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Intervention Summary

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Parenting with Love and Limits (PLL)

Parenting with Love and Limits (PLL) combines group therapy and family therapy to treat children and adolescents aged 10-18 who have severe emotional and behavioral problems (e.g., conduct disorder, oppositional defiant disorder, attention deficit/hyperactivity disorder) and frequently co-occurring problems such as depression, alcohol or drug use, chronic truancy, destruction of property, domestic violence, or suicidal ideation. The program also has been used with teenagers with less extreme behaviors. PLL teaches families how to reestablish adult authority through consistent limits while reclaiming a loving relationship. It includes six multifamily sessions, conducted by two facilitators, that employ group discussions, videotapes, age-specific breakout sessions, and role-play. Individual families also receive intensive 1- to 2-hour therapy sessions in an outpatient or home-based setting to practice the skills learned in the group setting. Three or four family therapy sessions are recommended for low- to moderate-risk adolescents; up to 20 sessions may be recommended for those with more severe problems such as involvement with the juvenile or criminal justice system. PLL's integration of group sessions and family therapy is designed to help families apply skills and concepts to real-life situations and prevent relapse.

Descriptive Information

Areas of Interest Mental health treatment
Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: June 2008
1: Conduct disorder behaviors
2: Readiness for change and parent-teen communication
3: Parental attitudes and behavior
4: Youth attitudes and behavior
5: Self-perception of substance abuse
Outcome Categories Alcohol
Drugs
Family/relationships
Social functioning
Ages 6-12 (Childhood)
13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Home
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History PLL has been widely used in the United States, Canada, and the Netherlands. As of 2010, 27 sites in the United States and 5 sites in the Netherlands have been licensed to implement and practice the PLL model.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations PLL materials have been translated into Dutch and Spanish.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: June 2008

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Sells, S. P., & Smith, T. E. (n.d.). Reducing adolescent oppositional and conduct disorders: Experimental research of a family-oriented psycho-education curriculum. Manuscript submitted for publication.

Study 2

Sells, S. P. (n.d.). Parenting with Love and Limits: A parenting program for resistant parents and adolescents with severe behavioral problems. Manuscript submitted for publication.

Study 3

Smith, T. E., Sells, S. P., Rodman, J., & Reynolds, L. R. (2006). Reducing adolescent substance abuse and delinquency: Pilot research of a family oriented psycho-education curriculum. Journal of Child and Adolescent Substance Abuse, 15(4), 105-115.

Outcomes

Outcome 1: Conduct disorder behaviors
Description of Measures Conduct disorder behaviors were measured using the Child Behavior Checklist (CBCL), which consists of 118 items related to child behavior problems scored on a 3-point scale ranging from not true to often true.
Key Findings Youth in the PLL group had significantly greater reductions in conduct disorder problem behaviors (p < .01) compared with youth in the control group. Specifically, they had greater improvements in anxiety/depression (p < .01), withdrawn/depression (p < .01), social problems (p < .05), attention problems (p < .01), rule-breaking problems (p < .01), aggressive behaviors (p < .01), internalizing problems (p < .01), and externalizing problems (p < .01).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Readiness for change and parent-teen communication
Description of Measures The Parents' Readiness Scale and Adolescent Readiness Scale were used to assess parents' and teens' stage of change (precontemplative, contemplative, preparation, action, and maintenance) and parent-teen communication.
Key Findings Mothers in the PLL group reported significantly greater readiness for change in the precontemplative (p < .01), contemplative (p < .05), and action (p < .01) stages compared with mothers in the control group. Mothers in the PLL group also exhibited significantly improved communication with their teenage children (p < .01) and significant reductions in negative perceptions of and negative attitudes toward their teenage children (p < .01) relative to control group mothers.

Teens in the PLL group reported significantly greater levels of readiness to change in the precontemplative (p < .05) and action (p < .01) stages and significantly improved communication with their mothers (p < .05) compared with teens in the control group.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 3: Parental attitudes and behavior
Description of Measures Parental attitudes and behavior were measured using the Caregiver Survey (Prevention and Early Intervention Protective Factor Survey for Caregivers). Five areas were assessed: knowledge of parenting, nurturing and attachment, parental resilience, social support, and problem solving/communication.
Key Findings The total scores of parents in the PLL group differed significantly (p < .05) from those of parents in the control group, indicating improved attitudes and behaviors. Parents in the PLL group reported greater parental resilience (p < .05), more social support (p < .05), and better problem solving/communication (p < .01) relative to the control group.
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 4: Youth attitudes and behavior
Description of Measures Youth attitudes and behavior were measured using the Youth Survey (Prevention and Early Intervention Protective Factor Survey for Youth), which measures 13 constructs related to teenagers' attitudes toward and behavior relative to parents and peers. Examples of constructs measured in this survey are clear rules and expectations, emotional support and absence of criticism, and high parental expectations.
Key Findings Youth in the PLL group exhibited significant increases relative to their control group counterparts in 2 of the 13 areas measured: "high value for helping others" (p < .05) and social competencies (p < .05).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 2.2 (0.0-4.0 scale)
Outcome 5: Self-perception of substance abuse
Description of Measures This outcome consisted of two constructs, both measured using subscales from the Adolescent Substance Abuse Subtle Screening Inventory (SASSI):

  • Self-perception of alcohol abuse, measured using the Face Valid Alcohol (FVA) subscale
  • Self-perception of other drug use, measured using the Face Valid Other Drug (FVOD) subscale
Key Findings Youth in the PLL group exhibited significantly lower scores (p < .001) on the FVA subscale, indicating they were less likely than youth in the control group to judge themselves as abusing alcohol.

Youth in the PLL group also exhibited significantly lower scores (p < .001) on the FVOD subscale, indicating they were less likely than youth in the control group to judge themselves as abusing other drugs such as marijuana.
Studies Measuring Outcome Study 3
Study Designs Preexperimental
Quality of Research Rating 2.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 57.9% Male
42.1% Female
81.6% Black or African American
10.5% White
5.3% Race/ethnicity unspecified
2.6% Hispanic or Latino
Study 2 6-12 (Childhood)
13-17 (Adolescent)
67.1% Male
32.9% Female
38.1% Hispanic or Latino
36.1% White
21.9% Black or African American
3.9% Race/ethnicity unspecified
Study 3 6-12 (Childhood)
13-17 (Adolescent)
56.9% Male
43.1% Female
82.4% White
11.8% Black or African American
4.8% Race/ethnicity unspecified
1% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Conduct disorder behaviors 3.5 3.5 3.5 2.0 2.0 3.0 2.9
2: Readiness for change and parent-teen communication 1.0 2.0 3.5 2.0 2.0 3.0 2.3
3: Parental attitudes and behavior 1.0 2.5 3.5 2.0 2.0 2.5 2.3
4: Youth attitudes and behavior 1.0 2.0 3.5 2.0 2.0 2.5 2.2
5: Self-perception of substance abuse 3.0 3.0 3.5 2.0 2.0 2.5 2.7

Study Strengths

Two of the three studies used random assignment and appropriate measurement instruments with established reliability and validity. A standardized fidelity manual was used to train group facilitators, who followed a systematic group leader's guide while implementing the 6-week intervention. The fidelity manual and a series of protocol adherence checks were used during live supervision of the group facilitators, and intensive training was conducted until the group facilitators demonstrated an acceptable level of reliability in administering the intervention.

Study Weaknesses

One study lacked random assignment and had a small sample size. In two studies where participant attrition occurred, no evaluation of attrition bias was performed to establish whether there were any differences between the participants who remained and those who did not. Some of the instruments lacked reliability and validity information.

Readiness for Dissemination
Review Date: June 2008

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Program Web site, http://www.gopll.com

Savannah Family Institute. (2006). Parenting with Love and Limits: Center of Excellence operations manual. Savannah, GA: Author. Retrieved from http://www.difficult.net/images/COEOpsMan.pdf

Savannah Family Institute. (2008). Parenting with Love and Limits: 5 day intensive training. Savannah, GA: Author.

Savannah Family Institute. (2008). Parenting with Love and Limits: Protocol checklists. Savannah, GA: Author. Retrieved from http://www.difficult.net/images/GTProtocolCheck.pdf

Savannah Family Institute. (n.d.). Checklist for successful implementation of PLL. Savannah, GA: Author.

Savannah Family Institute. (n.d.). Explanation of the terms: Survival, stable, success, and significance. Savannah, GA: Author.

Savannah Family Institute. (n.d.). Parenting with Love and Limits: Certification and application workshop [PowerPoint slides]. Savannah, GA: Author.

Sells, S. (2005). Parenting with Love and Limits: Group therapy leader's guide. Savannah, GA: Savannah Family Institute.

Sells, S. (2005). Parenting with Love and Limits: Level 2 parent's workbook. Savannah, GA: Savannah Family Institute.

Sells, S. (2005). Parenting with Love and Limits: Level 2 teen's workbook. Savannah, GA: Savannah Family Institute.

Sells, S. (n.d.). Treating the unmotivated and resistant parent and juvenile: A 7-step evidence-based approach [PowerPoint slides]. Savannah, GA: Savannah Family Institute.

Sells, S. P. (2005). Parenting with Love and Limits: Group therapy supervision manual. Savannah, GA: Savannah Family Institute. Retrieved from http://www.difficult.net/images/PLLSupervisionMan.pdf

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.8 3.8 3.9 3.8

Dissemination Strengths

Implementation materials capture program model content, provide guidance for overcoming common obstacles, and clearly describe the target population and implementer qualifications. A separate manual provides support for developing organizational capacities for implementing the intervention. The intensive training provided by the developer combines educational presentations and live demonstrations. A comprehensive certification process, booster trainings, and ongoing technical assistance also support implementation. Well-designed materials are provided to support the therapist coaching process. Tools for monitoring therapist adherence, real-time program outcomes, and implementation fidelity are provided to support quality assurance.

Dissemination Weaknesses

Little information is provided on what kinds of organizations are best suited for implementing this intervention and how the intervention should be integrated into regular organizational functions. While a training curriculum exists, a manual or handbook specifically guiding trainers is not provided. Additional guidance for the use of quality assurance tools is needed.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
All participant materials (includes quality assurance materials) $54 per family Yes
Therapist certification kit $324 each Yes
Co-facilitator certification kit $324 each Yes
Annual program licensing fee (includes 5-day, on-site clinical training, weekly or biweekly telephone consultation for 48 weeks, annual on-site consultation, ongoing consultation, and videotaped therapist supervision) $1,500 per family, plus travel expenses for training Yes
Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation or research, contact:
Scott P. Sells, Ph.D., LMFT, LCSW
(800) 735-9525
spsells@gopll.com

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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