1. COPE: Community Parent Education Program Evidence Base and Future Directions Charles E. Cunningham, Ph.D. Professor Department of Psychiatry & Behavioural Neurosciences Jack Laidlaw Chair in Patient-Centred Heath Care Faculty of Health Sciences McMaster University

2. Goals of the Morning: The Evidence for COPE Evidence Prompting the Development of COPE Parental Preference Modeling Studies Utilization Studies – Who Enrols in COPE Evidence on Large Group Process Efficacy Studies – Impact Under Optimal Conditions Effectiveness Studies – Effect in the Real World Economic Analysis FIKA

3. Ontario Child Health Study: Mental Health Problems in 6-18 Year Olds Ontario Child Health Study: Mental Health Problems in 6-18 Year Olds 18.1% Source: Offord et al. Archives of General Psychiatry (1989)

4. Percentage of Children Receiving Mental Health Services Percentage of Children Receiving Mental Health Services No Service 83% Service 17% Source: Offord et al. Archives of General Psychiatry (1989)

5. Rationale for Parent Training: Limited Parental Confidence Parent Subgroup Source: Cunningham et al., Journal of Abnormal Child Psychology 2002

6. Counter Productive Responses to to Preschool Behavior Problems Problem Type Source: Cunningham et al., Journal of Abnormal Child Psychology (2002)

7. Rationale for Parent Training: Preference for Coercive Responses Parent Subgroup Source: Cunningham et al., Journal of Abnormal Child Psychology, 2002

8. BCFPI: Impact of Problems on Family Life Source: Cunningham, et al., 2003 (670 3-6 Year Old Referrals)

9. What Do Parents Say About Universal School-based Parenting Programs? Source: Cunningham et al., Journal of Consulting & Clinical Psychology (2000)

10. BCFPI Interim Service Questions: Who Requests Information About Children’s Mental Health Problems Source: 23,420 consecutive referrals 75% of Referrals Interested in Parenting Groups

11. What Logistical Factors Prevent Participation in Parenting Interventions? Source: Cunningham et al., Journal of Consulting & Clinical Psychology (2000)

12. Is Parent Training Accessible? Do Multicultural Families Use Clinic Programs? Source: Cunningham, et al., Journal of Child Psychology & Psychiatry, 1995

13. Factors Influencing the Decision to Enroll in Parent Training Programs (n=1068) Importance Score Source: Cunningham, Buchanan & Deal, 2004

14. How Long Will Parents Travel for Parenting Programs (n=1068)? How Long Will Parents Travel for Parenting Programs (n=1068)? Source: Cunningham, Buchanan & Deal, 2004 Minutes to Parenting Program

15. Factors Influencing the Decision to Enroll in Parent Training Programs (n=1068) Importance Score Source: Cunningham, Buchanan & Deal, 2004

16. Parenting Course Preferences: Child Care (n=1068) Source: Cunningham, Buchanan & Deal, 2004

17. Factors Influencing the Decision to Enroll in Parent Training Programs (n=1068) Importance Score Source: Cunningham, Buchanan & Deal, 2004

18. What are the Most Convenient Times for Service (n=1068)? What are the Most Convenient Times for Service (n=1068)? Source: Cunningham, Buchanan & Deal, 2004

19. Factors Influencing the Decision to Enroll in Parent Training Programs (n=1068) Importance Score Source: Cunningham, Buchanan & Deal, 2004

20. Parenting Course Preferences: Learning Process (n=1068) Source: Cunningham, Buchanan & Deal (2004)

21. Watch Videotaped Errors

22. Identify Errors & Consequences

23. Review Subgroup Conclusions

24. Subgroups Propose Alternatives

25. Review Subgroup Suggestions

26. Leader Models Group’s Suggestions x 3

27. Subroups Brainstorm

28. Practice

29. Setting Homework Goals

30. Parenting Course Preferences: Goals of the Program (n=1068) Source: Cunningham, Buchanan, & Deal, 2004

31. The Curriculum of COPE Workshops

32. Parenting Program Consumer Preferences: Evidence Source: Cunningham et al., 2004

33. Utilization Studies Who Enrolls in COPE?

34. Utilization of COPE: Children with Severe Problems Source: Cunningham, et al.,Journal of Child Psychology & Psychiatry, 1995 Clinic COPE-Community

35. Utilization of Community Workshops: Multicultural Families Source: Cunningham, et al., Journal of Child Psychology & Psychiatry, 1995 Clinic COPE-Community

36. Factors Not Linked to Utilization of COPE Programs Source: Cunningham et al. Journal of Child Psychology & Psychiatry 1995; Journal of Consulting & Clinical Psychology, 2000 Parental Depression Scores Family Dysfunction Scores Income Economic Assistance

37. Who Enrolls in Universally Advertised COPE Workshops? High Child & Family Impairment Scores High Externalizing Scores Low Mood & Anxiety Problems

38. When Do Parents Enroll in COPE? Source: Cunningham, Buchanan & Deal, in preparation COPE Workshop Time Most Parents Enroll in Evening Workshops

39. Process Studies: Is COPEing Modeling the Best Way to Teach Parenting?

40. Does Participation in the Formulation of Solutions Effect Late Arrivals? Source: Cunningham et al., Journal of Consulting & Clinical Psychology, 1993 4 Session Blocks Participants Less Likely to be Late for COPE

41. Does Participation in The Development of Solutions Effect Attendance? Source: Cunningham et al., Journal of Consulting & Clinical Psychology, 1993 4 Session Blocks Participants Attend More COPE Sessions

42. Does Participation in the Development of Solutions Influence “Resistance” During Homework Reviews? Source: Cunningham et al., Journal of Consulting & Clinical Psychology, 1993 4 Session Blocks Less “Resistance” During COPE Homework Reviews

43. Does Participation in the Development of Solutions Effect Adherence? Source: Cunningham et al., Journal of Consulting & Clinical Psychology, 1993 4 Session Blocks Participants Completed More COPE Homework

44. Efficacy: Does COPE Work in Randomized Trials?

45. Improvement (Effect Size) in Problems at Home: Pre to 6 Mo F/U Source: Cunningham, et al., Journal of Child Psychology & Psychiatry, 1995 COPE Yields Large Effect Size at Follow-up

46. The COPE Family of Developmentally Sequenced Programs Right from the Start (Dr. Alison Niccols) COPEing with Toddler Behaviour (2-3 year olds) COPE for Parents of 4 to 12 Year Olds COPE for Parents of Teens

47. Randomized Trials: COPEing with Toddler Behaviour

48. Developed by Dr. Alison Niccols COPE Model Large Groups 8 Sessions 79 Parents Randomly Assigned to CWTB vs Control Children Average Age = 2 years Pre Post and 1 Month Follow-up Intent to Treat Analysis COPEing with Toddler Behaviour Source: Niccols, Journal of Child Psychology & Psychiatry, 2009

49. Improvement in Problems on ECPI: Pre to 1 Month F/U Source: Niccols, Journal of Child Psychology & Psychiatry, 2009 “The potential of the program to prevent later behavior problems is supported by improvements in six of the eight outcomes.”

50. Does COPE Work in Sweden?

51. “The main findings were that COPE was found to be effective in reducing conduct problems, hyperactivity/impulsivity, daily problem behaviours, parental stress, and lack of perceived control.”

52. Improvement (Effect Size) in Conduct Problems Source: Lisa Thorell. Journal of Clinical Child Psychology & Psychiatry (2009) COPE Yielded Large Effect Size in Children with High Symptoms

53. Effectiveness Studies: Does COPE Work in Practice?

54. Effectiveness of COPE Moderate-Severe Problems Sample Size = 109 1995 AM PM Control Source: Cunningham, Knight, Harrison, 2003

55. Economic Analyses

56. Cost of Large COPE Workshops: 150 Families Source: Cunningham, et al., Journal of Child Psychology & Psychiatry, 1995 Individual COPE Groups

57. Cost Effectiveness: (Cost Per Case For 1 SD Change) (Cost/Effect Size) Clinic Large Group Individual COPE Source: Based on Cunningham, et al., Journal of Child Psychology & Psychiatry, 1995

58. Experience in Other Cultures?

59. “The COPE program produced robust positive effects in the participants” “COPE is a culturally competent intervention for the population” http://www.bronxbehavioralnetwork.org/goals1.htm COPE in South Bronx New York

60. Utilization of Parent Training by High Risk Families: Prospectively Screened Samples