ARTICLE

Interventions to Reduce Behavioral Problems in

Children With Cerebral Palsy: An RCT
AUTHORS: Koa Whittingham, PhD,a,b Matthew Sanders,
PhD,b Lynne McKinlay, MD,c and Roslyn N. Boyd, PhDa
aQueensland Cerebral Palsy and Rehabilitation Research Centre,
School of Medicine, and bParenting and Family Support Centre,
School of Psychology, The University of Queensland, Brisbane,
Australia; and cQueensland Paediatric Rehabilitation Service,
Royal Children’s Hospital, Brisbane, Australia
KEY WORDS
parenting, behavioral family intervention, cerebral palsy,
acceptance and commitment therapy, mindfulness
ABBREVIATIONS
ACT—Acceptance and Commitment Therapy
ANCOVAs—analyses of covariance
ASDs—autism spectrum disorders
CI—confidence interval
CP—cerebral palsy
ECBI—Eyberg Child Behavior Inventory
GMFCS—Gross Motor Function Classification System
MD—mean difference
PS—Parenting Scale
RCT—randomized controlled trial
SDQ—Strengths and Difficulties Questionnaire
SSTP—Stepping Stones Triple P
Triple P—Positive Parenting Program
WL—waitlist control
Dr Whittingham conceptualized and designed the study, with
mentorship from senior authors, managed the randomized
controlled trial, conducted the analysis, and drafted the initial
manuscript; Drs Sanders, McKinlay, and Boyd provided
mentorship in the conceptualization and design of the study, and
reviewed and revised the manuscript; and all authors approved
the final manuscript as submitted.
This trial has been registered with the Australian New Zealand
Clinical Trials Registry (identifier 00336291).
www.pediatrics.org/cgi/doi/10.1542/peds.2013-3620
doi:10.1542/peds.2013-3620
Accepted for publication Feb 14, 2014
Address correspondence to Koa Whittingham, PhD, Queensland
Cerebral Palsy and Rehabilitation Research Centre, Level 7, Block
6, RBWH Herston, Brisbane, Australia 4029. E-mail:
koawhittingham@uq.edu.au
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
(Continued on last page)
WHAT’S KNOWN ON THIS SUBJECT: One in 4 children with
cerebral palsy (CP) have a behavioral disorder. Parenting
interventions are an efficacious approach to treating behavioral
disorders. There is a paucity of research on parenting
interventions with families of children with CP.
WHAT THIS STUDY ADDS: This is the first study to demonstrate
the efficacy of a parenting intervention in targeting behavioral
problems in children with CP. Further, results suggest that
Acceptance and Commitment Therapy delivers additive benefits
above and beyond established parenting interventions.
abstract
OBJECTIVE: To test Stepping Stones Triple P (SSTP) and Acceptance and
Commitment Therapy (ACT) in a trial targeting behavioral problems in
children with cerebral palsy (CP).
METHODS: Sixty-seven parents (97.0% mothers; mean age 38.7 6 7.1
years) of children (64.2% boys; mean age 5.3 6 3.0 years) with CP
(Gross Motor Function Classification System = 15, 22%; II = 18, 27%; III
=12, 18%; IV = 18, 27%; V = 4, 6%) participated and were randomly
assigned to SSTP, SSTP + ACT, or waitlist. Primary outcomes were
behavioral and emotional problems (Eyberg Child Behavior Inventory
[ECBI], Strengths and Difficulties Questionnaire [SDQ]) and parenting
style (Parenting Scale [PS]) at postintervention and 6-month follow-up.
RESULTS: SSTP with ACT was associated with decreased behavioral
problems (ECBI Intensity mean difference [MD] = 24.12, confidence in-
terval [CI] 10.22 to 38.03, P = .003; ECBI problem MD = 8.30, CI 4.63 to
11.97, P , .0001) including hyperactivity (SDQ MD = 1.66, CI 0.55 to
2.77, P = .004), as well as decreased parental overreactivity (PS MD =
0.60, CI 0.16 to 1.04, P = .008) and verbosity (PS MD = 0.68, CI 0.17 to
1.20, P = .01). SSTP alone was associated with decreased behavioral
problems (ECBI problems MD = 6.04, CI 2.20 to 9.89, P = .003) and
emotional symptoms (SDQ MD = 1.33, CI 0.45 to 2.21, P = .004).
Decreases in behavioral and emotional problems were maintained
at follow-up.
CONCLUSIONS: SSTP is an effective intervention for behavioral prob-
lems in children with CP. ACT delivers additive benefits. Pediatrics
2014;133:1–9

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Cerebral palsy (CP) is a permanent
disorder of the development of move-
ment and posture that is caused by
nonprogressive disturbance to the de-
veloping fetal or infant brain.1 It is the
most common physical disability in
childhood, occurring in 2.0 to 2.5 of ev-
ery 1000 live births.2 Children with CP,
akin to children with disabilities gener-
ally, are more likely to experience be-
havioral and emotional problems.3–5 A
recent meta-analysis showed that 1 in 4
children with CP have a behavioral dis-
order6 compared with 1 in 10 typically
developing children7; however, despite
recognition of the problem, there is
a paucity of research and clinical ser-
vices to address this issue.
Parenting interventions target behav-
ioral and emotional problems of child-
hood through enhancing parenting.8
Parenting interventions based in social
learning theory and behavioral analysis
have wide empirical support with typi-
cally developing children.9–11 Stepping
Stones Triple P (SSTP) is a variant of the
widely disseminated Positive Parenting
Program (Triple P) that targets families
of children with disabilities.12 A recent
meta-analysis found that SSTP has
a moderate effect on child behavioral
outcomes (d = 0.537) and a large effect
on parenting style (d= 0.725),13 consis-
tent with meta-analyses of Triple P with
typically developing children.14–17 Fur-
ther, SSTP has demonstrated efficacy
specifically for families of children with
autism spectrum disorders (ASDs).18
Although parenting interventions, such
as SSTP, are an evidence-based ap-
proach for targeting behavioral and
emotional problems in childhood and
are readily accessible by parents, there
are no published randomized controlled
trials (RCTs) of a parenting intervention
for families of children with CP.19
Acceptance and Commitment Therapy
(ACT) is a new cognitive behavioral
therapy that emphasizes nonjudgmental
psychological contact with present
2 WHITTINGHAM et al
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moment experience and engagement
in meaningful, values-driven activi-
ties.20 The goal of ACT is to increase
psychological flexibility, the ability to
persist or change one’s behavior, with
full awareness of the situational con-
text and one’s own present-moment
experience, in the service of chosen
values. ACT has a growing evidence
base; it is at least as effective as older
cognitive behavioral therapy models
with some evidence suggesting greater
efficacy.21–23 ACT may enhance estab-
lished behavioral parenting interven-
tions by addressing parental cognition
and emotions.24,25 This new approach is
particularly promising for families of
children with disabilities, with RCTs ur-
gently needed.26
Our aim was to test the efficacy of SSTP,
with and without ACT, in targeting child
behavioral and emotional problems
and dysfunctional parenting in families
of children with CP.
METHODS
Design
The study design is detailed in full in the
study protocol.27 This was a 2-phase RCT
with 3 groups (SSTP, SSTP + ACT, waitlist
control [WL]). The first phase, the pri-
mary focus of the study, involved a com-
parison among SSTP, SSTP with ACT, and
WL groups at postintervention. After
postintervention assessment, the WL
group, for ethical reasons, was offered
SSTP. If WL families completed SSTP, then
they also completed additional post-
intervention assessment, along with
6-month follow-up assessment. The sec-
ond phase of the study examined effects
at follow-up and included all families
who received an intervention and com-
pleted 6-month follow-up assessment.
The second phase included a pre-post
design component, examining the re-
tention of intervention effect from post-
intervention to 6-month follow-up, as
well as a comparison between families
who received SSTP and families who
received SSTP with ACT at 6-month
follow-up.
Ethical clearance was obtained from the
Children’s Health Queensland Human
Research Ethics Committee, the Univer-
sity of Queensland Behavioral and Social
Sciences Ethical Review Committee, and
the Cerebral Palsy League of Queens-
land Research Ethics Committee; all
participating parents signed a consent
form before participation.
Participants
Participants were parents of children (2–
12 years) with a diagnosis of CP (all
gross motor functioning severity levels)
who self-identified as needing a parent-
ing intervention after discussion on what
a parenting intervention could target.
Participants were recruited from the
databases of the Queensland Cerebral
Palsy and Rehabilitation Research Cen-
tre, the Cerebral Palsy League, and the
Queensland Cerebral Palsy Register, and
through presentation at the Queensland
Cerebral Palsy Health Service (Fig 1).
Sample Size Calculation
Sample size calculations were based on
the primary outcome: child behavior. An
effect size of 0.25 was assumed because
it is consistent with a clinically im-
portant difference of 0.5 SD and is
comparable to the effect size for SSTP
obtained with families of children with
ASD, h2 = 0.27.18 This leads to a total
sample size of 98 (power 0.8, 2-tailed,
P = .05) and 110 accounting for attrition.
This was not obtained, with recruitment
efforts in the available population lead-
ing to a final sample size of 67.
Procedure
The randomization process was com-
pleted by computerized sequence gen-
eration with block randomization to
ensure equal (or near equal) allocation
of participants to groups. The group
allocations were placed inside sealed,
opaque, and numbered envelopes by
 ARTICLE

FIGURE 1
Study protocol and participant flow.

PEDIATRICS Volume 133, Number 5, May 2014 3

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a staff member not involved in this study.
On enrolment of a family, the study co-
ordinator opened the next envelope in
sequence. Each study participant was
randomized to 1 of 3 groups: SSTP, SSTP
with ACT, or WL.
The interventions (SSTP and SSTP + ACT)
were delivered in a combined group (3–
10 families per group) and telephone
format. SSTP consisted of 6 (2-hour)
group sessions plus 3 (30-minute) tele-
phone consultations and was delivered
by psychologists with accreditation in
SSTP. SSTP sessions included strategies
for building a positive parent-child
relationship, encouraging desirable
behavior, teaching new skills and be-
haviors, managing misbehavior, and
managing high-risk situations. Parents
made specific goals for change and were
supported in enacting plans for manag-
ing challenging parenting situations.
For the SSTP with ACT group, the ACT
sessions (two 2-hour group sessions)
preceded SSTP. ACT sessions included
identifying values, mindfulness, cognitive
defusion (distancing from thoughts),
acceptance of emotions, and making
specific goals for acting on values. For
some groups, a weekend workshop for-
mat was used to allow for intervention
delivery as an outreach program in far
North Queensland (Table 1).
Assessment
The Family Background Questionnaire
was used to gather demographic data28
and the Gross Motor Function Classifi-
cation System (GMFCS) was used to
classify gross motor functional abil-
ity.29 This article focuses on reporting
the primary outcomes: child behavioral
and emotional problems (Eyberg Child
Behavior Inventory [ECBI], Strengths and
Difficulties Questionnaire [SDQ]) and
parenting style (Parenting Scale [PS]).
All outcomes are parent-report. The
ECBI30 produces 2 scales, the intensity
and the problem scales, and is consid-
ered to show high reliability and
4 WHITTINGHAM et al
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TABLE 1 Comparison of Intervention Content: SSTP and ACT
Intervention Content SSTP ACT
Discussion of how parents cope with stress with a focus on identifying the — x
workability of various coping strategies.
Use of metaphor to promote psychological flexibility (eg, the quicksand metaphor — x
is used to explain how struggling with psychological distress often increases
psychological distress).
Identification of values, that is, overarching desired qualities of living (eg, being — x
a loving parent).
Mindfulness exercises to promote psychological contact with the present — x
moment, including thoughts and emotions. Exercises included mindfulness of
breathing, mindfulness of thoughts and mindfulness of emotions.
Cognitive defusion exercises to create psychological distance from thoughts (eg, — x
saying the thought in the voice of a cartoon character).
Setting specific goals for acting on values (eg, acting on the value being a loving — x
parent by responding to child’s requests for physical affection).
Discussion of positive parenting (eg, using assertive discipline). x —
Discussion of the causes of child behavior problems (eg, accidentally rewarding x —
child’s behavior with attention).
Setting specific goals for change in parent and child behavior (eg, reducing the x —
frequency of temper tantrums).
Monitoring of child behavior (eg, recording the frequency of temper tantrums). x —
Reviewing parenting strategies to develop a positive parent-child relationship x —
(eg, quality time).
Reviewing parenting strategies to encourage desirable behavior (eg, using x —
descriptive praise).
Reviewing parenting strategies to teach new skills and behaviors (eg, using ask, x —
say, do to teach new skills in steps).
Reviewing parenting strategies to manage misbehavior (eg, planned ignoring). x —
Creating planned activities routines for high-risk parenting situations (eg, x —
creating a plan, including various parenting strategies to improve child
behavior while shopping).
Reviewing implemented planned activities routines, as well as other behavioral x —
change goals, and considering future changes in a structured way.
—, not included.
validity.31,32 The SDQ33 produces 5 sub- SSTP + ACT). A Bonferroni correction was
scales (emotional symptoms, conduct applied to linear contrasts to correct
problems, inattention/hyperactivity, peer for multiple comparisons, resulting in a
problems, and prosocial behavior) and P value of .0167. A sensitivity analysis
is considered to have high reliability was conducted with the last observation
and validity.34 The PS35 is a measure of 3 carried forward for all participants who
dysfunctional discipline styles: laxness, failed to complete the postintervention
overreactivity, and verbosity. The PS assessment.
shows strong reliability and validity. For The second phase of the study examined
full details, see the study protocol.27 effects at follow-up and included all
families who received an intervention
Statistical Analysis and completed 6-month follow-up as-
The first phase, a comparison among sessment (n = 28; SSTP = 12, SSTP + ACT
SSTP, SSTP with ACT, and WL groups at = 11, WL = 5). A pre-post examination
postintervention, was achieved through of the retention of the intervention ef-
a series of analyses of covariance fect from postintervention to 6-month
(ANCOVAs), with preintervention scores follow-up was tested with a series of
as a covariate. Significant results were t tests. A comparison between families
followed-up with linear contrasts ex- who received SSTP (n = 16) and families
amining group-by-group differences who received SSTP with ACT (n = 12) at
(ie, WL vs SSTP, WL vs SSTP + ACT, SSTP vs 6-month follow-up was conducted via
 ARTICLE

a series of ANCOVAs with preinterven- TABLE 2 Sample Characteristics of Participating Families (n = 67)
tion scores as a covariate. All WL fami- Variable WL (n = 22) SSTP (n = 22) SSTP + ACT (n = 23)
lies received SSTP alone except 1 that Demographics
received SSTP with ACT. Child age, y, mean (SD) 4.96 (2.95) 5.45 (3.16) 5.52 (3.17)
Child gender, boys, n (%) 13 (59.1) 13 (59.1) 17 (73.9)
Intellectual disability, n (%) 5 (22.7) 3 (13.4) 5 (21.7)
RESULTS Learning disability, n (%) 6 (27.3) 7 (31.8) 6 (26.1)
Autism spectrum disorder, n (%) 2 (9.1) 1 (5.9) 1 (4.3)
Sample Characteristics Attention deficit hyperactivity disorder, n (%) 1 (4.5) 0 0
Vision impairment, n (%) 4 (18.2) 3 (13.6) 7 (33.4)
A series of x2 and analysis of variance Hearing impairment, n (%) 1 (4.5) 3 (13.6) 2 (8.7)
tests identified no differences between Receiving services for emotional/behavioral 2 (9.1) 2 (9.5) 4 (17.4)
the groups on any demographic vari- problems, n (%)
Classification
able at baseline. Sample character-
GMFCS I 6 (27.3) 5 (22.7) 4 (17.4)
istics are presented in Table 2. GMFCS II 6 (27.3) 5 (22.7) 7 (30.4)
GMFCS III 3 (13.6) 5 (22.7) 4 (17.4)
GMFCS IV 6 (27.3) 5 (22.7) 7 (30.4)
Preliminary Analysis GMFCS V 1 (4.5) 2 (9.1) 1 (4.3)
Fewer than 10% of the data were Relationship to child, mother, n (%) 20 (90.9) 22 (100) 23 (100)
(if not mother, father)
missing and the pattern of missing data Parent age, y, mean (SD) 39.65 (6.09) 38.67 (5.55) 37.88 (9.39)
was random. In generating scale scores Parent marital status
if ,30% of items were missing for that Married 18 (81.8) 19 (86.4) 14 (60.9)
Defacto 0 1 (4.5) 5 (21.7)
participant on that scale, then the scale
Separated 1 (4.5) 1 (4.5) 1 (4.3)
score was generated from the re- Divorced 2 (9.1) 0 1 (4.3)
maining items. If .30% of items were Never married/defacto 0 1 (4.5) 2 (8.7)
missing for that participant, then that Family type
Original family 17 (77.3) 21 (95.5) 17 (73.9)
participant was excluded from the Sole parent family 4 (18.2) 1 (4.5) 3 (13.0)
analysis for that scale. Step family 1 (4.5) 0 3 (13.0)
Education level of participating parent
The assumption of equality of variance ,10 0 0 0
was violated for the PS Verbosity scale, Year 10/11 1 (4.5) 2 (9.1) 3 (13.0)
and the assumption of homogeneity of Year 12 4 (18.2) 1 (4.5) 1 (4.3)
Trade/apprenticeship 2 (9.1) 1 (4.5) 0
regression slopes was violated for the
TAFE/college certificate 4 (18.2) 5 (22.7) 9 (39.1)
PS Laxness scale. Original, untransformed University degree 11 (50.0) 13 (59.1) 10 (43.5)
data are reported. Employment of participating parent
Full-time 1 (4.5) 1 (4.5) 5 (21.7)
Part-time 9 (40.9) 13 (59.1) 10 (43.5)
Intervention Protocol Adherence Unemployed (seeking work) 1 (4.5) 1 (4.5) 0
Full-time parent/home duties 11 (50.0) 7 (31.8) 8 (34.8)
The SSTP and ACT content was delivered
Education level of partner (if applicable)
as per protocol in all scheduled group ,10 0 0 1 (4.3)
sessions with the exception that in Year 10/11 1 (4.5) 4 (18.2) 3 (13.0)
8.19% of sessions some aspect of the Year 12 2 (9.1) 1 (4.5) 2 (8.7)
Trade/apprenticeship 4 (18.2) 4 (18.2) 3 (13.0)
SSTP DVD was not played owing to Technical and Further Education 2 (9.1) 1 (9.1) 4 (17.4)
technical difficulties or time manage- (TAFE)/college certificate
ment. In all circumstances, the content University degree 9 (40.9) 9 (40.9) 6 (26.1)
Employment of partner (if applicable)
on the SSTP DVD was still delivered Full-time 16 (72.7) 18 (81.8) 13 (56.5)
verbally. Protocol delivery was rated by Part-time 1 (4.5) 1 (4.5) 3 (13.0)
a second therapist for 50.81% of ses- Unemployed (seeking work) 0 1 (4.5) 1 (4.3)
Full-time parent/home duties 1 (4.5) 0 2 (8.7)
sions with 100% agreement with the
Family income
primary therapist. Eleven families re- ,25 000 4 (18.2) 2 (9.1) 5 (21.7)
ceived the intervention via weekend 25 000–50 000 1 (4.5) 1 (4.5) 3 (13.0)
workshop format (4 SSTP groups, 4 50 000–75 000 8 (36.4) 2 (9.1) 4 (17.4)
75 000+ 6 (36.4) 16 (72.7) 11 (47.8)
SSTP + ACT groups, 3 WL groups). Within Professional advice in last 6 mo from
the SSTP group, participants attended Psychologist, n (%) 5 (22.7) 6 (27.3) 5 (21.7)
a mean of 5.31 (SD 0.79) of 6 group

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TABLE 2 Continued [MD] = 24.12, P = .003), the ECBI Problem
Variable WL (n = 22) SSTP (n = 22) SSTP + ACT (n = 23) scale (MD = 8.30, P , .000), and the SDQ
Psychiatrist, n (%) 1 (4.5) 1 (4.5) 3 (13.0) Hyperactivity scale (MD = 1.66, P = .004),
Counselor, n (%) 6 (27.3) 4 (18.2) 4 (17.4) as demonstrated in the MD scores. Sig-
Social worker, n (%) 5 (22.7) 6 (27.3) 3 (13.0)
nificant differences between SSTP with
Outcome measures at baseline
ECBI Intensity 116.09 (36.57) 116.36 (38.73) 111.94 (37.36) ACT and WL were not found on the SDQ
ECBI Problem 14.65 (7.88) 14.79 (8.83) 12.69 (8.40) Emotional symptoms scale. SSTP showed
SDQ Emotional symptoms 3.00 (2.72) 3.00 (2.67) 2.48 (1.53) decreased parent-reported child behav-
SDQ Conduct problems 2.00 (1.90) 2.04 (1.49) 1.77 (1.48)
SDQ Hyperactivity 4.82 (2.68) 4.91 (2.69) 6.22 (1.94) ioral and emotional problems in com-
SDQ Peer problems 3.86 (2.34) 3.14 (1.98) 3.61 (2.54) parison with the WL group on the ECBI
SDQ Prosocial 5.82 (2.74) 6.14 (2.73) 5.66 (2.96) Problem scale (MD = 6.04, P = .003) and
SDQ Impact 2.55 (2.78) 3.32 (3.38) 2.81 (2.66)
PS Laxness 2.79 (0.89) 2.77 (0.81) 2.84 (1.05)
the SDQ Emotional symptoms scale (MD
PS Overreactivity 3.04 (0.87) 3.04 (0.77) 2.68 (0.84) = 1.33, P = .004). Differences approached
PS Verbosity 3.47 (0.90) 3.62 (0.99) 3.17 (0.85) significance for the ECBI Intensity scale
Where P values are not given, the n per cell was insufficient to test. TAFE, . (MD = 15.43, P = .04). Significant differ-
ences between SSTP and WL were not
sessions and a mean of 2.87 (SD 0.34) of PS Overreactivity scale, F2,52 = 3.84, P = found on the SDQ Hyperactivity scale. No
3 phone consultations. Within the SSTP .03, and the PS Verbosity scale F2,53 = significant differences between SSTP and
with ACT group, participants attended 3.80, P = .03. Significant differences were SSTP with ACT were found. Differences
a mean of 5.25 (SD 0.97) of 6 group not found for the PS Laxness scale. The between the SSTP and SSTP with ACT
sessions, a mean of 2.75 (SD 0.44) of 3 results of all ANCOVAs are presented in approached significance for SDQ Emo-
phone consultations, and a mean of 1.95 detail in Table 3. tional symptoms scale only, with SSTP
ACT group sessions (SD 0.22). If a par- SSTP with ACT participants showed demonstrating lower parent-reported
ticipant missed a scheduled group decreased parent-reported child be- emotional symptoms.
session, every attempt was made to havioral and emotional problems in SSTP with ACT showed decreased dys-
arrange an individual make-up session, comparison with the WL group on the functional parenting styles in compar-
with SSTP participants receiving a
ECBI Intensity scale (mean difference ison with the WL group on the PS
mean of 0.44 (SD 0.40) SSTP make-up
sessions and SSTP with ACT partic-
ipants receiving a mean of 0.55 (SD 1.0) TABLE 3 Omnibus ANCOVA comparing WL, SSTP, and SSTP + ACT Groups at Postintervention with
Preintervention Scores as a Covariate
SSTP make-up sessions and a mean of
0.10 (SD 0.31) ACT make-up sessions. Variable Unadjusted Postinterention Means (SD) F Partial h2

WL SSTP SSTP + ACT

Primary Outcomes of RCT: ECBI Intensity 123.32 (36.27) 109.74 (27.66) 97.24 (30.61) 6.15 0.19
Comparison of Groups at P = .004*
Postintervention ECBI Problem 18.15 (8.17) 12.64 (7.03) 9.11 (5.09) 11.03 0.32
P , .000*
Consistent with an intervention effect, the SDQ Emotional symptoms 3.24 (2.56) 1.76 (2.02) 2.48 (1.44) 4.88 0.16
3 groups showed significant differences P = .01*
SDQ Conduct problems 2.21 (2.37) 1.41 (1.54) 1.70 (1.69) 1.91 0.07
at postintervention for parent-reported P = .16
child behavioral and emotional prob- SDQ Hyperactivity 5.37 (2.24) 5.18 (2.92) 4.90 (2.09) 4.55 0.15
lems,including ontheECBI Intensityscale, P = .01*
SDQ Peer problems 4.14 (2.22) 2.47 (1.46) 3.09 (2.26) 1.87 0.07
F2,54 = 6.15, P = .004; the ECBI Problem P = .16
scale, F2,48 = 11.03, P , .0001; the SDQ SDQ Prosocial 5.79 (2.64) 6.35 (3.41) 6.05 (2.69) 0.27 0.01
Emotional symptoms scale, F2,53 = 4.88, P = .76
SDQ Impact 3.79 (3.53) 3.83 (3.95) 2.82 (2.95) 0.76 0.04
P = .01; and the SDQ Hyperactivity scale,
P = .47
F2,54 = 4.55, P = .01. Significant differ- PS Laxness 2.76 (0.94) 2.34 (0.81) 2.28 (1.24) 1.65 0.06
ences were not found on the Conduct P = .20
problems, Peer problems, Prosocial, or PS Overreactivity 2.87 (0.94) 2.52 (1.02) 1.94 (0.73) 3.84 0.13
P = .03*
Impact scales of the SDQ. In addition, the PS Verbosity 3.18 (0.77) 2.79 (1.14) 2.29 (1.11) 3.80 0.12
3 groups showed significant differences P = .03*
in dysfunctional parenting styles on the *, significant.

6 WHITTINGHAM et al
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 ARTICLE

Overreactivity scale (MD = 0.60, P = .008) Prosocial scale, t14 = –0.26, P = .01, from with caution owing to lower sample
and the PS Verbosity scale (MD = 0.68, postintervention to 6-month follow-up size (SSTP = 16; SSTP + ACT = 12). The
P = .01). No significant differences were and significant increases in dysfunc- ANCOVAs and follow-up means are
found between SSTP and WL on dys- tional parenting on the PS Verbosity presented in full in Table 5.
functional parenting styles. No signifi- scale, t13 = –2.31, P = .04, from post-
cant differences were found between intervention to 6-month follow-up. Fam- DISCUSSION
SSTP and SSTP with ACTon dysfunctional ilies receiving SSTP with ACT showed
parenting styles. Linear contrasts are significant increases in dysfunctional Children with CP are at increased risk of
presented in full in Table 4. parenting from postintervention to 6- behavioral and emotional problems,
month follow-up on the PS Over- with 1 in 4 developing a behavioral dis-
Sensitivity Analysis: Intention to reactivity scale, t10 = –2.49, P = .3, and order.6 This study is the first to demon-
Treat the PS Verbosity scale, t10 = –3.09, P = strate that parenting intervention,
.01. All other t tests were nonsignificant, particularly SSTP or SSTP combined
A conservative sensitivity analysis, re-
consistent with maintenance of gains. with ACT, is efficacious in targeting be-
peating ANCOVAs with the last obser-
havioral and emotional problems in
vation carried forward for all families
Comparison of Families Receiving children with CP. SSTP alone was asso-
who failed to complete postintervention
SSTP and SSTP + ACT at Follow-Up ciated with reductions in parent-
assessments, was conducted to satisfy
reported child behavioral and emotional
intention to treat (n = 67). The in- Families that received SSTP with ACT problems consistent with previous
terpretation of the results was in all showed decreased child behavioral research.13,18 Further, SSTP combined
cases consistent with the results problems and dysfunctional parenting with ACT was associated with reduc-
reported previously. in comparison with families that re- tions in dysfunctional parenting styles.
ceived SSTP alone at 6-month follow-up The effect sizes obtained for the primary
Retention of Effect: A Pre-Post on the SDQ Hyperactivity scale, F2,24 =
Analysis From Postintervention to outcome (ECBI Intensity = 0.19; ECBI
7.29, P = .012; the PS Laxness scale, F2,23 Problem = 0.32) are comparable to
Follow-Up = 4.8, P = .038; and the PS Verbosity effects obtained in families of children
Families receiving SSTP showed sig- scale, F2,24 = 10.70, P = .003. These with ASDs (ECBI Intensity = 0.26; ECBI
nificant improvements on the SDQ comparisons should be interpreted Problem = 0.16).18 This illustrates the
urgent need for clinical services to ad-
dress behavioral and emotional prob-
TABLE 4 Linear Contrasts Identifying Group Differences at Postintervention Between WL and SSTP,
WL and SSTP + ACT, and SSTP and SSTP + ACT lems in children with CP, as well as the
Variable Mean Difference Mean Difference Between Mean Difference Between good fit between this clinical need and
Between WL and SSTP WL and SSTP + ACT SSTP and SSTP + ACT the efficacy of parenting intervention.
ECBI Intensity 15.43 (0.78 to 30.08) 24.12 (10.22 to 38.03) 8.69 (–5.65 to 23.04) Parenting interventions, particularly
P = .04 P = .003* P = .23 Triple P, are ideally translatable. Triple P
ECBI Problem 6.04 (2.20 to 9.89) 8.30 (4.63 to 11.97) 2.26 (–1.61 to 6.12)
is designed for population-level dis-
P = .003* P , .0001* P = .25
SDQ Emotional symptoms 1.33 (0.45 to 2.21) 0.37 (–0.46 to 1.21) 20.95 (–1.81 to –0.09) semination, easily implemented within
P = .004* P = .371 P = .03 health or educational services, deliver-
SDQ Conduct problems 0.85 (–0.23 to 1.72) 0.43 (–0.41 to 1.26) 20.42 (–1.28 to 0.44) able in high- and low-resource areas,
P = .056 P = .310 P = .332
SDQ Hyperactivity 0.73 (–0.40 to 1.86) 1.66 (0.55 to 2.77) 0.93 (–0.17 to 2.04) and available in 25 countries.36 Parent-
P = .203 P = .004* P = .097 ing interventions, such as SSTP, should
SDQ Peer problems 0.77 (–0.10 to 1.65) 0.64 (–0.18 to 1.46) 20.13 (–0.98 to 0.61) therefore form part of standard care
P = .083 P = .122 P = .754
SDQ Prosocial 20.44 (–1.68 to 0.78) 20.16 (–1.33 to 0.78) 0.29 (–0.91 to 1.49)
for families of children with CP.
P = .470 P = .784 P = .634 To our knowledge, this was the first RCT
SDQ Impact 0.67 (–1.14 to 2.50) 1.00 (–0.66 to 2.67) 0.33 (–1.42 to 2.07)
to test the additive benefit of ACT, above
P = .230 P = .230 P = .707
PS Laxness 0.39 (–0.14 to 0.93) 0.42 (–0.09 to 0.92) 0.02 (–0.49 to 0.54) and beyond an established behavioral
P = .14 P = .10 P = .14 parenting intervention. The results
PS Overreactivity 0.27 (–0.18 to 0.72) 0.60 (0.16 to 1.04) 0.33 (–0.10 to 0.77) suggest that ACT provides an additional
P = .24 P = .008* P = .13
PS Verbosity 0.50 (–0.03 to 1.04) 0.68 (0.17 to 1.20) 0.18 (–0.36 to 0.72) contribution, with particular benefits
P = .06 P = .01* P = .51 shown for parenting style and child
Values are MD (CI); *, significant. hyperactivity. The combined SSTP and

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TABLE 5 Omnibus ANCOVA Comparing Families Receiving SSTP and SSTP + ACT at 6- Month Follow-
Up With Preintervention Scores as a Covariate
Variable Unadjusted Follow-Up Means (SD)
SSTP
ECBI Intensity 107.31 (28.40)
ECBI Problem 6.61 (7.51)
SDQ Emotional symptoms 1.56 (1.96)
SDQ Conduct problems 0.87 (1.20)
SDQ Hyperactivity 5.18 (2.97)
SDQ Peer problems 2.69 (1.49)
SDQ Prosocial 6.62 (2.70)
SDQ Impact 1.17 (1.70)
PS Laxness 2.59 (0.69)
PS Overreactivity 2.61 (0.95)
PS Verbosity 3.04 (0.71)
*, significant.
ACT intervention, but not SSTPalone, was
associated with reductions in child hy-
peractivity, parental overreactivity, pa-
rental verbosity, and child behavioral
problems on the ECBI Intensity scale. At
6-month follow-up, families who had
received the combined SSTP with ACT
intervention showed reductions in child
hyperactivity, parental laxness, and pa-
rental verbosity compared with families
who had received SSTP alone. The
combined SSTP with ACT intervention
may have enhanced parenting by in-
creasing psychological flexibility.24
Families receiving SSTP alone and not
families receiving combined SSTP with
ACT, showed decreased child emotional
symptoms on the SDQ compared with
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(Continued from first page)

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This work was supported by a National Health and Medical Research Council postdoctoral fellowship, grant 631712, to Dr Whittingham; a National Health
and Medical Research Council career development fellowship, grant 1037220, to Dr Boyd; and a Smart State Fellowship to Dr Boyd.
POTENTIAL CONFLICT OF INTEREST: Stepping Stones Triple P is owned by the University of Queensland and sublicensed to Uniquest, the University of Queensland’s
Technology Transfer Company. Dr Sanders is a coauthor of the Stepping Stones Triple P program and receives royalty payments from the publisher, Triple P
International, in accordance with the University of Queensland Intellectual Property Policy. The other authors have no conflicts of interest to disclose.

PEDIATRICS Volume 133, Number 5, May 2014 9

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Interventions to Reduce Behavioral Problems in Children With Cerebral Palsy:
An RCT
Koa Whittingham, Matthew Sanders, Lynne McKinlay and Roslyn N. Boyd
Pediatrics originally published online April 7, 2014;

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Interventions to Reduce Behavioral Problems in Children With Cerebral Palsy:
An RCT
Koa Whittingham, Matthew Sanders, Lynne McKinlay and Roslyn N. Boyd
Pediatrics originally published online April 7, 2014;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2014/04/02/peds.2013-3620

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