Clinical Child and Family Psychology Review, Vol. 2, No.

3, 1999

Engagement in Child and Adolescent Treatment: The Role

of Parental Cognitions and Attributions
Erin Morrissey-Kane1 and Ronald J. Prinz1,2

Parental engagement in the treatment process is influenced by parents' beliefs about the
cause of their children's problems, perceptions about their ability to handle such problems,
and expectations about the ability of therapy to help them. This paper examines the role of
parental cognitions related to attributions and expectations in relation to engagement in
child mental health treatment. Reviewed studies indicate that parental attributions and
expectations influence three aspects of treatment: help seeking, engagement and retention,
and outcome. This paper integrates findings from developmental and clinical research, highlights gaps in the literature, presents the beginnings of a model regarding the parental
attributional process as it relates to engagement in treatment, recommends future research
directions, and discusses clinical implications.
KEY WORDS: Parenting; family intervention; engagement; children and adolescents; parental cognitions; parental attributions.

INTRODUCTION

and other caregivers is viewed as essential to therapeutic success and is recommended for both the planning and treatment phases of therapy (Henggeler,
1994). Successful treatment of child and adolescent
mental health problems, then, relies heavily on the
motivation of parents not only to bring their children
consistently to therapy, but also to participate fully
in the treatment process. However, many parents
are reluctant to initiate treatment as evidenced by a
15-35% no-show rate to first appointments following
an initial telephone request for services (Ewalt, Cohen, & Harmatz, 1972; Kourany, Garber, & Tornusciolo, 1990). Furthermore, parents who initiate treatment have been shown to drop out prematurely from
child and family treatment at a rate as high as 60%
(Armbruster & Fallon, 1994; Gould, Shaffer, &
Kaplan, 1985; Pekarik & Stephenson, 1988; Weisz,
Weiss, & Langmeyer, 1987).
Attrition from therapy is a significant challenge
that impacts the effectiveness and cost of services,
the strain on an overburdened service delivery
system, and the growing rate of untreated mental
health problems among youth (Armbruster & Kazdin, 1994; Prinz & Miller, 1996; Weisz et al., 1987).
Further, only a small percentage of families seek

Given the multidetermined nature of many

childhood psychological disorders, treatment strategies that focus only on the individual child in therapy
have shown limited impact (Weisz, Weiss, & Donenberg, 1992). Consequently, treatment of children
and adolescents has shifted toward interventions that
more heavily involve parents in the process
(Fauber & Long, 1991; Rodrique, 1994), although
Kovacs and Lohr (1995) reported that only 40% of
studies from 1970 to 1988 pertaining to mental health
treatment of children/adolescents included parents
in the treatment process. Parental involvement in
child and adolescent treatment has been shown to
improve the treatment effectiveness of interventions
for externalizing (Erhardt & Baker, 1990; Page,
Poertner, & Lindbloom, 1995) and internalizing disorders (Clarke et al., 1992). Involvement of parents
1

Department of Psychology, University of South Carolina, Columbia, South Carolina.

2
Address all correspondence to Ronald J. Prinz, Department of
Psychology, University of South Carolina, Columbia, South Carolina 29208; e-mail: prinz@sc.edu

183
1096-4037/99/0900-0183$16.00/0 1999 Plenum Publishing Corporation

184
help for childhood psychological problems (Costello
et al., 1988; Stouthamer-Loeber, Loeber, & Thomas,
1992). Therefore, when families reach out for mental
health treatment, it is imperative that clinicians and
service systems foster and secure the engagement
of these families in the treatment process.
Although factors related to attrition have been
widely studied in adult populations, fewer studies
have focused on attrition in child treatment (Armbruster & Kazdin, 1994; Pekarik & Stephenson,
1988). The available research does suggest, however,
that the factors related to attrition in adult populations (i.e., therapist-client match, treatment modality, problem severity, distance from the clinic, age
and gender of client) do not account for attrition in
child treatment (Armbruster & Kazdin, 1994; Armbruster & Fallon, 1994; Gaines & Steadman, 1981;
Kazdin & Mazurick, 1994; Kazdin, Mazurick, & Bass,
1993; McMahon, Forehand, Griest, & Wells, 1981;
Pekarik & Stephenson, 1988; Weisz et al., 1987). In
contrast, some family demographic charcteristics
such as family composition, socioeconomic status,
and minority status have yielded moderate, but inconsistent, associations (Armbruster & Fallon, 1994;
Frankel & Simmons, 1992; Gaines & Stedman, 1981;
Gould et al., 1985; Kazdin et al., 1993; Kazdin &
Mazurick, 1994; Kazdin, Stolar, & Marciano, 1995;
Pekarik & Stephenson, 1988; Viale-Val, Rosenthal,
Curtiss, & Marohn, 1984; Weisz et al., 1987). Studies
that support the influence of socioeconomic status
(SES) and minority status on engagement suggest
that the mechanism by which these variables operate
is related to different class-linked or culturally linked
beliefs and expectations for treatment. These, in turn,
may influence a parent's decision to pursue or terminate treatment (Armbruster & Fallon, 1994;
Gaines & Stedman, 1981; Gould et al., 1985; Kazdin
et al., 1993; Kazdin & Mazurick, 1994; Kazdin et al.,
1995; Pekarik & Stephenson, 1988).
Child, therapist, and treatment characteristics
do not seem to account for attrition, while cultural
and SES variables seem to have some association
with attrition. That cultural and SES variables may
infleunce parental beliefs and expecatations has led
to a focus on potential contributions parents might
make to attrition from child mental health treatment
(Armbruster & Kazdin, 1994). In fact, Pekarik and
Stephenson (1988) argued that the only reliable
finding in the child dropout literature pertains to
parental characteristics. A focus on parents seems
appropriate given that they are often the primary
decision-maker regarding when to pursue and termi-

Morrissey-Kane and Prinz

nate treatment (Pekarik & Stephenson, 1988). Several studies investigating the role of parental characteristics on attrition in child treatment suggest that
parents who were uncooperative, negative, or had
no desire to make change in themselves were more
likely to have their children dropout of treatment
(Frankel & Simmons, 1992; Gould et al., 1985).
One of the most important factors influencing retention or continuation in child treatment appears
to be the parents' positive attitude toward, and
motivation for, participation in child treatment
(Ewalt et al., 1972; Pekarik & Stephenson, 1988;
Singh, Janes, & Schechtman, 1982; Viale-Val et
al., 1984).
Normative-developmental and clinical research
both underscore the importance of cognitions and
attributions on parental behavior, which in turn has
implications for understanding treatment engagement. For example, the attributions parents make
about their children influence parenting behaviors
such as disciplinary actions (Bugental & Shennum,
1984; Janssens, 1994) and communication style (Bugental & Shennum, 1984). Parental attributions have
also been implicated in the adverse reactions that
some parents show when faced with challenging
child problems. Parents who perceive their children
as deviant tend to develop a pessimistic attributional
style that is related to parental stress (Mouton &
Tuma, 1988), perceived parental incompetence (Baden & Howe, 1992; Day, Factor, & Szkiba-Day,
1994; Johnston, 1996; Mash & Johnston, 1983; Sobol,
Ashbourne, Earn, & Cunningham, 1989), and psychological maladjustment (Griest, Wells, & Forehand, 1979; Griest & Wells, 1983). Attributions that
mediate parental behavior might also play a role
in the treatment process. Parents who believe, for
example, that they are ineffective caregivers, that
nothing they try works, or that their child's behavior
is unchangeable, might not engage easily in treatment. We suggest that parental cognition may be
a critical variable in determining engagement in
child and adolescent treatment. In considering the
topic of parental cognitions, the purposes of this
review are as follows: (1) to establish the roles of
attributions in parental reactions to child misbehavior; (2) to examine the roles of parental perceptions,
attributions, and expectations in the child treatment
process; (3) to present a framework for understanding the parental attribution process as it relates to
treatment engagement; and (4) to identify potentially fruitful research directions and treatment applications.

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Parental Cognitions and Treatment Engagement

THE INFLUENCE OF PARENTAL
ATTRIBUTIONS ON PARENT BEHAVIOR
Developmental Research on Parenting
Research has focused on the role of parental
social cognitions, or their interpretations of social
events, as an influence on parental feelings and actions (Goodnow, 1988). Numerous studies have
linked maternal social cognitions to a variety of child
outcomes such as social competence (Goodnow,
1984; Miller, 1988), and evidence is increasing that
parental attributions affect their behavioral and emotional reactions toward their children (Dix, Ruble,
Grusec, & Nixon, 1986; Dix, Ruble, & Zambarano,
1989). In general, individuals readily tend to form
attributions about themselves and others (Kelley,
1973), and so it is not surprising that parents spontaneously offer causal explanations for their children's
behavior (Johnston, Reynolds, Freeman, & Geller,
1998). Parental attributions, or the explanations parents make regarding their children's behavior, have
been divided into two categories: child-referent
causes such as child disposition, judgment, or ability,
and parent-referent causes such as parental competence and skill in managing child behavior (Bugental,
Blue, & Cruzcosa, 1989).
Child-referent attributions made by parents that
children are competent and therefore responsible for
their misbehavior, influence parental emotional and
behavioral reactions. For example, parental perceptions regarding child age, competence, and intentionality influence reactions to child misbehavior (Dix et
al., 1986, 1989). Specifically, mothers who perceived
the child's behavior as intentional were more upset
and indicated a preference for the use of a stern
disciplinary style. Moreover, parents believe older
children are more responsible for their misconduct
than younger children are. Attributions of intentionality tend to be associated with maternal reports of
greater emotional reactivity and use of more severe
discipline with older children (Dix et al., 1986, 1989).
Similarly, Smith and O'Leary (1995) found that
mothers who reported using negative child-centered
attributions to explain children's negative affect (e.g.,
whining, crying) observed in video depictions were
more likely to become emotionally aroused and endorse the use of harsh discipline tactics.
Further, Slep and O'Leary (1998) demonstrated
a link between maternal attributions and mothers'
subsequent behavior and affect. In a sample of mothers and difficult toddlers, they found that experimen-

tally manipulating the explanation given to mothers

about why their children would likely be noncompliant during the subsequent parent-child interaction
significantly influenced maternal discipline style and
emotional reactivity. Mothers who were given childresponsible explanations (e.g., to get their way or to
solicit attention) became more overreactive in their
discipline and reported feeling more angry during
the interaction.
Research on the influence of parent-referent attributions on parental behavior has mainly focused
on parental locus of control (Campis, Lyman, & Prentice-Dunn, 1986; Rotter, 1966). Parents who have
an external locus of control believe their children's
behavior and development are determined by factors
outside parental control, such as by chance, by other
people (e.g., teacher, peers), or by dispositional qualities of the child (e.g., temperament, personality). In
contrast, parents with an internal locus of control
view their children's behavior and development to
be derived from their own parenting practices
(Campis-et al., 1986; Janssens, 1994). Locus of control,
though not the only component or facet of an attribution (Bugental, Johnston, New, & Silvester, 1998;
Weiner, 1986), has received much consideration in
the parental attribution literature. Bugental and
Shennum (1984) demonstrated that parental attributions moderate the relationship between child behavior and parent behavior, such that parents with an
internal locus of control feel confident that they can
manage the behavior of any child, and consequently,
they modify their behavior depending on whether
the child was easy or difficult. However, parents with
an external locus of control feel less sure of their
parenting abilities, and when faced with a difficult
child may take a defeatist attitude and adopt an apathetic approach. Such parents in the midst of feeling
powerless and ineffectual might "cling to power" by
using a more authoritarian parenting style (Janssens, 1994).
Thus, normative research has established that
parental attributions clearly affect parental behavior
and parenting style. The next section considers the
role of attributions when parents face challenging
child behavior.
Parental Attributions and Deviant Child Behavior
The Parental Attributional Shift
Developmental research on parenting has shown
that in most situations mothers use a positive attribu-

186
tional bias when observing their children. In other
words, prosocial behavior is perceived by most parents as stable and dispositional, and negative behavior is viewed as temporary and situational (Dix &
Grusec, 1985; Dix et al., 1986; Goodnow, Knight, &
Cashmore, 1986; Gretarsson & Gelfand, 1988). Such
a positive perception of child behavior facilitates the
maintenance of parental perceptions of worth and
competence and results in parental responses that are
potentially more consistent, confident, and effective
(Goodnow, 1985; Sameroff & Feil, 1985). However,
studies of mothers rearing children with behavioral
problems show that mothers respond in the opposite
directionthat is, they tend to attribute the cause
of their child's negative behavior to stable and dispositional qualities within the child (Compas, Adelman,
Freundl, Nelson, & Taylor, 1982). Such mothers have
also been shown to place less emphasis on the importance of parental practices in child outcomes
(Himelstein, Graham, & Weiner, 1991). It appears
that when child behavior is perceived as more negative, parents view the problem as solely a function
of child factors, and almost in a protective stance
minimize their own responsibility for child misconduct. Such attributions that a child's behavior is unchangeable and uncontrollable may serve to protect
parental self-esteem, but could result in lower participation by parents in the treatment process.
Parental Attributions in Clinical Samples
Consistent with the developmental literature on
problematic child behavior, clinical studies have also
shown that parents of children with psychological
disorders tend to attribute their children's negative
behavior to factors external to themselves and outside their control. The literature in this area, focusing
primarily on parents of children with disruptive behavior disorders, illustrates the influence of parental
attributions on perpetuating child problems, decreasing perceived parental competence, and increasing
parental distress.
Mouton and Tuma (1988), using the Parental
Locus of Control Scale (PLOC; Campis et al., 1986),
found that mothers referred to a mental health clinic
had higher external locus of control scores than nonreferred mothers. Similarly, studies of community
samples have shown that most parents reflect an internal locus of control (Janssens, 1994). Clinical research has shown that parents of childen with hyperactive (Sobol et al., 1989), oppositional (Johnston &

Morrissey-Kane and Prinz

Patenaude, 1994; Roberts, Joe, & Hallbert-Rowe,

1992), or conduct-disordered (Baden & Howe, 1992)
profiles report a more external locus of control or
perceived lack of control in interactions with their
children. Parents of children with behavior disorders
perceive that they are not able to control their children's behavior, which in turn seems to affect how
these parents respond to their children. For example,
some parents withdraw from their children in an attempt to avoid further experience with failure (Barkley & Cunningham, 1979), whereas other parents use
more harsh and punitive discipline (Baden & Howe,
1992; Day et al., 1994; Johnston, 1996; Johnston &
Patenaude, 1994). Minimizing parental responsibility
for child problem behavior might be viewed as adaptive because it reduces the self-blame and guilt associated with personal responsibility for failure (Weiner,
1985, 1986); however, such denial of responsibility
can also serve as a barrier to parental participation
in helping to improve child behavior (Hinshaw,
Henker, & Whalen, 1984; Himelstein et al., 1991).
Parents who deny responsibility for the problem may
more likely believe they cannot be an effective part
of the solution, thus limiting parental participation
and engagement.
With respect to parent-referent attributions, parents of children with disruptive behavior disorders
may view themselves as having minimal parental
competence (Baden & Howe, 1992; Day et al., 1994;
Johnston, 1996; Mash & Johnston, 1983; Sobol et al.,
1989), which in turn leads to lower expectations for
future child compliance (Baden & Howe, 1992; Sobol
et al., 1989). In other words, parents who have little
belief in their own ability will expect less compliance
from their child and may inadvertently perpetuate
further child noncompliance. Baden and Howe
(1992) demonstrated that parents attributed their
children's conduct-disordered behavior to causes internal to the child and beyond parental control. Such
an attributional pattern of child blame and parental
helplessness led to the establishment and maintenance of a coercive parent-child exchange (Patterson, 1982; MacKinnon, Lamb, Belsky, & Baum,
1990). Minimal expectations for child improvement
and lack of parental competence could be related to
a lack of parental perseverance in treatment, and
may lead to an expectancy set that minimizes success
and dwells on failure.
In sum, parental cognitions affect parenting and
disciplinary practices and parent-child interactions.
To facilitate the engagement of parents in the treatment process and to promote better treatment out-

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Parental Cognitions and Treatment Engagement

comes, an understanding of the role of parental cognitions in the treatment process is critical.

PARENTAL COGNITIONS AND THE

TREATMENT PROCESS
The previously reviewed research indicated how
parental cognitions affect general parenting styles
and parental reactions to difficult child behavior.
Moving to consideration of how parental attributions
affect the treatment process, parental cognitions are
discussed in relation to three stages of the child/
family treatment process: help seeking, engagement
and retention, and outome.
Phase 1: Help Seeking
Many studies have documented that average
pre-treatment dropout rates from child and adolescent clinics range from 15 to 35% (Ewalt et al., 1972;
Kourany et al., 1990; Wenning & King, 1995). A significant portion of parents who seek help for their
children do not follow through with their intentions
for a variety of reasons. The most common reasons
parents miss their first scheduled appointment are
schedule conflicts, an inability to afford treatment,
and a perception shift that the child's problem has
improved or is no longer a problem (Kournay et al.,
1990). Scheduling and finances are known barriers
to services that can be overcome with service planning and financial assistance. However, closer examination is needed to understand the cognitive processes associated with parent's shifting perceptions
regarding child manageability and the need for therapeutic services. We first examine how parental perceptions impact help seeking and then how parental
locus of control relates to treatment initiation.
Parental Perception of Child Problems
Epidemiological studies indicate only a small
percentage of the children who have psychological
disorders receive treatment at any given time (Costello et al., 1988; Stouthamer-Loeber et al., 1992).
Therefore the presence of child psychological problems must not be sufficient by itself for the initiation
of treatment. Although the severity of a child's problem is related to parental help seeking (Gustafson,
McNamara, & Jensen, 1994; Raviv, Maddy-Weitz-

man, & Raviv, 1992; Stouthamer-Loeber et al., 1992),

maternal reports of the severity of child behavior are
not always accurate or in agreement with observed
behavior (Greist, Forehand, Wells, & McMahon,
1980), paternal or teacher report (Webster-Stratton,
1988), or child self-report (Hricik & Keane, 1988;
Kazdin, Esveldt-Dawson, Unis, & Rancurello, 1993).
Apparently irrespective of the objective severity of
the child's behavior, it is the caregiver's perception
of child behavior as deviant that influences the initiation of child treatment (Griest et al., 1980; Hricik &
Keane, 1988). Moreover, the strongest predictor of
treatment initiation for child problems is the presence
of parental perceived burden (e.g., stigma, threat to
parental well-being, restriction on personal activities;
see Angold, Messer, Stangl, Farmer, Costello, &
Burns, 1998). Parental perception of child behavior
and adjustment seems to predict help seeking more
strongly than does severity of child behavior as rated
by clinicians, teachers or observers.

Parental Locus of Control

Parents with an external locus of control view
their children's problems as stable, unchangeable,
and outside parental influence. Given a belief in the
unchangeable nature of their children's problems,
such parents may never seek treatment for their child
(Roberts et al., 1992). In fact, there are many parents
with behavior problem children who never seek help
(Stouthamer-Loeber et al., 1992). However, Campis
et al., (1986) showed that parents who have sought
professional services for parenting problems actually
reflect greater external locus of control than parents
who do not seek services. Parents of children in clinic
samples show greater external locus of control than
parents of nonreferred children (Baden & Howe,
1992; Johnston & Patenaude, 1994; Mouton & Tuma,
1988; Roberts et al., 1992). One possible explanation
for the presentation of externally oriented parents at
the clinic is that parental expectations for the children's ability to change may be higher than expectations that the parents themselves would be effective
change agents. Parents may not have confidence in
their abilities to manage child behavior, yet may still
believe therapists can "fix" their children. An alternate possible explanation is that parental level of
distress may be high enough that out of "desperation" the parents seek help even if expectations for
change are low.

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Phase 2: Treatment Engagement
Out of those families who have sought help and
initiated the treatment process, between 28 and 60%
never completed treatment (Gould et al., 1985;
Prinz & Miller, 1996). Some families who remain in
treatment may exhibit other indicators of low engagement, such as sporadic attendance, missed and late
appointments, failure to complete homework assignments, and minimal participation in sessions (Prinz &
Miller, 1996). This section considers the possible role
of parental cognitions in relation to engagement during treatment.
Parental Perceptions of Barriers to Engagement
and Treatment
Kazdin, Holland, and Crowley (1997) observed
that a parental perception of barriers to treatment
predicted premature termination in a sample of 242
referred families seeking services for children with
disruptive behavior problems. Perceived barriers to
treatment contributed uniquely to dropout even
when other familial, parental, and child variables
were controlled (e.g., family composition, SES). Examples of perceived barriers included stressors and
obstacles that competed with treatment, perceived
treatment demands, perceived irrelevance of treatment, and problematic relationship with the therapist. When each of these domains was analyzed separately, perceived irrelevance of treatment best
discriminated dropouts from completers. Thus, parental perception of the importance and relevance
of treatment has been established as an important
variable related to engagement.
Parental Expectations and Treatment Engagement
The expectations that a parent holds regarding
treatment can play a role in a parent's willingness to
participate. For example, parents who believe treatment should focus solely on the identified child may
be reluctant to take part in assessment and treatment
(Furey & Basili, 1988). Burck (1975) found that 7 of
10 randomly selected families attending a child clinic
had expectations that were mismatched with the
treatment process, such as that the parent would not
need to participate or that treatment success would
be reached in one or two sessions. These dissonant
expectations related to missed appointments and dis-

Morrissey-Kane and Prinz

satisfaction with services. Similarly, Day and Reznikoff (1980) and Plunkett (1984) found that parents
having these same kind of expectations about child
therapy at the onset of treatment were likely to drop
out early.

Parental Attributions and Treatment Acceptability

Reimers, Wacker, Derby, and Cooper (1995)
found that parents seeking child mental health services who used child-referent dispositional explanations of their child's behavior problems (i.e., internal
to child), rated the recommended behavioral intervention strategies as less acceptable. That is, if parents believe the problem is dispositional within the
child, then a treatment aimed at getting parents to
manipulate environmental contingencies is incompatible with the parents' beliefs. For example, parents
who believe medication is the answer to their children's problems would not see learning parent management skills as relevant and might balk at treatment. Further, parents who only partially believe in
the purpose of an intervention are likely to employ
the intervention in an inconsistent manner, thus
threatening treatment fidelity and minimizing benefits.
Parental Attributions and Treatment Dropout
Evidence connecting locus of control to treatment engagement has been previously established in
the adult clinical literature (Bowen, South, Fischer, &
Looman, 1994). Clients with a greater sense of control have been shown to have a more favorable response to behavioral and other therapies. Moreover,
a higher degree of perceived control predicted lower
depression, greater number of sessions attended, and
a more positive overall outcome.
Given that the engagement of parents in the
child treatment process is often crucial, it is necessary
to understand the impact of parental locus of control
on treatment dropout. Campis et al., (1986), the developers of the PLOC, maintain that high ratings
on the PLOC, indicating elevated external locus of
control, could identify families at risk for treatment
failure. To test such an hypothesis, Roberts et al.
(1992) examined whether the locus of control for
parents in a parenting program predicted premature
termination from treatment. Out of 72 families who
sought treatment for oppositional child behavior,

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Parental Cognitions and Treatment Engagement

there were 4 dropouts immediately following intake,
11 premature terminations after the onset of treatment activities, and 57 treatment completions. Inconsistent with hypotheses, results indicated that external locus of control did not correlate with family
treatment completion status, although the method of
analysis and the low number of initial dropouts may
have limited the possibility of detecting a relationship. Future tests of this issue should include measurement of parental expectations for treatment,
which might clarify how locus of control attributions
influence decisions to drop out.

Modifying Parental Expectations Through

Client Preparation
Given the importance of parental expectations
and attitudes on treatment engagement, research that
establishes the impact of client preparation for treatment on parental cognitions is an important next
step. Day and Reznikoff (1980), using a videotape
preparation procedure for parents seeking treatment
in a child psychiatric clinic, found that the prepared
group had fewer incorrect expectations of treatment
and had fewer cancellations and failed appointments
than did a non-prepared group. Similarly, Bonner
and Everett (1986) demonstrated that an audiotape
preparation procedure enhanced parent and child
knowledge of therapy, receptivity to therapy and
therapists, and expectations for therapy outcome.
In sum, findings are inconsistent regarding the
role of parental congitions on treatment engagement.
Although a clear relationship between parental locus
of control and treatment dropout was not found, parental causal explanations for child behavior were
related to treatment acceptability. Additionally, parental expectations for treatment were related to
treatment engagement, in that incongruent or unrealistic expectations led to premature dropout. Consequently, preparing clients for treatment seems to
have a positive effect in terms of modifying unrealistic expectations, reducing attrition, and increasing
receptivity to therapy.
Phase 3: Treatment Outcome
The discussion now turns to the relationship between parental attributions and treatment outcome.
We focus on parental attributions as predictors of
treatment outcome, linkages between parental per-

ceptions of child deviancy and treatment outcome,

and the modification of parental attributions
throughout the treatment process.

Predicting Treatment Outcome from Pretreatment

Parental Attributions
Given that parental attributions have been
shown to be realted to beliefs in their children's ability to change, it follows that the attributions parents
hold at the beginning of treatment could predict therapeutic outcome. Parents who perceive their children's problems as unchangeable may view any attempts to intervene as futile. Watson (1986)
hypothesized that parents with preconceived beliefs
that their children's difficulties are internal and dispositional would see less successful outcomes from therapy. As predicted, less success in therapy (as judged
by therapists, teachers, and parents) occurred when
mothers held dispositional attributions assuming the
locus of the problem was internal to the child. However, fathers' pretreatment attributions held no clear
predictive value. Watson (1986) found that mothers
were more likely than fathers to hold themselves
responsible for their children's behavior, and that
maternal self-attributed responsibility correlated
positively with therapy outcome.

Parental Perceptions of Treatment Barriers in

Relation to Outcome
Kazdin and Wassell (1999) found in a sample
of 200 children referred to an outpatient clinic for
disruptive behavior disorders that parental perceptions of treatment barriers related to treatment outcome. Greater perception of treatment barriers was
associated with lower improvement in child behavior.
The four domains of perceived barriers included (1)
stressors and obstacles competing with treatment, (2)
demandingness of treatment, (3) perceived relevance
of treatment, and (4) parent's relationship with the
therpist (Kazdin, Holland, Crowley, & Breton, 1997).
The findings suggested that the two parental cognitive domains (Nos. 2 and 3) were mostly highly correlated with therapy outcome, underscoring the importance of parental cognitions above and beyond
environmental obstacles in relation to treatment
outcome.

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Parental Perceptions of Child Deviancy and
Treatment Outcome
Parental perceptions of child deviancy can affect
outcome, as demonstrated by Furey and Basili
(1988), who examined parental satisfaction with a
program designed to help parents of noncompliant
children. Furey and Basili (1988) found that while
parents who were satisfied with the outcome of training viewed their children's behavior as significantly
improved after treatment, the parents who were dissatisfied with treatment outcome continued to view
their child's behavior as problematic despite objective reports of child improvement and parental use of
effective parenting strategies. Although the learned
parenting behaviors had effectively reduced child behavior problems, parental cognitions were not sufficiently modified in the dissatisfied parents. Parental
satisfaction was unrelated to the severity of child
deviant behavior, but was related to pretreatment
levels of parental depression. Depression was highest
in those mothers who dropped out, second highest
in the dissatisfied mothers that completed treatment,
and lowest in mothers who were satisfied with treatment outcome. Therefore, this study confirms that
depressed mothers may be at risk for inaccurate perceptions of treatment gains and for treatment drop
out. Furey and Basili (1988) recommend that treatment programs continue to follow parents for longer
posttreatment intervals and suggest the use of
booster sessions to help sustain positive changes in
parenting skills and parental perceptions.
Dumas (1984) did not find support for a relationship between parental perception of child deviance
at intake and subsequent treatment outcome. Rather,
successful treatment outcome depended primarily on
the level of family functioning. That is, when maternal psychopathology, marital conflict, and maternal
social isolation were low, the child had a better
chance of benefiting from treatment. In examining
the role of parental perceptions of child problems on
treatment outcome, Dumas (1986) found that parental perceptions of child problems were influenced
both by child level of functioning and by parental
level of distress. However, similar to Dumas (1984),
yet contrary to other studies (Furey & Basili, 1988),
the best fit model did not demonstrate a causal relationship between parental perceptions of child behavior and treatment outcome. Further, the model
suggested that treatment involvement and outcome
may be solely determined by socioeconomic variables. This finding is in contrast to other parent train-

Morrissey-Kane and Prinz

ing studies that have demonstrated a strong relationship between parental functioning and treatment
involvement and outcome (McMahon et al., 1981).
One explanation for such discrepant findings is that
Dumas (1986) used a higher criterion for treatment
success than did Furey and Basili (1988). Dumas defined a family's outcome as successful only after they
had completed both phases of treatment, demonstrated the necessary skills at termination, did not
use other services for one year, and maintained such
improvements at one-year follow-up.
Modifying Parental Attributions Through Treatment
Roberts et al. (1992) found that families who
had successful outcomes in treating their oppositional
child had a significant decrease in parental locus of
control. As hypothesized, parents who developed a
more internal locus of control at the completion of
treatment tended to also have the most treatment
success. These parents shifted their attributions from
the belief that they had no control to the belief that
they could effectively manage their children's behavior. Future research should examine underlying
mechanisms leading to a change in locus of control
and identify essential treatment components for
modifying parental attributions.
Attributions during treatment can be influenced
by initial treatment procedures. Alexander, Waldron,
Barton, and Mas (1989) used a pretreatment intervention to demonstrate that creating either a positive
or negative attributional set would significantly affect
the rate of blaming attributions in parents of adolescent offenders. Thirty high-conflict families were
asked to report two recent behaviors of the other
two family members that were either satisfying (positive set condition) or dissatisfying (negative set condition). The negative-set condition, in comparison with
the positive-set condition, generated more negative
interactions and blaming attributions. The study
nicely showed how cognitions can affect family interactions and causal explanations of behavior. However, in a follow-up study by Alexander et al. (1989),
parental blaming attributions proved resistant to oneshot attempts at therapeutic manipulation (e.g.,
relabel, introducing positive information). Indeed,
modifying such attributions is likely to take sustained
effort throughout the course of treatment in order
for change to occur.
In sum, limited support is emerging for the relationship of parental locus of control and treatment

Parental Cognitions and Treatment Engagement

outcome and for possible modifications of parental
attributions during the treatment process. Future research hopefully will uncover effective strategies that
lead to attributional change in treatment and contribute to our understanding of the processes by which
attributions are modified.
EVOLVING CONCEPTUAL FRAMEWORK
The majority of reviewed studies demonstrated
that parental cognitions, and in particular attributions
and expectations, influence parental engagement in
the treatment process. Most of the past research in
this area has lacked a unifying conceptual framework.
However, using attribution theory as a backdrop, the
seeds of a framework for the parental attributional
process are proposed here. Attribution theory focuses on the causal explanation process for the behavior of self and other (Heider, 1958; Kelley, 1973). In
general, individuals have a tendency to acknowledge
responsibility for success and deny responsibility for
failure consistent with a hedonic bias (Harvey &
Weary, 1981). Weiner (1980, 1985) has proposed a
cognition-emotion-action attributional model that
takes into account the impact of attributions on emotional reactions, future expectancies, and subsequent
motivation for action. This type of model is especially
relevant for linking parental attributions to expectancies for change and to subsequent decisions to pursue treatment.
In his work on classroom achievement, Weiner
(1986) proposed that causal explanations for outcomes can be described with three attributional dimensions: locus (internal vs. external), stability
(temporary vs. permanent), and controllability (controllable vs. uncontrollable). Weiner has demonstrated that the judgment an individual makes regarding the cause of an event, influences that individual's
emotional reactions and expectations for future success. For example, students who failed a test and
attributed the failure to an enduring lack of ability
(dispositional, permanent, and uncontrollable) would
likely feel helpless, expect similar failure in the future, and be unmotivated to apply themselves on
future tests. Conversely, if the student attributed the
failure to a lack of effort (situational, temporary,
controllable), they would be likely to expect that
future success is possible and be motivated to apply
more effort in the future. A similar attributional process can be applied to parent's causal explanations
for their children's behavior. However, the picture is

191
a little different because there are two players, parent
and child, rather than just one. Weiner's model has
been applied specifically to personal "failures," such
as alcoholism (McHugh, Beckman, & Frieze, 1979),
crime (Carroll, 1978), and domestic violence (Frieze,
1979), but the model is relevant to parenting if we
view parenting as an achievement process. Similarly,
child outcomes might also be judged as "successes"
and "failures." Furthermore, motivation is an important factor in treatment engagement (Miller, 1985),
and so an attributional model such as Weiner's that
focuses on motivation seems appropriate to use in
child and adolescent treatment process research.
As shown in Fig. 1, the proposed model of the
parental attribution process with respect to engagement in child mental health treatment is adapted
from Weiner's model to allow for both child-referent
and self-referent attributions. The model suggests
that parents who are ineffective at modifying their
child's behavior will spontaneously make both childreferent and parent-referent attributions that influence their affective response, expectancy for future
success, and subsequent behavior.
The model is consistent with both the developmental and clinical literatures reviewed in this paper.
For example, the parental self-referent pathway demonstrates that experiences with failure often lead parents to make attributions that the locus for such
events is caused by reasons outside themselves, that
they have no control over correcting the situation,
and that failure is certain in the future. Such attributions have also been supported in the clinical literature showing that parents of children with behavioral
disorders, who report increased difficulties in controlling their child, report an external locus of control
(Baden & Howe, 1992; Johnston & Patenaude, 1994;
Roberts et al., 1992; Sobol et al., 1989). The model
then suggests that parents using such pessimistic attributions would have feelings of apathy, helplessness,
and hopelessness. Such affect is consistent with findings show that parents of deviant children report decreased parental competence (Baden & Howe, 1992;
Day et al., 1994; Johnston, 1996; Mash & Johnston,
1983; Sobol et al., 1989), and increased stress (Mouton & Tuma, 1988; Mash & Johnston, 1983; Patterson,
1982), and depression (Griest et al., 1979; Griest &
Wells, 1983; Patterson, 1980). Barlow (1988) has emphasized that uncontrollability and unpredictability
are central to theories of anxiety, thus again directing
a focus at the role of attributions in mediating parental adjustment.
The implications of such cognitions and emo-

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Morrissey-Kane and Prinz

Parental Cognitions and Treatment Engagement

tions on the expectancy for future success are relatively clear. Helplessness, hopelessness, and low belief in one's abilities to be an effective change agent
impact the treatment process by limiting parental
motivation for, and participation in, treatment. It is
suggested that parents, believing themselves ineffectual, may enter therapy in the hopes that the therapist
will "fix" their child. Enthusiasm for treatment may
wane, however, as therapists attempt to reassign responsibility for change to the parents. In this case,
without modifying parental attributions, the parents
would maintain their expectations for failure and inconsistently implement the treatment recommendations, thus confirming their expectations for failure.
This may lead to treatment rejection and possible
dropout.
The child-referent pathway suggests that "failure" experiences lead parents to attribute the cause
of their children's problems to factors within the
child, to believe that the negative behavior was intentional, and to view such problems as stable (e.g.,
dispositional) and unchangeable. Such cognitions often lead to parental feelings of shame, anger, and
hopelessness, all of which may be a further detriment
to the parents' ability to feel ready to face their children's problems. Such pessimism must have negative
consequences for parental motivation and participation during treatment. The most challenging and all
too common scenario occurs when parents have
formed negative attributions in both the parent-referent and child-referent domains. Such attributions are
likely to negatively impact the parent's expectations
for success in treatment. Such a parent can be a challenging client; however, awareness of the role of parental cognitions in the treatment process can facilitate more successful engagement and bolster parental
confidence and motivation.
RESEARCH AND CLINICAL IMPLICATIONS

193
were longitudinal in structure. Longitudinal studies
with community populations could help establish a
greater understanding of the normative patterns of
parental attributions. Similarly, longitudinal studies
with clinical populations could contribute to an understanding of how parental attributions change over
time, taking into account therapeutic intervention,
and might include long-term treatment follow-up to
determine the endurance of modifications to parental
attributions and the relationship of attributions to relapse.
Future research should focus on the development of models and measures that better capture the
complexity of relationships among child behavior,
parental cognitions, parenting behavior, and treatment engagement. Researchers may need to move
beyond linear models to more transactional ones that
reflect the interplay between parent and child, factoring in cognitions, affect, and behavior (Bugental
et al., 1998; Slep & O'Leary, 1998). The complexity
of parent-child relationships and the influence of
spontaneous attributions on behavior, provide a case
for conceptualizations of a more systems or relational
perspective, with a shift in methodology to analyzing
the transactional nature of parent-child relationships
in more naturalistic settings (Bugental et al., 1998;
McHale & Fivaz-Depeursinge, 1999; Slep &
O'Leary, 1998).
Parental cognitions are related to treatment engagement, and many parents at risk for early drop
out can be identified at their first contact with the
treatment setting. Previous research has begun to
establish that parental attributions and expectations
can indeed be modified (Alexander et al., 1989; Roberts et al., 1992; Slep & O'Leary, 1998), and that
explicitly preparing families for treatment can lead to
improved expectations and engagement (Bonner &
Everett, 1986; Day & Reiznikoff, 1980). Future research should continue to identify strategies to be
used to modify parental cognitions both prior to and
during treatment.

Research Directions
This area of work can be improved methodologically through (1) consistent use of standardized measures of attributions, (2) assessment via multiple informants (including assessment of fathers), (3)
attention to measurement bias (blind conditions),
and (4) enhancement of external validity by studying
demographically diverse samples that are found in
clinical settings.
Of the studies reviewed in this article, few if any

Clinical Recommendations
Several previous articles have described successful intervention strategies designed to improve initial
follow-through and sustained treatment engagement
with the use of letter writing (Lown & Britton, 1991),
intensive telephone contact (McKay, McCadam, &
Gonzales, 1996), parent orientation meetings (Wenning & King, 1995), modifying treatment to address

Morrissey-Kane and Prinz

194

the parent's expressed needs (Prinz & Miller, 1994),

influencing the client's social networks (Carr, 1990;
Pescosolido, 1996), and more comprehensive engagement strategies based on Strategic Structural Systems
Engagement (Santisteban et al., 1996) and Multidimensional Family Therapy (Liddle, 1995). Indeed,
engaging families in treatment, especially highly resistant families, is best addressed with an ecological,
multilevel approach that integrates interventions at
the child, parent, social network, school, agency, and
community level. However, the common denominator in many of these interventions is the science of
persuading and motivating parents to sustain their
commitment to bringing the family to treatment. The
research on social persuasion contains a number of
useful ideas that can be adapted for clinical application (Cialdini, 1993; Friestad & Wright, 1999; Yukl,
Kim, & Chavez, 1999). The study of parental cognitions is at the base of understanding how parents
make decisions regarding service use. Such understanding is central to designing effective interventions
to improve engagement.
This article has illustrated the importance of focusing on parental cognitions as a means to improve
engagement in child and family treatment. In order to
prevent pretreatment dropout, clinicians can modify
early contacts with families (e.g., initial phone contact, intake interview) in order to address parent expectations and begin garnering their motivation to
initiate and follow-through with treatment. Once parents enter treatment, an initial assessment of parental
attributions and expectations can inform the clinician
which parents may be at risk for treatment resistance
and dropout. Such families should receive additional
intervention aimed at bolstering motivation and addressing expectations and attributions. Normalizing
parental feelings of frustration and hopelessness and
focusing on building parental confidence and competence may be crucial to parental engagement. Defusing feelings of blame, and getting parents to focus
on themselves as a central part of the solution to their
child's difficulties is important. Also, early sessions
should focus on clarifying the parent's expectations
for treatment and modifying maladaptive expectations (i.e., "quick fix"). When families feel frustrated
or "struck" in the treatment process, discussion of
the typical phases of treatment (Spitzer, WebsterStratton, & Hollinsworth, 1991) may be useful to
normalize their experience and keep the family motivated.
Specific strategies for increasing a parent's motivation to stay involved in treatment can be developed

by adapting strategies used in motivational interviewing (Miller & Rollnick, 1991; Walitzer, Dermen, & Connors, 1999) Solution-Focused Therapy
(Selekman, 1997), engagement-focused dialogue
(Liddle, 1995), or interventions based on the Stages
of Change theory that aim to foster the initiation and
maintenance of healthy behaviors (Fairhurst, 1996;
Prochaska, DiClemente, & Norcross, 1992), or from
strategies used in recruiting and retaining families in
prevention research (Spoth, Goldberg, & Redmond,
1999). When teaching behavioral management skills
to parents, the modification of parental behaviors
may be facilitated by focusing on emotional arousal
and attributions (Smith & O'Leary, 1995). Bloomquist (1996) also more directly targets parental cognitions by preparing parents for change through a discussion of both unhelpful and helpful parental
cognitions that may affect the treatment process.
Such a direct discussion and modification of parental
cognitions will surely help facilitate the parent's continued involvement in the child and adolescent treatment process.
Given that depressed parents may be at higher
risk for treatment dropout and for underestimate of
treatment gains (Furey & Basili, 1988), interventions
that pay particular attention to parental cognitions
in this population may be especially important. Assessing parental attributions and expectations
throughout the treatment process could facilitate
identification of parents at risk for attrition. Interventions with depressed parents can be informed by the
cognitive therapy literature (Beck, 1995; Burns,
1989). Perhaps the modification of parental cognitions throughout treatment might be facilitated by
combining Bloomquist's (1996) list of unhelpful parental cognitions with interventions designed to identify and modify "faulty" cognitions or negative automatic thoughts. Depressed parents can be educated
about the potential role of depression in perpetuating
child problems and increasing parental perceived
stress, and can be encouraged to seek treatment to
directly address their depression. Finally, Furey and
Basili (1988) recommend that treatment programs
continue to follow parents for longer posttreatment
intervals, and suggest the use of booster sessions to
help sustain positive changes in parenting skills and
parental cognitions.
Conclusion
This paper has examined the role of parental
attributions and expectations on the child and adoles-

Parental Cognitions and Treatment Engagement

cent treatment process. On balance, the studies presented in this review support the usefulness of an
attributional framework for understanding some of
the determinants of parental participation and perseverance in child and adolescent treatment. Although
other variables may be important in the engagement
process (i.e., SES, education, life stressors), parental
attributions have been an area that has of yet been
largely neglected. This review has established that
there is a need for further study of parental attributions in the treatment process and has provided a
means to direct such study by proposing a preliminary
conceptual framework.
Overall, results from the studies reviewed indicate that parental attributions influence help seeking,
treatment engagement, and treatment outcome. Parents with an external locus of control have been
shown to use a more authoritarian parenting style, be
more dissatisfied with treatment, perceive behavioral
parent management strategies to be less relevant and
acceptable, and have poorer treatment outcomes.
Conversely, parents who believe they can exert control over their environment, their children in particular, are more likely to remain involved in the treatment process and demonstrate greater therapeutic
success. Research has also established that parental
attributions can be modified through the treatment
process; however, additional research is needed to
clarify what treatment strategies are most effective
at creating such modifications.

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