2009). One of the primary roles of service providers in early intervention is to work with and support families to enhance their children’s development (Early Childhood Intervention Australia, 2016). Reviews of early intervention programs for at-risk children have indicated that effective programs should target both children and their parents (Manning et al., 2010). However, most existing parent training programs for children with DD, such as Stepping Stones Triple P and the Heidelberg Parent-Based Language Intervention, target only one or two domains of development (e.g. child behavior or child language) (Buschmann et al., 2015; Tellegen and Sanders, 2013). Very few parent training programs target multiple domains of child development.

The Royal Australian College of Physicians (2013) recommended a comprehensive early intervention for children with DD that incorporates a multidisciplinary model of care addressing the needs of children in all areas, including cognitive, language, fine motor, gross motor, and psychosocial domains. Children with DD commonly experience difficulties in more than one developmental domain. Motor, cognitive, and language domains of child development are highly correlated with each other (Houwen et al., 2016; Wang et al., 2014). Furthermore, difficulties in these domains are also associated with child behavior problems. Previous studies have documented behavior problems such as temper tantrums due to children’s difficulties in communicating needs and feelings (Durand and Carr, 1991; Durand and Merges, 2001) or their sense of failure on tasks with high demands of gross and fine motor skills (Bar-Haim and Bart, 2006). Behavior problems may also negatively impact learning (Roberts et al., 2006), resulting in a vicious circle. Therefore, a parent training program for children with DD should target multiple domains. Parenting children with DD is stressful, as their developmental needs and behaviors can be challenging. Parents of children with DD experience higher parenting stress and the need to adjust to having a child with DD (Roberts et al., 2006). Parents also need extra support in raising their children and sustaining family functioning (Leung et al., 2010). Understanding children’s developmental needs and acquiring strategies to manage their challenging behaviors can help reduce parenting stress, which is also associated with child behavior problems (Baker et al., 2003). At present, there is no comprehensive train-the-trainer program targeting parents of children with DD.

The promoting holistic development of young kids (Poly Kids) program

The Poly Kids program was designed to address the knowledge gap. This program aimed to provide a comprehensive train-the-trainer program for parents of preschool children with DD, targeting multiple domains of child development, including language, fine and gross motor skills, behavior, and learning. The program was designed by a team of experienced educational psychologists, speech therapists, occupational therapists, physical therapists, and a pediatrician.

The Poly Kids program first provided parents with general knowledge on child development, such as developmental milestones in various domains and the nature of developmental disability. For child behavior and learning, the intervention was based on the cognitive–behavioral model, which is known to be effective in producing positive outcomes for children and their parents (Roberts et al., 2006). The content was based on evidence-based cognitive–behavioral programs, such as Stepping Stones Triple P, the Happy Parenting Program, and Incredible Years (Kong and Au, 2018; Leung et al., 2016; Tellegen and Sanders, 2013). These programs were found to be effective in reducing child behavior problems and parenting stress and improving child cognitive development (Buschmann et al., 2015; Kong and Au, 2018; Leung et al., 2016). More specifically, these programs taught parents strategies for responding to their children’s needs, structuring the environment and planning activities to minimize undesirable behaviors, and responding contingently to their children’s behaviors appropriately (Kong and Au, 2018; Leung et al., 2016; Macvean et al., 2016; Tellegen and Sanders, 2013). To facilitate children’s learning of preschool concepts (e.g. colors and shapes), task analysis and teaching strategies were taught, including demonstration, guided practice, and the use of verbal and physical prompts (Tellegen and Sanders, 2013). Regarding language and communication, parent–child reading skills and different stimulation approaches were taught to enhance children’s language development (Chow and McBride-Chang, 2003; Girolametto and Weitzman, 2006). For gross motor development, basic movement concepts were taught, such as how to move smoothly, maintain balance, and manipulate objects such as balls and basic concepts in motor planning and sequencing activities (Gordon and McGill, 2012; Laban, 1970; Stagnitti, 2004). In terms of fine motor development, it was found that engaging in more fine motor activities at home led to better fine motor skills in preschool children (Suggate et al., 2017). In the present program, the use of daily activities and play to promote bilateral coordination, in-hand manipulation, object manipulation, and prewriting skills were taught in a graded manner. Details of the program are shown in Table 1.

Table 1.

Program outline of the Poly Kids program.

Session	Topic	Facilitator	Participants
1	Introduction and overview—understanding child development and developmental disability; strategies in enhancing parent–child relationship	Educational psychologist	Parents
2	Milestones in language development and communication, skills in enhancing parent–child interaction	Speech therapist	Parents
3	Factors affecting child behavior and overview of behavior management, applied behavior analysis	Educational psychologist	Parents
4	Milestones in child fine motor development Use of daily activities in fine motor skills training	Occupational therapist	Parents
5	Task analysis, use of prompts and preschool concepts (number)	Educational psychologist	Parents
6	Milestones in child gross motor development, gross motor skills—basic movement concepts, and basic concepts in motor planning and sequencing activities	Physical therapist	Parents
7	Strategies for increasing positive behavior—praise, rewards and behavior charts, and setting ground rules	Educational psychologist	Parents
8	Practice session	All	Parents and children
9	Preschool concepts—color, shape, and comparison	Educational psychologist	Parents
10	Strategies to promote language skills	Speech therapist	Parents
11	Preschool concepts—sequencing and categorization	Educational psychologist	Parents
12	Strategies to prevent behavior problems and strategies to manage minor behavior problems	Educational psychologist	Parents
13	Practice session	All	Parents and children
14	Strategies to manage serious behavior problems	Educational psychologist	Parents
15	Paired reading	Speech therapist	Parents
16	Preparing for potentially challenging situations and future situations	Educational psychologist	Parents

This study aimed to evaluate the effectiveness of the Poly Kids program using a single-blind randomized waitlist controlled trial design. The primary outcomes were child learning, expressive language, fine and gross motor skills, and behavior. The secondary outcomes were parenting stress and sense of competence. The hypotheses were

The intervention group parents would report significantly fewer child behavior problems than the control group parents post-intervention.

The intervention group children would show greater improvement in learning (cognitive skills, motivation, school readiness, and academic competence), expressive language skills, and fine and gross motor skills than the control group children post-intervention.

The intervention group parents would report lower parenting stress and higher parenting sense of competence than the control group parents post-intervention.

Methods

Participants

The inclusion criteria were (i) children aged two years and nine months to four years and six months at the commencement of the program; (ii) children diagnosed with mild delay (between one and two standard deviations below the mean) in at least two developmental domains or language delay; (iii) parents and children must speak and understand Cantonese; (iv) parents and children lived in Hong Kong; (v) parents lived with the target children; and (vi) children not receiving any government-funded rehabilitation services at the time of referral. Children with a confirmed diagnosis of autism spectrum disorder (ASD) or similar features and those with a confirmed diagnosis of attention-deficit hyperactivity disorder (ADHD) or similar features were not excluded, unless they had severe disruptive behavior, which might significantly distract the other participants. Children with significant physical, hearing, or visual impairment were excluded.

Based on a previous study on the effectiveness of a parent training program for preschool children with DD where the effect size for child behavior problems was between .32 and .46 (Leung et al., 2016), we aimed for an effect size of .40. The sample size required was 132 per group (power = .90, α = .05).

Measures

All children in the study were individually assessed for cognitive skills, expressive language, and gross and fine motor skills using the following outcome measures by the respective health professionals, who were blind to the group status of the children.

The Cognition Scale of the Hong Kong Comprehensive Assessment Scale for Preschool Children (HKCAS-P; Leung et al., 2013b) was developed for Hong Kong children aged three years and four months to six years and three months as an individually administered test, which consists of 40 items on preschool concepts such as shapes, categorization, and verbal comprehension. The raw total scores are converted into scaled scores standardized for age groups (mean = 10, SD = 3). Scaled scores ≤6 are considered to be below average.

To measure changes in language expression, language samples were obtained from a 20-minute free play session between each study child and a speech therapist (Lee et al., 1996). The language samples produced by each child were audio-recorded for linguistic analyses, including sentence complexity and lexical diversity, which were analyzed by a speech therapist experienced in linguistic analyses who was blind to the group status of the children.

The Movement Assessment Battery for Children-version 2 (MABC-2; Henderson et al., 2007) is a standardized assessment tool for children aged 3–16 years old, with good psychometric properties (Wuang et al., 2012), that consists of a series of motor tasks in three age bands (3–6 years, 7–10 years, and 11–16 years old). Each series consists of eight test items on manual dexterity, aiming and catching, and balance. The raw total score was used in this study. The assessment was conducted by two physical therapists, with excellent intra- and inter-rater reliability (intraclass correlation >.85 based on 10 children randomly selected from the whole cohort).

The Hong Kong Preschool Fine Motor Developmental Assessment (HK-PFMDA; Heep Hong Society, 2009) was developed for Hong Kong children from birth to six years of age. It consists of 87 items that measure grasping, bilateral coordination, basic hand skills, manipulative skills, and pre-writing skills. This test was validated with good psychometric properties and the Hong Kong norm was established (Siu et al., 2011). Based on the scoring criterion of each test item, the examiner rates the performance of the children on a three-point scale to obtain the raw score and the Rasch score. Higher scores represent better performance in fine motor aspects.

All parents in the study were asked to report their children’s behavior problems and learning and their parenting stress and sense of competence using the following instruments.

The Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus, 1999) contains 36 items on disruptive behavior (e.g. temper tantrums), with an intensity scale and a problem scale. The former measures the frequency of problem behaviors on a seven-point scale, while the latter measures whether the specific behaviors are perceived as problematic (yes or no). Higher scores indicate a higher frequency of problem behavior and parental concern. The cut-off scores for clinical referral for the Intensity and Problem Scales are 131 and 15, respectively. The means of a group of children referred for behavior problems in a Chinese validation study (Leung et al., 2003) were similar to the original cut-off scores, and thus the original cut-off scores were adopted in the present study.

Academic competence (Leung et al., 2012) was measured using a 15-item scale based on the Behavior Rating Scale for Presented Academic Self-Esteem in Young Children (Fuchs-Beauchamp, 1996). In the validated Chinese version (Leung et al., 2012), parents rate their children on each statement (e.g. sense of competence and persistence) on a four-point scale. Higher scores indicate higher academic competence.

Effort and task motivation is originated from the Inventory of School Motivation (McInerney and Ali, 2006) and consists of two subscales, Effort and Task. The former measures effort attribution and effort-focused motivation and the latter measures task orientation and involvement. In the validated Chinese version (Leung and Lo, 2013), parents indicate their ratings of each statement on a four-point scale. Higher scores indicate higher motivation.

School readiness was based on the Gumpel School Readiness Scale (Gumpel, 1999), which consists of six items such as counting forward and backward. In the validated Chinese version (Ho et al., 2013), parents rate their children on each item using a four-point scale. Higher scores indicate higher readiness.

The Parenting Stress Index-short form (PSI; Abidin, 1990) consists of 36 items measuring three domains of parenting stress: parental distress (impaired sense of parental competence and depression); parent–child dysfunctional interaction (dissatisfaction with parent–child interaction); and difficult child (child behavior problems). A total score is calculated, with a higher score representing a higher level of parenting stress. A validated Chinese version was used in the present study (Lam, 1999).

The Parenting Sense of Competence Scale (PSOC; Gibaud-Wallston and Wandersman, 1978) is a 16-item questionnaire that assesses parents’ views of their competence as parents using a 6-point scale. A validated Chinese version was used in this study (Ngai et al., 2007). Higher scores indicate a higher sense of competence.

Procedures

All the participants were recruited through the Child Assessment Service (CAS) of the Department of Health, Hong Kong SAR Government, which provides comprehensive assessment, rehabilitation prescriptions, and management services to children with special needs and their families. Upon meeting the inclusion criteria, the CAS health professionals introduced the Poly Kids program to the parents, who could enroll themselves or through the CAS. All the children of the potential parent participants were on a waitlist for local early intervention programs. Recruitment was open from June 2015 to September 2016. The full program was delivered to the participants in two batches. The first batch started in January 2016 and the second batch started in October 2016.

The participants were assigned to either the intervention group or waitlist control group by random allocation; a research assistant generated a list of random numbers and placed them in sealed envelopes, and the first author assigned the random numbers to each child on the enrollment list. Those with an odd number were allocated to the intervention group and those with an even number to the control group.

All the participants attended a pre-intervention assessment about one month prior to the commencement of the program and the parents completed a consent form on-site. Within one month after the completion of the program by the intervention group, all the participants returned for a post-intervention assessment. On both occasions, the children were individually assessed for their cognitive skills, expressive language, and fine and gross motor skills when their parents completed questionnaires.

While the intervention group was participating in the Poly Kids program, no specific service was offered to the waitlist control group. However, they were free to attend any intervention at their own expense. Upon completion of the Poly Kids program by the intervention group, the waitlist control group was offered the program.

The program was delivered at a tertiary institute with easy access via public transport. The study was registered with the International Standard Randomized Controlled Trial Number Registry. The study was approved by the Human Subjects Ethics Sub-Committee of the authors’ institution.

The intervention

Details of the Poly Kids program are listed in Table 1. The program consisted of 16 two-hour weekly group sessions, with 14 sessions for the parents (nine sessions on child behavior and learning, three sessions on language, one session on fine motor skills, and one session on gross motor skills) and two sessions for both parents and children covering learning, language, and fine and gross motor skills. Each of the parent-only sessions began with a revision of homework from the previous session, followed by a talk or discussion of the topic of the current session. Then, the facilitator demonstrated the homework activities of the current lesson, followed by further practice among the parents through role-playing. The parent-only sessions were facilitated by the respective disciplines. In the two sessions attended by both parents and children, the parent–child dyads attended three stations each run by the same group of professionals of the respective disciplines for the parent-only sessions for 40 minutes per station in a small group of four dyads. The professional team first observed and coached the parents to work with their children on selected activities taught in previous sessions and further coached them to work on new activities.

To ensure that the parents could practice and master the skills taught, the parents were given structured daily homework activities based on the skills taught in the lesson. The facilitators provided written feedback on their homework performance. To ensure that the facilitators integrated their own content area with that of the other disciplines, each facilitator was required to observe the sessions conducted by the other disciplines during the pilot phase. To facilitate fidelity in delivery, a manual was developed, which included lesson notes for facilitators, notes for parents, PowerPoint slides, and homework activities. To ensure program fidelity for each session, a session checklist was completed by the session facilitator and a postgraduate psychology student, who acted as an observer.

Data analyses

Analyses were conducted using both complete data and intention-to-treat analysis. Missing data were estimated using multiple imputation (five imputations). Multiple regression was used for all the analyses, with group status and pre-intervention scores as independent variables and post-intervention scores as dependent variables. The McNemar test was used to examine the proportion of participants with changes in clinical classification. SPSS version 23 was used for all statistical analyses. Adjusted and unadjusted effect sizes (Cohen’s d indicating the standardized difference between the post-intervention means of each outcome measure of the intervention and control groups) were calculated.

Results

Two hundred and forty-four participants were referred and randomized into the intervention (n = 125) and the control (n = 119) groups. Among them, 218 participants completed the pre-assessment (intervention group n = 107, 85.60%; control group n = 111, 93.28%). Fifteen participants in the intervention group dropped out: 11 did not attend any sessions and 4 dropped out in sessions 2, 3, 5, and 10, respectively; 11 participants in the intervention group and 23 in the control group did not complete the post-assessment. Finally, 83 participants in the intervention group (including two dropouts, 77.57%) and 88 in the control group (79.28%) completed pre- and post-intervention data (see Figure 1). No difference was found in the demographic characteristics and pre-intervention scores between the participants with and without post-intervention data, except marital status (χ²(2) = 7.67, p = .022). There were more married participants among those with post-intervention data (n = 163, 96.45%) than those without post-intervention data (n = 43, 87.76%). The average attendance of the participants was 74.12% (range = 0–100%). Seventy-nine intervention participants (73.83%) attended at least 80% (13/16) of the sessions.

Figure 1.

Flow of participants.

The demographic characteristics of the participating families and their mean pre-intervention scores are shown in Table 2, while the mean post-intervention scores of the participants are shown in Table 3. The reliability estimates of most scales were above .70, except for the school readiness scale. There were no differences in the demographic characteristics and pre-intervention scores between the intervention and control groups. The McNemar test results for the participants who showed changes in clinical status are shown in Table 4. In the program fidelity check, the average coverage of core components was 97.85% (ranging from 53.33% to 100%). In 82.14% of the sessions, all core components of the lessons were covered and the inter-rater agreement was 100%.

Table 2.

Baseline characteristics of intervention and control groups (participants with complete data).

	Intervention group (n = 83)	Control group (n = 88)	p-Value
Target child
Gender—male	60 (72.29%)	63 (71.59%)	.919
Mean age in years (SD)	3.30 (.43)	3.37 (.50)	.327
Impairment^a
Hearing impairment	2 (2.41%)	0 (0.0%)	.143
Visual impairment	2 (2.41%)	2 (2.27%)	.953
Autism spectrum disorder	11 (13.25%)	19 (21.59%)	.152
Delay in ≥2 developmental domains	52 (62.65%)	54 (61.36%)	.862
Language delay	31 (37.35%)	33 (37.50%)	.984
Attention deficit/hyperactivity disorder	22 (26.51%)	19 (21.59%)	.452
Co-ordination disorder	14 (16.87%)	7 (7.95%)	.076
Preschool attendance	81 (97.59%)	87 (98.86%)	.526
Target parent
Mother	70 (84.34%)	74 (84.09%)	.367
Father	13 (15.66%)	12 (13.64%)
Others	0 (0.0%)	2 (2.27%)
Family status
Nuclear	58 (69.88%)	58 (65.91%)	.360
Extended	24 (28.92%)	25 (28.41%)
Re-constituted	1 (1.20%)	2 (2.27%)
Others	0 (0.00%)	3 (3.41%)
Marital status
Married/de facto	83 (100.0%)	82 (93.18%)	.053
Separated/divorced/widowed	0 (0.0%)	5 (5.68%)
Single	0 (0.0%)	1 (1.14%)
Mother’s education
Junior secondary or below	5 (6.02%)	12 (13.64%)	.096
Senior secondary or above	78 (93.98%)	76 (86.36%)
Father’s education
Junior secondary or below	10 (12.05%)	17 (19.54%)	.182
Senior secondary or above	73 (87.95%)	70 (80.46%)
Mother employed	47 (56.63%)	51 (57.95%)	.861
Father employed	80 (96.39%)	81 (93.10%)	.339
Monthly income
≤$19,999	19 (22.89%)	28 (31.82%)	.191
≥$20,000	64 (77.11%)	60 (68.18%)	.191
On social security	3 (3.61%)	1 (1.14%)	.356
Mean age of mother (SD)	36.75 (4.38)	36.16 (4.89)	.405
Mean age of father (SD)	39.88 (7.11)	39.91 (6.14)	.975
Outcome measures
ECBI-Intensity	131.82 (25.24)	133.73 (23.32)	.608
ECBI-Problem	12.05 (7.66)	12.02 (7.97)	.983
Task Motivation	7.94 (2.45)	7.99 (2.57)	.899
School Readiness	10.20 (2.75)	10.03 (2.95)	.697
Academic Competence	26.40 (6.62)	26.92 (7.38)	.627
Effort Motivation	13.16 (3.85)	12.34 (4.80)	.224
HKCAS-P Cognition raw scores	8.63 (5.12)	9.66 (5.81)	.225
HKCAS-P Cognition scaled scores	6.69 (2.76)	6.84 (2.83)	.779
Total number of words^b	194.29 (166.13)	185.34 (181.68)	.755
Total number of different words^b	67.72 (41.03)	65.36 (44.49)	.738
Total number of utterances^b	102.10 (70.95)	99.19 (81.22)	.817
Mean length of utterances^b	1.77 (.59)	1.71 (.61)	.560
HK-PFMDA Rasch score	67.15 (5.34)	68.16 (6.11)	.253
MABC-2 total score	55.46 (16.49)	54.78 (16.70)	.790
Parenting Stress Index	98.67 (19.72)	99.01 (18.34)	.908
Parenting Sense of Competence	57.35 (8.70)	57.81 (8.01)	.721

SD: standard deviation; ECBI: Eyberg Child Behavior Inventory; HKCAS-P: Hong Kong Comprehensive Assessment Scale for Preschool Children; HK-PFMDA: Hong Kong Preschool Fine Motor Developmental Assessment; MABC-2: Movement Assessment Battery for Children-version 2.

^a Parents could choose more than one category.

^b Intervention: 72, control: 77.

Table 3.

Pre-intervention and post-intervention scores of outcome measures (based on participants with complete data).

	Intervention group post mean (SD)	Control group post mean (SD)	Adjusted effect size (d) [95% CI]	Unadjusted effect size (d) [95% CI]
ECBI-Intensity	124.75 (25.94)	130.93 (27.17)	.18 [−.13, .48]	.23 [−.07, .53]
ECBI-Problem	8.39 (6.69)	10.34 (8.38)	.34 [.03, .64]	.26 [−.05, .55]
Task Motivation	9.16 (2.20)	8.51 (2.47)	.63 [.31, .92]	.28 [−.03, .57]
School Readiness	11.95 (2.73)	11.81 (2.88)	.13 [−.17, .43]	.05 [−.25, .35]
Academic Competence	28.78 (6.51)	29.08 (6.86)	.04 [−.26, .34]	−.04 [−.34, .26]
Effort Motivation	14.28 (3.70)	13.93 (4.44)	.15 [−.16, .44]	.09 [−.22, .38]
HKCAS-P Cognition raw scores	15.23 (6.46)	15.48 (6.78)	.06 [−.25, .35]	−.04 [−.34, .26]
HKCAS-P Cognition scaled scores	8.13 (2.79)	7.46 (3.20)	.39 [−.01, .77]	.22 [−.17, .60]
Total number of words^a	327.75 (234.76)	260.79 (154.15)	.82 [.47, 1.14]	.34 [.01, .66]
Total number of different words^a	99.08 (48.65)	92.61 (42.87)	.34 [.01, .66]	.14 [−.18, .46]
Total number of utterances^a	137.79 (86.69)	121.69 (61.44)	1.01 [.65, 1.33]	.22 [−.11, .53]
Mean length of utterances^a	2.26 (0.71)	2.10 (0.71)	.33 [.00, .65]	.23 [−.10, .54]
HK-PFMDA Rasch Score	73.13 (5.23)	74.31 (5.83)	−.24 [−.54, .06]	−.21 [−.51, .09]
MABC-2 total score	63.24 (14.71)	65.58 (16.93)	−.24 [−.54, .06]	−.15 [−.45, .16]
Parenting Stress Index	91.53 (20.02)	96.15 (19.51)	.25 [−.05, .55]	.23 [−.07, .53]
Parenting Sense of Competence	59.83 (9.06)	57.98 (8.12)	.39 [.08, .69]	.22 [−.09, .51]

SD: standard deviation; CI: confidence interval; ECBI: Eyberg Child Behavior Inventory; HKCAS-P: Hong Kong Comprehensive Assessment Scale for Preschool Children; HK-PFMDA: Hong Kong Preschool Fine Motor Developmental Assessment; MABC-2: Movement Assessment Battery for Children-version 2.

^a Intervention: 72, control: 77.

Table 4.

Changes in clinical status (based on participants with complete data).

	Intervention group (n = 83)		Control group (n = 88)
	ECBI-Intensity
	Below clinical cut-off at pre-intervention	Above clinical cut-off at pre-intervention	Below clinical cut-off at pre-intervention	Above clinical cut-off at pre-intervention
Below clinical cut-off at post-intervention	32 (38.55%)	16 (19.28%)	41 (46.59%)	8 (9.09%)
Above clinical cut-off at post-intervention	4 (4.82%)	31 (37.35%)	6 (6.82%)	33 (37.50%)
McNemar test result	p = .012		p = .791
ECBI-Problem
Below clinical cut-off at post-intervention	56 (67.47%)	11 (13.25%)	50 (56.82%)	13 (14.77%)
Above clinical cut-off at post-intervention	2 (2.41%)	14 (16.87%)	6 (6.82%)	19 (21.59%)
McNemar test result	p = .022		p = .167
HKCAS-P cognition
	Average or above at pre-intervention	Below average at pre-intervention	Average or above at pre-intervention	Below average at pre-intervention
Average or above at post-intervention	20 (41.67%)	14 (29.17%)	26 (45.61%)	6 (10.53%)
Below average at post-intervention	3 (6.25%)	11 (22.92%)	5 (8.77%)	20 (35.09%)
McNemar test result	p = .013 (n = 48)		p = 1.00 (n = 57)

HKCAS-P: Hong Kong Comprehensive Assessment Scale for Preschool Children.

Analysis based on participants with complete data

Child behavior

The intervention group reported significantly lower child behavior problems post-intervention (see Table 3). Group status was significant for the ECBI-Problem Scale (b = 1.97, t = 2.39, p = .018, d = .34), but the difference was not statistically significant for the ECBI-Intensity Scale (b = 4.45, t = 1.96, p = .051, d = .18). The McNemar test results indicated a significant improvement in clinical status in terms of the ECBI-Intensity and ECBI-Problem Scales for the intervention group, but not the control group (see Table 4).

Child learning

The intervention group reported significantly higher task motivation post-intervention compared with the control group (b = −.67, t = 2.08, p = .039, d = .63) (see Table 3). The results, however, were not significant for school readiness (b = −.05, t = .13, p = .895, d = .13), academic competence (b = −.05, t = .07, p = .942, d = .04), effort motivation (b = .07, t = .13, p = .895, d = .15), HKCAS-P Cognition raw scores (b = −.69, t = 1.02, p = .308, d = .06), and HKCAS-P Cognition scaled scores (b = −.78, t = 1.73, p = .087, d = .39) (see Table 3). The McNemar test results indicated a significant improvement in developmental status in terms of the HKCAS-P Cognition scaled scores for the intervention group, but not the control group (scaled scores ≤6 are below average; see Table 4).

Child language

The intervention group used a significantly higher total number of words than the control group post-intervention (b = −62.78, t = 2.12, p = .035, d = .82) (see Table 3). The results were not significant for the total number of different words (b = −5.42, t = .79, p = .429, d = .34), total utterances (b = −15.42, t = 1.29, p = .198, d = 1.01), and the mean length of utterances (MLUs) (b = −.11, t = 1.24, p = .216, d = .33).

Fine and gross motor skills

No significant difference was found in the post-intervention scores between the two groups (HK-PFMDA: b = .32, t = .80, p = .424, d = −.24; MABC-2: b = 2.73, t = 1.40, p = .162, d = −.24).

Parenting

The parents in the intervention group reported significantly lower parenting stress post-intervention compared with those in the control group (b = 4.37, t = 2.02, p = .045, d = .25); but the difference was not statistically significant for parenting sense of competence post-intervention (b = −2.12, t = 1.95, p = = .052, d = .39) (see Table 3).

Intention-to-treat analysis

No significant difference in child behavior (ECBI-Intensity and ECBI-Problem Scales) was found between the two groups post-intervention (see Online Supplementary Appendix B). However, the McNemar test results indicating an improvement in clinical status in terms of the ECBI-Intensity and ECBI-Problem Scales remained significant for the intervention group, but not the control group (see Online Supplementary Appendix C).

The children in the intervention group showed significantly higher task motivation post-intervention (see Online Supplementary Appendix B). The results were not significant for school readiness, academic competence, effort motivation, HKCAS-P Cognition raw scores, and HKCAS-P Cognition scaled scores (see Online Supplementary Appendix B). The McNemar test results indicated a significant improvement in developmental status in terms of the HKCAS-P Cognition scaled scores for the intervention group, but not the control group (see Online Supplementary Appendix C).

The results of the child language outcomes (total utterances, total number of words used, total number of different words, and MLUs) and fine and gross motor skills, as well as parenting stress and sense of competence, remained insignificant based on the intention-to-treat analysis (see Online Supplementary Appendix B).

Discussion

The Poly Kids program is a pioneer multidisciplinary parent training program targeting various developmental domains of preschool children with DD and parenting stress and sense of competence. Attempts were made to connect the various domains, for example, using gross motor activities to teach preschool concepts (e.g. jumping onto a named color spot on the floor) and enhancing the parent–child relationship and language skills by reflecting the children’s thoughts. The program was designed to support parents in creating a positive learning environment for their children with DD through preventing/managing child behavior problems and applying effective strategies to facilitate child development while waiting for early intervention. The program did not aim to replace direct professional intervention where indicated. If the vicious circle of increasing learning difficulties and escalating behavior challenges can be interrupted, the effectiveness of professional intervention may be enhanced.

The significant reduction in parental reports of child behavior problems in the intervention group compared with the control group among the participants with complete data (see Table 3) and the McNemar test results (see Table 4) provided some initial evidence that parent training programs such as Poly Kids are effective in reducing child behavior problems (Leung et al., 2016; Tellegen and Sanders, 2013). To further improve program effectiveness, extra weekly phone follow-up during the program may provide parents with timely assistance to tackle specific child behavior issues (Tellegen and Sanders, 2013). With the positive McNemar test results in the complete data and intention-to-treat analysis, it is reasonable to conclude that Poly Kids was effective in reducing the frequency of child behavior problems.

The significant results in task motivation and developmental status (HKCAS-P Cognition scaled scores), based on the complete data and intention-to-treat analysis (see Tables 3 and 4, and Online Supplementary Appendices B and C), provided promising evidence that Poly Kids was effective in improving learning in children with DD, which is consistent with current literature (Macvean et al., 2016). However, the improvement in child learning did not carry over to school readiness, academic competence, and effort motivation. It is possible that it may take longer before the impact on child learning from the program is shown regarding these learning domains.

The significant improvement of the intervention group in the total number of words produced in the language sample analysis among the participants with complete data is consistent with the literature on the effective facilitation of Chinese language development through parent–child reading (Chow and McBride-Chang, 2003). However, this improvement did not lead to an increase in the total number of different words used, total utterances, and MLUs (see Table 3). As for school readiness and academic competence, the children might have required a longer duration of training with their parents or with professionals before showing improvements in their repertoire of words used and utterances.

It was disappointing that there was no significant difference in fine and gross motor skills between the intervention and control groups (see Table 3). It is possible that this was due to a smaller number of sessions (only one parent-only session and one parent–child hands-on session) for these two domains compared with the others. Moreover, the assessment of fine and gross motor skills examined the quality of the children’s actual movement performance. Parents might require more individualized hands-on training to acquire the necessary skills to identify their children’s specific difficulties to provide targeted training. It is also possible that the children required an intensive training duration with professional intervention before showing improvements in these two domains.

For parenting, there was a significant decrease in parenting stress in the intervention group (see Table 3). Although the significant results were diminished in the intention-to-treat analysis, it is reasonable to conclude that Poly Kids was effective in reducing parenting stress as shown in other parent training programs (Leung et al., 2013a; Leung et al., 2016; Tellegen and Sanders, 2013). As Poly Kids focused on promoting child development and managing child behavior, parental emotional adjustment was not directly addressed. Strengthening emotional support for parents should be considered in future programs.

As a group program, Poly Kids was not designed to tackle specific difficulties of individual children. However, there was a wide variation in the participating children’s developmental functioning. To help parents relate the program strategies to their children’s specific needs, providing training materials with a wider range of difficulties to cater to different levels of functioning or grouping parents according to their children’s developmental levels should be considered.

In the intervention group, 26 (24.30%) dropped out or did not return for the post-assessment. The loss to follow-up was comparable to the attrition rate reported in a meta-analysis of Stepping Stones Triple P (up to 37%) (Tellegen and Sanders, 2013). One possible reason for the dropouts was the location of the program in a tertiary institute rather than local preschools. Preschool-based programs are likely to be more engaging as parents can access their local preschools easily (Gross and Grady, 2002). Encouragement from preschool principals and teachers may be important for parents to maintain their ongoing attendance in a 16-week program. Furthermore, with the involvement of preschools, home–school cooperation in providing consistent support to the children can be enhanced. The delivery of the Poly Kids program in local preschools should be explored.

Limitations of the study

The medium to long-term effect of the program was not examined. The control group was a waitlist group, and services were offered to them after the intervention group had completed the program. Future studies should consider using a control group with no intervention to investigate the medium to long-term effect. The outcome measures of child behavior were based on parental reports instead of independent observation of the children. Future studies should consider blinded assessment of child behavior by independent observers. Teachers’ reports on the children’s learning and behavior were not incorporated. Children with ASD or ADHD with severe disruptive behavior were excluded. The effectiveness of the Poly Kids program on these children should be further investigated. Some significant results for the participants with complete data were not found in the intention-to-treat analysis. This should be taken into consideration when interpreting the present results.

Conclusion

The Poly Kids program is a comprehensive parent training program targeting child behavior and learning, language, and fine and gross motor skills of children with DD and parenting stress and sense of competence. The results provided initial evidence that the program might be effective in improving aspects of child learning, language, and behavior and parenting.

Supplemental material

supplementary_material - Effectiveness of a multidisciplinary parent training program for children with developmental disabilities: A single-blind randomized waitlist controlled trial

supplementary_material for Effectiveness of a multidisciplinary parent training program for children with developmental disabilities: A single-blind randomized waitlist controlled trial by Cynthia Leung, Cynthia Lai, Dustin Lau, Shirley Leung and Tamis W Pin in Journal of Child Health Care

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Food and Health Bureau, Hong Kong SAR Government.

ORCID iDs

Cynthia Leung

Tamis W Pin

Supplemental material

Supplemental material for this article is available online.

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