AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
A Controlled Trial of the RAP Parent Program to Foster
Adolescent Wellbeing
Ham, David R.(1), & Shochet, Ian M.(2), School of Applied Psychology,
Griffith University
Summary
Introduction
Risk Factors
RAP-P
Evaluations
Conclusion
References
The Resourceful Adolescent Parent Program, RAP-P, presented as workshops or on videotape, aims to foster adolescent resilience and wellbeing and prevent adolescent depression by strengthening the family based protective factors of harmonious family environments and secure parental attachment, and reducing the risk factor of parent-adolescent conflict. A controlled trial of the RAP-P program as a school-based universal preventive intervention involves 250 Year 8 children and 350 of their parents, representing 15% of potential participants. Improved adolescents’ attachment to parents and reduced adolescent depressive symptoms are predicted for children in the intervention groups. Evaluations of both video and workshop programs were very positive although implementation of the video program was problematic. Results so far support the theoretical model for RAP-P with measures of conflict intensity, interactions with mothers and parental attachment predicting 44% of variance in adolescents’ depressive symptoms.
Lifetime prevalence for adolescent depression is estimated at up to 24% [1] with
approximately 5% of adolescents in Australia suffering from a depressive disorder and 2.7%
meeting criteria for major depressive disorder at any time [2]. One Queensland study found
that half of the youths who died by suicide were depressed, while adolescent depression is
associated with social deficits, poor academic performance, physical ill-health and
substance abuse [3] and strongly predicts later depression in adult life [4]. There is
therefore strong justification for programs to prevent, or reduce the effects of, the
development of depression in adolescents. One such preventive program, the Resourceful
Adolescent Program for Parents [RAP-P; 5] and a trial to evaluate RAP-P, will now be
described.
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Risk and Protective factors for adolescent depression.
There is strong evidence linking parent-adolescent conflict with the development of adolescent depression [6]. Parent-adolescent conflict has been found to be strongly related to self-report measures of adolescent depression in a non-clinical sample [7]. Critical, controlling parental behaviour and maladaptive conflict resolution strategies have been found to occur in the families of depressed children [6]. Conflict occurs most frequently in early adolescence [8], with differences between the adolescents' expectations of increasing autonomy and the levels of autonomy granted by parents being the primary cause of conflict [9]. When conflict occurs in generally supportive families where differences are discussed openly it may actually foster adolescent development, but in hostile families [10] and when it remains unresolved [11] conflict may have very negative effects on well-being.
While adolescents develop increasing independence from their parents, continuing close
relationships between parents and adolescents are important. Strong attachment to parents
[6], and high levels of parental care coupled with encouragement to develop independence,
have been found to correlate negatively with adolescent depressive symptoms, while low
levels of parental care coupled with parental intrusiveness into the lives of adolescents
have been associated with increased prevalence of depressive thoughts [12].
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The Resourceful Adolescent Parent Program (RAP-P)
The Resourceful Adolescent Program for Parents [5] has been developed as a universal preventive intervention intended to reduce the prevalence of adolescent depression by reducing the family-based risk factors of conflict and affectionless control, and strengthening the protective factor of supporting independence with attachment. RAP-P is intended to be administered to the parents of adolescents aged 11 to 14 years, and is often used as an adjunct to the Resourceful Adolescent Program for Adolescents, RAP-A [13], a school-based universal preventive intervention addressing various individual risk factors for adolescent depression.
RAP-P draws on an integration of Bowen Systems Theory [14, 15] and cognitive behavioural therapy. Bowen Systems Theory describes the development and maintenance of family conflict through the concept of differentiation of self. On the intrapersonal level a well-differentiated person is able to separate their rational and emotional functioning [14] while on the interpersonal level the well-differentiated person is able to balance intimacy and autonomy in relationships [16]. Poorly differentiated people are reactive to stress and anxiety and are also more likely to develop stressful situations in their relationships. A poorly differentiated parent perceives the changes and developing autonomy that characterise adolescence as rejection and struggles to hold on to their children, resulting in either conflict or capitulation to the children, and high levels of stress. Well-differentiated parents are able to foster individuality and difference in their children while maintaining appropriately close and supportive relationships with them [15]. Children of poorly differentiated parents usually experience the struggles that engender poor levels of differentiation and become poorly differentiated themselves, so differentiation has intergenerational effects.
From cognitive behavioural therapy RAP-P draws on methods of managing stress, cognitive restructuring and challenging negative self-talk, and strategies for self-managed change in behaviour and emotions. Social learning theory is applied through facilitators' modeling of communication skills applicable to the parent-adolescent dyad including active listening, validation, positive reinforcement and empathy. Psycho-education is used to help parents understand normal adolescent development and the normal developmental needs of adolescents. RAP-P does not focus on deficiencies or symptoms but on identifying and building on existing strengths and competencies and building differentiation through increased self-esteem.
The program is presented as a series of three facilitated workshop sessions for
parents, each of between two and three hours. In Session 1, "Parents are people
too!" parents identify what they are doing well as parents, how stress affects their
parenting, and ways of managing stress. In Session 2, "What makes teenagers
tick?" parents reflect on their own adolescence as a way of understanding their
teenager's needs, then discuss ways of building up teenagers' self-esteem and of
supporting independence with attachment. In Session 3, "Promoting positive family
relationships," parents discuss ways of maintaining a harmonious family environment,
as a buffer when conflict occurs; reducing and managing conflict, and looking forward to a
positive future with our teenagers when adolescence is past.
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Evaluations of RAP-P.
In the first trial of RAP-P [17] RAP-P was provided as a adjunct to RAP-A. Poor recruitment of parents precluded any evaluation of the effectiveness of RAP-P. To improve parent participation in RAP-P a flexible delivery format of the program using a videotape and workbook was developed. Pilot trials showed acceptance of this flexible format but indicated that personal contact through telephone facilitation was necessary.
A trial of RAP-P as a standalone intervention using both workshop and flexible formats is a PhD project of the first author and is the subject of this paper. In this trial eleven schools with a total Year 8 population of 1600 were randomly allocated to one of three conditions: RAP-P workshops, RAP-P video format, and a wait-list control condition. Parents and adolescents were recruited through the schools, with strong support from the schools. Adolescents and parents in all conditions completed pre-intervention testing after which parents in intervention groups received the allocated intervention. This was followed by post-intervention testing for all conditions. Follow-up testing will be administered to all participants 12 months after the intervention, after which the program will be provided for parents in control schools.
Recruitment was again disappointing, with only 15% of parents consenting to participate. The video format did not improve recruitment; in fact this condition attracted the lowest recruitment rate of 11.6% while 19.4% of potential parents in workshop schools and 13.7% of those in control schools consented to participate. Other implementation problems arose with the video format: the need to make multiple calls to establish telephone contact made the intervention very expensive of facilitator time; and parents who did not undertake the intervention within the first couple of weeks were unlikely to watch the video at all. Six months after the commencement of the intervention phase only 36 % of parents in this condition had completed the intervention and evaluations and only 25% completed the post-intervention questionnaires and further efforts to increase the response in this condition were abandoned. In the workshop condition, 72% of parents (109) attended one or more sessions, with 7% of these attending only one session, 21% attending two sessions and 72% attending all three sessions. Session 1 was attended by 101 parents, Session 2 by 97 parents and Session 3 by 90 parents.
Both programs, but more so the workshop format, were reported by parents to be very acceptable. Means for evaluations of overall satisfaction with the program and how helpful , how enjoyable, and how encouraging parents perceived the program to be, on a five-point scale, were respectively 4.45 (SD = .63), 4.40 (.71), 4.41 (.67) and 4.43 (.68) for the workshops (n = 97), and 3.96 (.88), 3.61 (.90), 3.92 (.73) and 3.61 (.87) for the videotape format (n = 36), with the workshops significantly more acceptable, p < .01 for all comparisons.
Measures administered to Year 8s were the Children's Depression Inventory [CDI; 18], the Issues Checklist [IC; 19], a measure of the number of issues discussed in families, and the frequency and emotional intensity of conflict about these issues; the Interaction Behavior Questionnaire [IBQ; 19], a measure of adolescents' perceptions of their interactions with their mothers and fathers and of the parent-child dyad; and the Parental Attachment Questionnaire [PAQ; 20], a measure of adolescents' views of the affective quality of their relationships with their parents, parents as facilitators of independence and parents as sources of support. Parents completed the IC; the parent form of the IBQ, measuring parents' views of their adolescents' interactions with them; the Differentiation of Self Inventory [DSI; 16], a measure of adults' differentiation of self; the Parental Bonding Inventory [PBI; 21] a retrospective report of adults' views of their relationships with their parents; and the State form of the State Trait Anxiety Inventory [22], a measure of current levels of anxiety.
Early data analysis has confirmed the theoretical model underpinning RAP-P. An initial path model is shown in Figure 1. Regression analysis indicated that the adolescents' IC Intensity scale and the adolescents' mother IBQ scale contributed 22% and 52% respectively of the variance in the adolescents' PAQ Affective Quality scale. Further regression analysis with the PAQ Affective Quality scale, the mother IBQ scale and the IC Intensity scale entered in that order showed that these scales respectively contributed 39%, 2.3% and 2.5% of variance in the CDI score, a total of 43.8% of the variance. This indicates that the PAQ scale partially mediates between conflict intensity and parental interactions and depressive symptomatology and supports the proposal that reducing the intensity of parent-adolescent conflict, and ensuring positive interactions between mothers and adolescents, should positively impact on adolescents' depression.
r2 = .023*
r2 = .22**
r2 = .39 **
r2 = .52**
r2 = .025*
Figure 1: Initial model. Note. *p <. 01; **p < .001
Analysis of the relationship between parents' differentiation of self and adolescents'
depressive symptoms [23] indicated that for families whose number of conflict topics was
below the 30th percentile, but not for families above the 70th percentile, mothers'
self-reported differentiation of self moderated the effect of parents' reports of conflict
on adolescents' reports of depressive symptoms measured by the CDI. In this group where
mothers' DSI scores were in the upper 30%, the mean CDI score was 3, whereas for mothers
whose DSI scores fell in the lowest 30% the mean CDI score with similar levels of conflict
was significantly higher at 7 (p < .05). Better maternal differentiation
apparently enabled mothers to deal with these lower levels of conflict in a way that
minimised the negative effects on their children but had no influence where conflict
levels were high.
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Although this trial has not yet provided any evidence for the efficacy of RAP-P as a
standalone intervention, it has provided further evidence that family factors are very
important in the development of adolescent depression, and allowed us to commence building
a model that furthers our understanding of the paths through which the different factors
operate. The results so far have indicated the importance of reducing the intensity of
conflict between adolescents and parents, and of developing interaction patterns between
adolescents and parents that strengthen the attachment of adolescents to their parents.
The RAP-P workshops are very well accepted by parents while the videotaped format was also
well accepted although implementation problems indicated that this format may not be
useful as a universal preventive intervention. However this trial has again emphasised the
difficulty of engaging parents in a preventive intervention. The recruitment of parents
requires to be significantly improved if preventive interventions involving parents are to
be widely distributed and effective.
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