Is the Egokitzen post-divorce intervention program effective in the community context?

Is the Egokitzen post-divorce intervention program effective in the community context? Ana Martínez-Pampliegaa, Marta Herreroa, Mireia Sanz b, Susana Corrala, Susana Cormenzanaa, Laura Merinoa, Leire Iriartea, Iñigo Ochoa de Aldac, Leire Alcanize, Irati Alvarezb. aDepartment of Social Psychology and Developmental Psychology, Faculty of Psychology and Education, University of Deusto, Avda. Universidades 24, 48007 Bilbao (Bizkaia), Spain bDepartment of Psychopedagogy, Begoñako Andra Mari Teacher Training University College, BAM, Larrauri Kalea, 1A, 48160 Derio, Bizkaia, Spain cDepartment of Personality, Evaluation and Treatment, Faculty of Psychology, University of the Basque Country, Tolosa Hiribidea, 70, 20018 Donostia, Gipuzkoa, Spain dDepartment of Personality, Evaluation and Treatment, Faculty of Psychology, University of the Basque Country, Barraincua Kalea, 2, 48009 Bilbao (Bizkaia), Spain eDepartment of Finance. Deusto Business School, University of Deusto, Avda. Universidades 24, 48007 Bilbao (Bizkaia), Spain ⁎Corresponding author at: Universidad de Deusto, University of Deusto, Department of Social Psychology and Developmental Psychology, Faculty of Psychology and Education, Avda. Universidades, 24, 48007 Bilbao (Bizkaia), Spain. Abstract Background : Evidence-based postdivorce intervention programs, aimed at promoting childreńs psychological adjustment, are scarce internationally. In Spain, the Egokitzen program has been established its effectiveness in the context of a university laboratory, but there is no evidence of its effectiveness when implemented from a community context. Objective : To evaluate the effectiveness of the Egokitzen program in the perception of externalizing and internalizing child symptomatology, when delivered by community-based agencies. Method : 372 parents with children under the age of 12 participated in a quasi-experimental prepost intervention approach with a wait-list comparison group and two follow-up measures at 6 and 12 months. 270 were part of the experimental group (EG) and 112 of the control group (CG). The postdivorce intervention consisted of the Egokitzen program. The following variables were measured through the information provided by the parents: childhood symptomatology (somatization, aggressiveness, anxiety/depression; Child Behavior Checklist, CBCL), parental mental health symptomatology (anxiety, depression, and This is the accepted manuscript of the article that appeared in final form in Children and Youth Services Review 129 : (2021) // Article ID 106220, which has been published in final form at https://doi.org/10.1016/j.childyouth.2021.106220. © 2021 Elsevier under CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) interpersonal sensitivity; Symptoms Checklist SCL-90), and parenting (inductive, indulgent, and rigid styles; Scale of Rules and Demands. Parents's versión, ENE-P). Results : The intervention program had an indirect effect on childhood symptomatology and a direct effect on parental symptomatology and parenting. The mediating role of parental symptomatology on childhood symptomatology was confirmed through the direct effect of the program on parental symptomatology. Despite the effect on parental patterns, they did not play a mediating role in childhood symptomatology. Concluions : T he Egokitzen program seems to be effective in the community context and, according to the parents, could reduce their children's symptomatology indirectly th rough the reduction of parental symptomatology. At the longitudinal level, in the intervention group, that the results obtained after participation in theEgokitzen program were maintained and e ven increased at 6 and 12 months symptomatology. Keywords: Divorce, Preventive intervention, Child symptomatology, Parental symptomatology, Parenting 1. Background Approximately 1 million families undergo divorce each year in Europe (Instituto de Política Familiar, 2018) and more than 60% of these families have children (OECD27_Family_Database, 2015). In Spain, the divorce rate is 58% (Instituto Nacional de Estadística [INE-National Institute of Statistics], 2019; Instituto de Política Familiar [Family Policy Institute], 2019); every year, 100,000 children experience the divorce of their parents, and 75,000 of these children are 18-year-old minors. The link between divorce and children’s psychological, behavioral, and social problems is one of the most consistent findings concerning divorce (Emery & Tornello, 2014; Jaffe, 2014; Mahrer, O’Hara, Sandler, & Wolchik, 2018; Martínez-Pampliega, A; Cormenzana, S; Corral, S; Iraurgi, I., & Sanz, M., 2021), including both externalizing (dissocial disorders, aggressiveness, etc.) internalizing manifestations (somatic disorders, anxiety, depression, social withdrawal) (van Dijk et al., 2020). These results are similar in different countries and cultures (Amato, 2010; Martinón et al., 2017; Velderman et al., 2018), confirming that parental divorce is a fundamental stressor. The high prevalence of associated problems and the risk for the children turn divorce into a public health issue, and makes the development of effective postdivorce programs in the community context a social urgency. These postdivorce intervention programs are aimed at addressing the children's issues associated with the divorce process; for them to be effective, they should focus on the explanatory factors of this relationship. That is why research in recent decades has been focused on this goal (Grych, 2005). From the cognitive-contextual model (Grych & Fincham, 1990) and the emotional security theory (Cummings & Davies, 2010; Davies & Cummings, 1994; Davies, Martin, & Cicchetti, 2012), destructive interparental conflict (i.e., situations of anger, hostility, noncooperative parenting, fights and legal conflict) has been identified as the first explanatory factor (Mahrer et al., 2018; Smyth & Chisholm, 2017; Yárnoz-Yaben & Garmendia, 2016). However, both models have emphasized that the impact of conflict is not only—or even primarily—direct, but rather indirect, through parenting. In other words, the conflict affects children indirectly when it overwhelms the parents and affects the quality of their relationships with their children (Davies & Cummings, 1994; Lipscomb et al., 2011). In addition, all the variables that influence parenting practices will also affect the children's psychological adjustment. In this sense, the parents’ mental health symptoms, linked to a highly conflictive divorce process, is one of the variables that has received the most attention because of its direct and indirect impact on the children’s increased risk of emotional, cognitive, and behavioral problems (Clark et al., 2018; Deutsch & Clyman, 2016; Zumbach, 2016). Among the different intervention initiatives (mediation, psychotherapy, child intervention programs, etc.), one of the most prevalent options is psycho-educational programs targeting parents. These are structured interventions aimed at preventing or minimizing the harm of divorce in the children (Grych, 2005; Pedro-Carroll & Jones, 2005) through the modification of the parents’ relational patterns. These programs have been proliferating since the mid-1990s: Children in the Middle (Arbuthnot & Gordon, 1994; Kramer, 1997), New Beginning Program (NBP, Sandler et al., 2018; Wolchik et al., 2000, 1993), Children First (Jewell, Schmittel, Mccobin, & Hupp, 2017), Parents Forever (Becher et al., 2018; Brotherson et al., 2010), Parenting through Change (Forgach, 1994; Forgatch et al., 2009), among others. The current objective is to study the efficacy and effectiveness of these intervention programs. Despite their widespread use, research-based interventions are scarce (Jewell et al., 2017; McIntosh & Tan, 2017; Philip & Brien, 2017). This, together with the absence of published intervention programs applicable to the Hispanic population and with efficacy studies, led to the development of the Egokitzen program. Egokitzen is a preventive program, based on a systemic approach to family functioning (Martínez-Pampliega et al., 2016). The intervention takes place over 11 weekly hour-and-a-half sessions. Throughout the sessions, 3 key areas are addressed dynamically (role-playing, group activities, project activities): a) divorce and its impact (2 sessions focused on the divorce process, reactions to divorce, etc.); b) interparental conflicts (4 sessions focused on dealing with conflictive situations); c) parenting (6 sessions focused on parenting guidelines, communication, discipline, etc.). The initial results in the context of a university clinic were highly promising (Apraiz, Ugarte, Aguado, & Martínez-Pampliega, 2015; Martínez-Pampliega et al., 2016) in terms of efficacy and efficiency. The main changes were found in the significant reduction in the parents' perception of their own and their children’s symptomatology (externalizing and internalizing), which was further reduced up to the 6-month follow-up after the intervention had been completed. To date, however, there are no studies of Egokitzen’s effectiveness in the community context. Implementing a program in the community complex would allow many more users of different social services to benefit from it but, for this purpose, its adequacy for different user profiles must be established, even if the technical conditions may be simplified (without recordings, one-way mirrors, involving fewer professionals, without the need for facilitators' clinical training, etc.). For this purpose, the present study was developed with the collaboration of multiple judicial referral centers at the national level, targeting divorced participants with a high level of interparental conflict. As a starting hypothesis and, following the cognitive-contextual model (Grych & Fincham, 1990) and the emotional security theory (Cummings & Davies, 2010; Davies & Cummings, 1994; Davies, Martin, & Cicchetti, 2012), we expected that the children of parents participating in the program (Intervention Group) would show lower symptomatology than the children of non-participating parents (Control Group). In addition, based on the theoretical review, the reduction in the parents’ mental health symptomatology and improvement in their parenting styles are expected to act as mediating variables that explain the reduction in the children's symptomatology. 2. Method 2.1.Participants The study was carried out with 372 parents presenting high interparental conflict who attended family visitation centers (FVC) in Spain. These centers are a resource of judicial referral in high-conflict family situations (Torre, 2018). The following inclusion criteria were applied: all the parents were legally divorced from their ex-partners; they did not live with their ex-spouse; they had no active estrangement order for gender-based violence (for safety reasons), and they did not have any severe nosological disorder. Concerning group assignation, 260 of the participants were assigned to the intervention group (IG) and 112 to the control group (CG) (see assignment procedure). Only one parent per family participated in the intervention program, with 40% of the cases being the father and 60% the mother. Concerning their divorce, 48% of the participants had been divorced for more than 3 years, followed by 20% who reported between 1 and 2 years, 13% who had been divorced between 2 and 3 years, 10% from 6 months to 1 year, 7% from 2 to 6 months, and 1% less than 2 months. Concerning custody, 78% of the participants reported having joint legal custody (JLC), that is, both parents share the rights and duties involved in the children's upbringing, and 22% had joint physical custody (JPC), which implies that, besides sharing parental responsibility, the time spent with the child is shared. The parents’ average age was 41.18 years (SD = 6.50) and the children’s average age was 7.59 years (SD = 4.14) and, concerning the children's gender, 48% were boys and 52% were girls. 3. Measures The participants' and their children's description variables were collected through an ad hoc questionnaire. Facilitators’ adherence was collected through a semi-structured instrument (Adherence Scale), whereby the facilitators indicated whether they had followed (yes, partly, or no) the program's guidelines regarding the use of the materials, the fulfillment of the sessions’ objectives, and their dynamics, and a section of observations to describe and explain possible deviations. The variable interparental conflict was evaluated taking into account the judicial referral report and interviews conducted by the professionals of the FVC, conceptualizing interparental conflict as being characterized by hostility, escalating distress, and detachment (Davies et al., 2016). The existence of a nosological disorder or restraining order was checked through the judicial and health reports contained in the case history. Finally, the variable support perceived in the group was collected through a visual analog scale, ranging from 1 (not at all supported) to 10 (completely supported), in which participants were asked to what extent they had felt supported within the group. The rest of the variables were collected through the following instruments, all of them adequately adapted to the Spanish sample and psychometrically robust: 3.1.“Escala de Normas y Exigencias - versión padres” (ENE–P, Bersabé, Fuentes, & Motrico, 2001 [Scale of Rules and Demands -Parents's version]). This scale assesses the level of rules and demands that parents use in their parenting, based on Baumrind's (1971) parenting styles. This scale consists of 28 items (e.g., “I explain the reasons why they must follow the rules”) structured in three dimensions. The first dimension, Inductive Parenting Style (10 items), corresponds to the most positive educational style, in which parents explain the rules and adapt them according to the needs and possibilities of their children. The second dimension, Rigid Parenting Style (10 items), corresponds to the imposition and high demand for rules and their inadequacy for the children's needs. The third dimension, Indulgent Parenting Style (8 items), refers either to the absence of rules or boundaries, or, if they exist, their compliance is not required. This questionnaire is rated on a five-point Likert scale ranging from 1 (never) to 5 (always). In this study, these dimensions obtained an adequate internal consistency (α = .80 Inductive style, α = .73 Rigid style, and α = .75 Indulgent style). 3.2. Symptom Checklist (SCL-90; Derogatis, 1992; Spanish version, González de Rivera et al., 2002). This scale evaluates parents’ mental health symptoms (e.g., “Feeling suddenly afraid for no reason”). The following three dimensions were analyzed in this study: Interpersonal Sensitivity (9 items), Depression (13 items), and Anxiety (10 items). All three dimensions had high reliability, .87, .92, and .91, respectively, as did Overall Symptomatology, composed of the previous three dimensions (α = .96). Symptoms are scored on a 5-point Likert scale, ranging from 0 = not at all to 4 = very much. 3.3. Child Behavior Checklist (CBCL; Achenbach, 1991; Spanish version, Sardinero et al., 1997). This measure assesses the prevalence of internalizing and externalizing symptoms of children and adolescents (“Breaks his/her own things”), through the parent's report. In this study, we assessed three dimensions: Somatization (12 items), Anxiety-Depression (13 items), and Aggressiveness (18 items), as the most frequently studied in the literature on the impact of divorce. Items are answered on a 3-point scale (0 = Not true; 1 = Sometimes true; 2 = Very often or quite often true). The reliability coefficients found in this study were appropriate for all three dimensions (Somatization: α = .73; Anxiety-Depression: α = .75; Aggressiveness: α = .91), and the three dimensions or Global Symptomatology also had very high reliability (α = .92). 4. Procedure The program was offered at the national level, and 10 of the 19 Spanish autonomous communities, a total of 13 FVCs, agreed to participate. All centers had the permission and support of town halls and related ministerial services. The professionals of the centers identified the users based on the inclusion criteria. For this purpose, the judicial referral report and/or the case history registered at the center was checked for the existence of high interparental conflict, a nosological diagnosis, or an active restraining order. We subsequently contacted the users who might be interested by telephone, confirming the inclusion criteria. As shown in Fig. 1, Of the 1538 users contacted by telephone, 450 (29.3%) responded positively after the program's features (number of sessions, content, and periodicity) had been explained. When both parents responded positively, we randomly selected the one who would participate in the initial edition. They were subsequently summoned for an in-person interview, which was attended by 82.6% (n = 372). This interview was aimed at resolving doubts and explaining the commitment of their participation (attendance, questionnaires, informed consent, etc.). Following the explanation, the attendees first completed the informed consent in which issues related to anonymity, confidentiality, and the possibility of leaving the study at any time were addressed. They subsequently completed the evaluation protocol. Each IG consisted of 6-8 participants. Participants were randomly distributed between the IG and the waiting-list CG. However, this distribution was not random in all cases because the CG was also made up of those participants who, despite having agreed to participate, were unable to do so for practical reasons (work schedule, group schedules, children's difficulties). In such cases, and as an ethical commitment (due to the problematic situation of the families), they were given the option of being part of the waiting-list CG, so they completed the questionnaire again 4 months later, at which point they re-assessed their availability to participate in a new IG. For the purposes of this investigation, they constituted only the CG. In addition, despite completing the questionnaires at two times, pretest and posttest, not all the participants in the waiting-list CG would subsequently join the intervention program, due to personal issues similar to those indicated above. In general, random allocation was higher than 80% in all groups, and all the participants, IG and CG, completed the questionnaires on paper (lasting approximately 30 min). As most of the children were under the age of 12, the participating parents completed the questionnaires. In no case was there any financial compensation. The intervention was conducted in a total of 39 groups (IG), with an average number of 6.5 participants per group. All groups were mixed regarding the participants' gender. Between pretest and posttest, there was a sample loss of 102 participants, which led to a final sample of the study of 270 participants, 197 in the IG (attrition = 24.2%) and 73 in the CG (attrition = 34.8%). Despite the significant number of drop-outs, there were no differences between the two groups in any of the variables considered (see Appendices A and B). Of the 197 people in the IG, only 105 completed the follow-up questionnaire at the 6-month followup, and 69 also completed a fourth questionnaire at the 12-month follow-up. The number of Management Training (Degarmo et al., 2004; Forgatch et al., 2009; Forgatch & DeGarmo, 2007; Sandler et al., 2019; Wolchik et al., 2013). These results supported the improvement and maintenance of the children's mental health, even years after the intervention (2, 6, 9, 15 years). In any event, there are few studies in the community context, (Sandler et al., 2019; Stallman & Sanders, 2014) to allow us to make comparisons in this context. On the one hand, Stallman and Sander, applying the Triple P, found main effects of the program already as of its initiation. However, the measures analyzed (intensity and number of behavioral problems) are different from those used in this study or in other previously mentioned ones (anxiety, somatization, aggressiveness, etc.), which does not allow reaching conclusive results. In the same vein with the data obtained in our study, Sandler (2019) highlighted that the NBP showed no significant differences after the intervention, although it did so at 10 months. As is well known, the NBP program has plenty of evidence about its relevance, which allows supporting the existence of a cascade effect, difficult to check at the beginning, but which shows the complex relationship between the variables and the need to comprehend them systemically (Degarmo et al., 2004; Forgatch et al., 2009). Therefore, the first relevant result of this study is the indirect protective role of the intervention program in the reduction of childhood symptomatology, due to the impact on the parents' symptomatology. Considering the number of children exposed to their parents' divorce, these results mean that many children will benefit. Readers are reminded that there is a proven relationship between child adjustment and the development of mental disorders or substance abuse in young adults (Wolchik et al., 2013, 2016), even 15 years later. Despite this, the effects are not as robust as we would have liked. This can be explained, first, by the difficulty in isolating the pretreatment change that the interviews or the completion of the questionnaires may provoke in the group; the attention of the professionals per se is a form of intervention, as already highlighted (Martínez-Pampliega et al., 2016). In addition, increased awareness of their children's difficulties could make some parents—especially parents of children with moderate scores—score higher after the intervention than they would have scored previously, because they may be more sensitive to the detection of their children's difficulties. In this way, the prepost intervention difference in the IG decreased in relation to that of the CG. Another objective of the study was to analyze the role of parenting styles in the reduction of childrens’ symptomatology. The hypothesis proposed the existence of a mediating role, but the data have not supported this, which is contrary to the patterns inferred from the theoretical reference models (Davies & Cummings, 1994; Grych & Fincham, 1990) and to the empirical studies (van Dijk et al., 2020). However, we note that the IG participants showed post-intervention improvement of their inadequate parental styles, that is, reducing rigid and indulgent patterns. On the one hand, this result, in itself, is very relevant, as many of the components of the intervention program are linked to working with parental patterns (discipline, rules, communication, etc.), an effect that was maintained over time. However, no changes were observed in the inductive parenting style. This result is consistent with the cited meta-analysis (van Dijk et al., 2020), which found that hostile parenting was the most strongly related to conflictive divorce. At the intervention level, this aspect could lead us to hypothesize, following the results of Forgatch et al., (2009), that in families with a high level of interparental conflict, the process of socialization could be entangled by the traps of negative reinforcement. In fact, those authors found that the reduction per year in coercive parenthood predicted the growth of positive parenting three years later. However, this could only be verified after a follow-up of the participants over the next few years. In any case, we emphasize the difficulty of making comparisons between the studies that have addressed parenting, as this variable has been understood in very different ways by the different researchers (Becher et al., 2018; Dawson-McClure et al., 2004; Forgatch et al., 2009; Stallman & Sanders, 2014). In short, the results about parenting styles should lead us to assume that we are far from knowing its role in children’s symptomatology. Perhaps in the short term, the greatest impact on children’s symptomatology comes from parental adjustment, mainly affecting internalizing symptomatology and, in comparison, parenting style (especially the negative styles) could play a more mediating and indirect role in the children’s externalizing symptomatology in the medium or long term. This possibility is consistent with the analysis carried out by DawsonMcClure et al. (2004) in a 6-year follow-up of the intervention program. The systemic analysis of Forgatch et al. (2009) in children aged 9 is also very appropriate, highlighting how changes in one member can initiate a complex process that can affect the entire family system in the long run. But to date, we do not know these processes clearly. In short, it seems that the Egokitzen program has been effective in the community context to reduce children’s symptomatology, through the impact of the intervention on parents’ symptomatology. The program also seems to improve the more inadequate educational styles, especially rigid styles, but this improvement does not appear to be responsible for the impact of the program on children’s symptomatology, which requires further research in the future. On the other hand, in this study, moderators such as parents' gender or age or the support of their participation group do not appear to be linked to the results, implying that the program was equally effective for all participants, no matter whether the parents were mothers or fathers, younger or older, and regardless of the support of the group. This result is very relevant, given the need to continue to incorporate both parents into the studies, regardless of their age. It is also relevant to emphasize that the objectives were achieved in the community context. The facilitators did not present difficulties with the implementation, which was carried out with great adherence to the guidelines and was highly satisfactory for the participants. This has contributed to the transfer of the program, and therefore, the intervention program will continue to be used as an intervention tool in the respective services. This preventive line will undoubtedly contribute to the amplification of the results obtained in the laboratory context and introduce the evaluation and implementation of evidence-based interventions in the community context. Finally, many future lines of work open up without having completed the present work; some are the result of the limitations that we have been able to identify. On the one hand, in this study, only parental measures were used, as all children were under the age of 12. This is the usual practice, especially in children under 9 years of age (Braver et al., 2005; Degarmo et al., 2004; Sandler et al., 2018; Velderman et al., 2018). However, we emphasize that the parents' perception could be affected by their participation in the intervention program, after which they may be more sensitive to identifying distress in their children. Hence, we recommend supplementing parental reports with measures by other mental health professionals because the changes could be influenced, even negatively, by the intervention itself. It would also be relevant to incorporate emotional adjustment variables (coping, insecurity, insensitivity) that would help us understand the differential effect of the program on some variables versus others (anxiety/depression vs. aggression, somatization). Another important limitation of the study is its quasi-experimental design. Although the initial intention was random allocation, this was not possible in all cases. In addition, we must highlight the small number of participants, starting from those invited initially, which generates a self-selecting effect that can lead to overestimation or underestimation of the data, both of the CG and the IG. Both issues require careful consideration of the results. Without denying the above, as other authors also point out (Philip & O´Brien, 2017), this reflects a real situation in a very difficult community context. Finally, we should also highlight the limitation linked to the number of participants. Despite the effort required, 39 groups (IG), 372 participants, is still a small number when sophisticated statistical analyses and robust results are desired. Finally, we note the significant number of drop-outs throughout the follow-up, which should lead to a reflection on the need to use shorter evaluation protocols and the desirability of using an active CG, that is, participating in another intervention, rather than a waiting-list CG. On another hand, developing intent-to-treat analysis could be a key strategy to alleviate the impact of the high level of drop-outs. In conclusion, Egokitzen is the first postdivorce intervention program developed for its Spanish application that has studies of efficacy and effectiveness. However, it is clear that the study must continue under more stringent research conditions and with measures sustained over time, both in the participants and in the waiting-list CG. Childhood is a key period for psychological adjustment, with fundamental repercussions in adolescence and adulthood, making this program and similar ones a major preventive initiative. Given the scope of this task, it would be desirable to achieve greater coordination among researchers around a joint strategy that takes into account variables, study populations, children's age, and other variables already noted above. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgments This work was supported by the Ministerio de Economía y Competitividad [grant RETOS 2015: PSI2015-67983-R] and by Ministerio de Sanidad, Servicios Sociales e Igualdad [FEDEPE_grant n° exp 492, programa 002; 9/12/2016]. The authors thank the professionals and users of the Family Visitation Centers for their participation in this study. Appendix A Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.childyouth.2021.106220. References Achenbach, T. M. (1991). Manual for the Child Behavior Checklist and Profile. University of Vermont, Department of Psychiatry. Amato, P. R. (2010). Research on divorce: Continuing trends and new developments. Journal of Marriage and Family, 72(3), 650–666. 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ANOVA Results on Pre-Post Intergroup Differences Contrasts of Intergroup Differences Study variable β SE t P 95% CI η2p d Parental patterns Inductive style -0.01 0.64 0.01 .990 [-1.24, 1.26] < .01 < .01 Rigid style 1.59 0.68 2.35 .020 [0.26, 2.93] .021 .29 Indulgent style 0.91 0.53 1.70 .091 [-0.15, 1.96] .011 .21 Parental symptomatology Global 4.14 1.98 2.09 .037 [0.25, 8.03] .017 .26 Anxiety 0.99 0.67 1.47 .144 [-0.34, 2.31] .008 .18 Depression 1.95 1.02 1.92 .056 [-0.05, 3.95] .014 .24 Interpersonal Sensitivity 1.20 0.63 1.91 .058 [-0.39, 2.44] .014 .24 Children's symptomatology Global 0.03 0.03 0.90 .369 [-0.03, 0.08] .003 .11 Somatization 0.01 0.03 0.43 .671 [-0.05, 0.07] < .01 .06 Anxiety/Depression < 0.01 0.04 0.05 .960 [-0.08, 0.08] < .01 < .01 Aggressiveness 0.02 0.04 0.38 .700 [-0.06, 0.09] < .01 .06 Table 3. Clinical Significance of Pretest to Posttest on Study Variables CG (n = 73) IG (n = 197) % Improvement % No change % Gets worse % Improvement % No change % Gets worse Parental patterns Inductive style 4 88 8 5 88 7 Rigid style 4 93 3 6 93 1 Indulgent style 7 86 7 4 93 3 Parental symptomatology Global 15 75 10 30 62 8 Anxiety 10 86 4 15 81 4 Depression 9 88 3 21 74 5 Interpersonal Sensitivity 4 92 4 11 86 3 Children's symptomatology Global 1 96 3 4 95 1 Somatization 17 71 12 17 70 17 Anxiety/Depression 12 85 3 10 84 7 Aggressiveness 12 84 4 18 76 6 Table 4. Pre-Post Intragroup Differences Control Egokitzen intervention Study variable t ∆Mean 95% CI d t ∆Mean 95% CI d Parental patterns Inductive style 0.73 0.47 [-0.81, 1.74] .09 1.54 0.47 [-0.13, 1.08] .08 Rigid style -0.54 -0.32 [-1.49, 0.86] -.05 3.61*** 1.28 [0.58, 1.98] .21 Indulgent style -0.55 -0.27 [-1.27, 0.72] -.06 2.34* 0.63 [0.10, 1.16] .15 Parental symptomatology Global 2.32* 2.78 [0.39, 5.17] .12 6.05*** 6.92 [4.66, 9.18] .30 Anxiety 1.98 1.01 [-0.01, 2.03] .14 5.21*** 2.00 [1.27, 2.73] .26 Depression 2.54* 1.48 [0.32, 2.64] .15 5.72*** 3.43 [2.26, 4.60] .31 Interpersonal Sensitivity 0.70 0.29 [-0.53, 1.11] .05 4.02*** 1.49 [0.78, 2.20] .23 Children's symptomatology Global 0.56 0.02 [-0.04, 0.07] .06 2.80** 0.04 [0.01, 0.07] .16 Somatization -0.23 -0.01 [-0.07, 0.05] -.03 0.41 0.01 [-0.02, 0.04] .02 Anxiety/ Depression 1.20 0.04 [-0.03, 0.11] .14 2.13* 0.05 [<0.01, 0.09] .13 Aggressiveness 1.10 0.04 [-0.02, 0.10] .10 2.57* 0.05 [0.01, 0.09] .14 * p < .05. ** p < .01 *** p < .001. Table 5. Post to 6-month Follow-Up and 6-month to 12-month Follow-Up. Intragroup Differences in the IG. Postto 6-month Follow-up 6-month to 12-month Follow-up Study variable t ∆Mean 95% CI d t ∆Mean 95% CI d Parental patterns Inductive style 1.27 0.69 [-0.39, 1.77] .13 -1.87t -1.50 [-3.10, 0.10] -.20 Rigid style 1.48 0.88 [-0.31, 2.07] .15 -0.07 -0.05 [-1.51, 1.41] -.01 Indulgent style 0.99 0.38 [-0.38, 1.14] .10 -1.03 -0.47 [-1.38, 0.44] .12 Parental symptomatology Global 4.58*** 9.09 [5.15, 13.03] .46 0.48 0.63 [-2.00, 3.26] .03 Anxiety 3.44** 2.09 [0.88, 3.30] .34 0.69 0.29 [-0.55, 1.13] .05 Depression 4.99*** 5.01 [3.02, 7.00] .50 0.02 0.02 [-1.39, 1.42] < .01 Interpersonal Sensitivity 3.46** 1.99 [0.86, 3.12] .35 0.98 0.40 [-0.42, 1.23] .08 Children's symptomatology Global 3.47** 0.07 [0.03, 0.11] .34 0.75 0.01 [-0.02, 0.05] .06 Somatization 1.83t 0.04 [<-0.01, 0.10] .20 -0.43 -0.01 [-0.06, 0.04] -.04 Anxiety/ Depression 3.32** 0.11 [0.04, 0.17] .31 -0.69 -0.02 [-0.09, 0.04] -.07 Aggressiveness 3.19** 0.10 [0.04, 0.16] .32 1.41 0.05 [-0.02, 0.11] .13 t p < .10. * p < .05. ** p < .01. *** p < .001. Table 6. Indirect Effects of Egokitzen Intervention on the Children's Symptomatology Mediator Rigid Parental Style Parents' symptomatology Dependent variables IE B SE LLCI UPCI r2 d IE B SE LLCI UPCI r2 d Global Symptomatology -0.02 0.03 -0.08 0.04 .01 -.14 -0.04 0.03 -0.11 >-0.01 .03 -.34 Somatization < 0.01 0.03 -0.05 0.05 .01 .23 -0.02 0.03 -0.08 0.03 .02 -.26 Anxiety -0.01 0.03 -0.07 0.05 < .01 -.08 -0.06 0.03 -0.13 >-0.01 .04 -.39 Aggressiveness -0.02 0.03 -0.08 0.05 < .01 -.12 -0.01 0.02 -0.06 0.04 < .01 -.09 Note. IE = Indirect effect; B SE = Bootstrap Standard Error; LLCI = Bootstrap 95% Lower Limit Confidence Interval; ULCI = Bootstrap 95% Upper Limit Confidence Interval.