Does Size Matter? Determining Differences in Family Outcomes Based on Cohort Size of HOT DOCS Parent Behavior Management Groups

Does Size Matter? 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Determining Differences in Family Outcomes Based on Cohort Size of HOT DOCS Parent Behavior Management Groups Hannah Cooper, Sarah Dickinson, Danielle Thomas, Tarie Taylor, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6882775/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Disruptive behavior in youth is a common challenge for caregivers. Behavioral parent management training (BPMT) is an effective way to intervene with disruptive behaviors of childhood. Dissemination of BPMT is needed considering the prevalence of disruptive behavior. Group formatted BPMT is one way to provide efficacious strategies for managing challenging behaviors to wider audiences. Still, questions remain as to the impact of group factors, namely cohort size, on group outcomes. The purpose of this study was to examine whether group size was related to self-reported parenting stress, the intensity of parent-reported child disruptive behaviors, and overall satisfaction amongst caregivers who completed the Helping Our Toddlers, Developing Our Children’s Skills (HOT DOCS) BPMT. Participants (N = 631) were grouped by cohort size (smaller, recommended, or larger size). Analyses compared pre- to post-intervention change across groups on parenting stress and disruptive behavior. Additional analyses evaluated post-test program satisfaction between groups. The results demonstrated that HOT DOCS was effective at reducing parent stress and the intensity of problematic behavior in children. There was no effect of group size on outcomes, nor was there an interaction between HOT DOCS participation and group size on these outcomes. Still, participants from smaller groups had greater satisfaction with the program, albeit this difference lacked clinical meaningfulness. These results indicated that group size neither enhanced nor detracted from the success of caregivers in managing their own stress and their child’s behaviors. Findings from this study may inform the implementation of similar behavior-focused parent training programs. Disruptive behavior child caregivers group behavior management Highlights HOTDOCS is an effective intervention at reducing parenting stress and disruptive behaviors in children The size of the parenting group cohort does not impact the benefit of the intervention on parenting stress or disruptive behavior Caregiver attitudes toward the intervention were slightly more positive from those in smaller groups; this effect was small and lacks clinical meaningfulness Clinicians should not be deterred from delivering group parent management interventions to larger cohort sizes Introduction Disruptive behavior in childhood is a common parenting challenge and a frequent concern that caregivers discuss with their children’s medical providers (Duncan et al., 2013 ). In fact, disruptive behavior is developmentally appropriate for young children as they learn to navigate their world. Subclinical patterns of disruptive behavior are common, with caregivers of one in six children reporting developmental or behavioral challenges (Canino et al., 2010 ; Cree et al., 2018 ; Egger & Angold, 2006 ). However, the intensity and frequency of symptoms are what differentiates normative disruptive behaviors from those that are of clinical concern (American Psychiatric Association, 2022 ; Egger & Angold, 2006 ). Per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), childhood disruptive behavior is transdiagnostic and presents in a variety of ways including oppositionality, aggression, irritability, vindictiveness, and argumentativeness (American Psychiatric Association, 2022 ; Hong et al., 2015 ). The DSM-5-TR offers several ways of categorizing distinct presentations of disruptive behaviors of clinical concern, including Oppositional Defiant Disorder, Intermittent Explosive Disorder, and Conduct Disorder (American Psychiatric Association, 2022 ), each with a prevalence rate of 3.3%, 4%, and 4%, respectively (Canino et al., 2010 ; Coccaro & McCloskey, 2019 ; Costello et al., 2005 ). Studies have demonstrated that clinically significant disruptive behavior in young children is linked to poor academic achievement (Brennan et al., 2012 ; Sayal et al., 2015 ) and social development (Kouros et al., 2010 ), as well as internalizing disorders such as depression and anxiety (Boylan et al., 2007 ). Childhood disruptive behavior is also related to adverse consequences in caregivers, including depression, marital challenges, and high levels of stress (Blacher & Baker, 2019 ; Calzada et al., 2004 ; Gopalan et al., 2010 ; Jones et al., 2017 ). The impact of disruptive behaviors in youth is cyclical: child disruptive behaviors are linked to parenting stress, and parenting stress is related to increased negative parenting practices and greater behavioral problems in children (Mackler et al., 2015 ; Neece et al., 2012 ). Interrupting this problematic cycle is pivotal for healthy family functioning. Early prevention and intervention strategies aimed at refining parenting practices are highly effective at improving behavior in youth and creating long term, positive adjustment into adulthood (Kazdin, 1997 ; Long et al., 1994 ; Sandler et al., 2011 ). These practices are known generally as behavioral parent management training (BPMT) and include teaching caregivers techniques such as positive reinforcement and logical consequences to either encourage favorable behaviors or extinguish inappropriate ones (Leijten et al., 2019 ). BPMT interventions have been shown to increase a caregiver’s ability to confidently and effectively manage their child’s disruptive behaviors (Roskam et al., 2015 ). Not only do BPMT interventions positively impact child behavior, they also effectively reduce parenting stress and strengthen the parent-child relationship (Kazdin, 1997 ). There are numerous curricula for parenting interventions such as the Positive Parenting Program (Sanders, 1999 ), the Incredible Years (Webster-Stratton et al., 2004 ), and Parent-Child Interaction Therapy (Eyberg & Funderburk, 2011 ). Intervention formats vary; a common delivery method is one-on-one (i.e., provider to single family). However, when considering the high level of need in the population, clinicians must question whether providing care on a single-family basis is the most effective intervention for problematic behavior of childhood. An alternate form of service delivery is group BPMT. Not only are group BPMTs highly effective at reducing behavioral challenges in children (Agazzi et al., 2020 ; Barlow et al., 2012 ; Chacko et al., 2016 ), but they also decrease depression, anxiety, and stress in caregivers (Furlong et al., 2012 ). Group BPMT is a particularly appealing option for many families due to accessibility. Individual BPMTs can be costly and time-intensive, lasting 12 or more sessions (Shaffer et al., 2001 ). Group BPMTs can increase accessibility by serving multiple families at one time at regular increments throughout the year. Thus, in the time it takes to serve one family in individual treatment, up to 15 families can be served in a group format, which increases access to care. Group BMPT has further benefits in terms of peer support, vicarious learning opportunities, and reduced stigma, making groups an attractive option for many families (Niec et al., 2016 ; Niec et al., 2005 ). One accessible and short-term group BPMT, and the intervention used in the present study, is Helping Our Toddlers, Developing Our Children’s Skills (HOT DOCS; (Agazzi et al., 2020 ). The HOT DOCS program is a six-week intervention for caregivers of children ages birth to five years. Each session ranges from 1.5 to two hours and includes opportunities for individualized problem-solving. Group size ranges from two to 17 individuals. Prior research with HOT DOCS has shown significant pre- to post-intervention improvements in parenting stress and parent-reported child disruptive behaviors, regardless of group format (in-person vs. telehealth; (Agazzi et al., 2021 ; Armstrong, 2006). More rigorous waitlist control studies have shown improvements in parent-reported child disruptive behaviors and parent-reported knowledge of positive parenting practices in comparison to waitlist (Childres et al., 2011 ). Additionally, HOT DOCS has been effective when adapted for Spanish-speaking families and for families of children with autism (Agazzi et al., 2010 ; Childres et al., 2012 ). Considering the effectiveness and efficiency of group BPMTs such as HOT DOCS, clinicians must rely on best practices to inform implementation with regard to group size, opportunities to respond, and session length. Of particular interest to these authors is the impact of group factors on outcomes, namely cohort size. Tanner and colleagues interviewed members of attachment-based parenting intervention groups for caregivers with children under 18 months of age (Tanner et al., 2024 ). Although opinions between group members differed, the researchers concluded that groups of three participants were found to be less impactful when compared to groups of five to seven. In smaller groups, interpersonal differences interfered with the group process. Additionally, the groups engaged in more off-topic conversation due to having fewer members to support consistent on-topic conversation. This derailing interfered with treatment fidelity. Members of this program shared that groups of five to 10 would be a preferable cohort size to maximize group cohesion and helpful discussion. Generally, groups of six to 10 participants have been recommended by other authors as an ideal size for therapeutic groups, though this recommendation may vary from four to nine participants or eight to 12 participants (Ezhumalai et al., 2018 ; MacNair-Semands, 2021 ; McLaughlin et al., 2019 ; Waterman & Walker, 2009 ; Yalom & Crouch, 1990 ). Current research from adult group therapies suggests mixed results when considering group size and symptom reduction, with some studies demonstrating better outcomes with smaller groups and others suggesting better outcomes with larger groups (Dueweke et al., 2022 ). Altogether, the literature is surprisingly limited in its detailing of the best group size for optimal outcomes in group therapies as a whole; it is even more limited when considering this same factor in group BPMT. Purpose of the Current Study While many clinicians may rely on their personal and institutional preference to inform the number of individuals they enroll, there is little data to inform what is best practice when it pertains to sizing groups in BPMTs. The purpose of the current study was to determine whether group size affected self-reported parenting stress, parent-reported child disruptive behaviors, and overall satisfaction with the parent training program known as HOT DOCS. To our knowledge, this is the first quantitative study focused on BPMT and group size. We developed the following research questions: What HOT DOCS group size is associated with greatest improvements in the intensity of child problematic behavior from pre- to post-intervention? What HOT DOCS group size is associated with greatest improvements in parenting stress from pre- to post-intervention? What HOT DOCS group size is associated with greatest level of participant satisfaction in the program? Method Participants Participants were caregivers ( N = 631) who attended HOT DOCS sessions between 2019 and 2024. The program was implemented over six weeks using both in-person and virtual formats to meet the needs of diverse families. Eligible participants included caregivers (biological parents, foster or adoptive parents, grandparents, babysitters, etc.) with children ages birth to five years who attended at least four of the six sessions. Materials The HOT DOCS Demographic Form was used to collect information about the program participants at pre-intervention and is described in Table 1. Eyberg Child Behavior Inventory (ECBI) The ECBI (Eyberg & Pincus, 1999 ) is a 36-item measure for children ages 2 to 16 years designed to assess the intensity of disruptive behaviors using a 7-point Likert scale (1 = Never to 7 = Always). The ECBI scale has demonstrated reliability coefficients from .86 (test-retest) to .98 (internal consistency), indicating the inventory is stable and homogeneous. Inter-item correlations and factor analyses have suggested the ECBI measures a single construct and, thus, is an internally valid measure (Eyberg & Pincus, 1999 ). The child behavior intensity score on the ECBI ranges from 36 to 252 with a clinical cutoff score of 131 indicating more significant child behavior challenges than is typical. Child behavior intensity score was measured using the ECBI at pre- and post-intervention for all children ages 2 to 5 years. DOCS Parenting Stress Measure (DOCS PSM) The DOCS PSM is a 17-item Likert scale assessing parenting stress associated with daily living and adaptive skills, as well as social-communication skills. It was adapted from the Autism Parenting Stress Index (APSI; (Silva & Schalock, 2012 ) by modifying the wording of several items (e.g., changing your child’s diet to your child’s feeding difficulties ). Also, four items assessing the time, effort, and finances involved in parenting were added to the scale. Scores range from 0 to 68 and the DOCS PSM demonstrated excellent internal consistency (α = .90; (Agazzi et al., 2021 ). The APSI has good internal consistency and test-retest reliability (Silva & Schalock, 2012 ). The DOCS PSM was used to assess caregiver parenting stress at pre- and post-intervention for all participants. Therapy Attitude Inventory (TAI) The TAI (Eyberg, 1993) is a 10-item questionnaire designed to measure satisfaction with treatment as well as the impact of therapy on parenting skills and child behavior. Caregivers rate items on a scale from 1 (dissatisfaction with treatment, or a worsening of problems) to 5 (maximum satisfaction with treatment, or improvement of problems). External validity was demonstrated by moderate correlations (.36 to .49) between TAI scores (total and factor) and changes during treatment measured by pre- to posttreatment difference scores on the ECBI (Brestan et al., 1999 ) and on behavioral observations of compliance. Likewise, reliability of the measure using Cronbach's alpha was excellent (.91) and the internal consistency was acceptable (.85; (Brestan et al., 1999 ). The TAI was used to measure caregiver satisfaction with program participation at post-intervention. Procedure The study was approved by the Institutional Review Board at the authors’ institution and a written or electronic informed consent was collected for all participants. Participants completed the ECBI, DOCS PSM, and demographic form at pre-test. The TAI, ECBI, and DOCS PSM were administered the last week of intervention (post-test). Design The present study used quantitative, archival data collected via convenience sampling. Data were collected at pre- and post-intervention for each participant. Post intervention data were used to capture group differences in parent satisfaction with the course, as captured by the TAI. Data included repeated measures of child behavior intensity and parental stress, measured through the Intensity score on the ECBI and overall score on the DOCS PSM, respectively. Data Analysis Data were analyzed using SPSS version 30.0. All participants in the current sample attended at least four of the six HOT DOCS sessions. A variable was created to indicate the number of participants in their respective cohort. This variable was transformed into one of three categorical variables representing the participant's group size: smaller group (two to five participants), recommended group (six to 10 participants), or larger group (over 10 participants). Group sizes were developed based on theoretical recommendations for group size described above. Participants were also assigned a value for their change scores from pre- to post-test on repeated measures (ECBI Intensity and DOCS PSM). Listwise deletion for missing values was used during analyses by SPSS default. Means and standard deviations were calculated for each variable. Sample descriptives and frequencies were used to describe the sample’s demographic features. Chi square tests were run to determine any demographic differences between the three groups. Repeated measures ANOVAs were used to measure differences between groups in ECBI Intensity and DOCS PSM scores from pre- to post-intervention, as a function of participants’ group size. Post hoc pairwise comparisons were used to identify group differences on outcome scores. Independent samples ANOVA was used to compare post-test scores on the TAI between groups scores. Post hoc Bonferroni test for multiple comparisons was used to identify differences in TAI scores across groups. Results The sample’s demographic breakdown as a whole and by group category is illustrated in Table 1. Participants were primarily female (71.3%), biological parent caregivers (91%), of white race (74.2%) and non-Hispanic/Latino ethnicity (68.3%) with a mean age of 38.14 (SD = 7.57 ). Participants were predominantly caregivers in two-parent households (84.5%). Most of these caregivers’ children were not yet in school or pre-kindergarten (62.7%). Mean age of the child for whom caregivers were reporting was 3.69 years ( SD = 2.05). From the sample of 631 participants, 110 participants were in a cohort of the smaller size group, 239 participants were in a cohort of the recommended size, and 282 participants were in a cohort of the larger size. A total of 93, 205, and 239 children were included in the ECBI analysis from the smaller, recommended, and larger samples, respectively. This represents the number of children who were ages 2 years or older at pre- and post-intervention and therefore were eligible for their caregiver to complete the ECBI. Analyses were conducted for the total sample for parenting stress and group satisfaction. A chi square test demonstrated no significant differences between the groups based on their demographic makeup ( p > .05) beyond the participants’ relationship to the child ( p < .05); most participants reported being the biological caregiver of the rated child. The first repeated-measures ANOVA was used to determine the effect of the HOT DOCS intervention and group size on caregiver reported child ECBI Intensity scores. The analysis demonstrated a main effect of HOT DOCS on ECBI Intensity scores ( F (1,526) = 240.89, p < .001, η 2 = .314), such that scores decreased over time. There was no main effect of group size on ECBI Intensity scores ( F (2,526) = 1.98, p = .14, η 2 = .01). There was no significant interaction between the HOT DOCS intervention and group size on ECBI Intensity from pre- to post-intervention ( F (1,571) = 80.3, p < .001, η 2 = .12). The next repeated-measures ANOVA identified the effect of HOT DOCS intervention and group size on caregiver DOCS PSM stress scores. The analysis showed a main effect of HOT DOCS on DOCS PSM ( F (1,571) = 80.3, p = < .001, η 2 = .123), such that scores decreased over time. There was no main effect of group size on DOCS PSM scores ( F (2,571) = .61, p = .55, η 2 = .01). There was no significant interaction between HOT DOCS and group size on ECBI Intensity scores ( F (2,526) = .54, p = .57, η 2 = .01) or between HOT DOCS and group size on DOCS PSM scores ( F (2,571) = .03, p = .97, η 2 = .00). Table 2 includes the breakdown of outcomes of interest by group membership. Following Bonferroni’s adjustment for multiple comparisons, mean change in ECBI Intensity scores from pre- to post-intervention was − 19.99 ( p < .001, η 2 = .31). Average pre-test ECBI scores were 139, 132, and 132 for smaller, recommended, and larger group sizes respectively. These scores are above the clinical cutoff of 131 for disruptive behaviors, meaning all groups reported more challenging behavior than is typical for children at pre-test. Average post-test scores were below the clinical cutoff of 131 with smaller, recommended, and larger group sizes reporting 118, 113, and 112, respectively. Mean change in parenting stress scores from pre- to post-intervention was − 3.69 ( p < .001, η 2 = .12). Levene’s test demonstrated homogeneity of variances between group sizes on mean intervention satisfaction ( p < .05). Independent samples ANOVA confirmed differences in TAI scores between the three groups ( F (2,583) = 4.66, p < .01, η 2 = .02). Post Hoc, Bonferroni tests confirmed significant differences in TAI scores between the smaller group and the recommended size group (mean difference = 1.82, p < .01) and the smaller group and the larger group (mean difference = 1.56, p = .03), with the smaller group reporting higher satisfaction than other groups. No difference was found when comparing TAI scores between the larger and the recommended group ( p > .05). Discussion Challenging behaviors early in life are common and can play a role in a child’s social, academic, and psychological development if left unaddressed (Duncan et al., 2013 ; Kouros et al., 2010 ; Sayal et al., 2015 ). Challenging behaviors are particularly impactful to the parent-child relationship, where challenging behaviors increase parenting stress, thereby increasing coercive parenting practices and further exacerbating existing concerns (Blacher & Baker, 2019 ). Best practice recommendations for treating challenging behaviors include individual and group BPMT, and HOT DOCS is one such effective group BPMT (Agazzi et al., 2020 ; Childres et al., 2011 ). Despite group BPMT being an effective intervention avenue, very little is known about the effect of group size on participant outcomes. Some studies from adult group therapy literature suggest mixed results when considering group size on outcomes, and no quantitative studies to the current researchers’ knowledge explore the effect of group size on parent training outcomes. The purpose of this study was to determine whether parenting stress, child behavior, and participant satisfaction with HOT DOCS differed between groups of three sizes. While groups of six to 10 participants are theoretically recommended for ideal group size, results suggested no significant differences across smaller, recommended, and larger group sizes for parenting stress and child disruptive behaviors. However, post hoc Bonferoni tests showed that satisfaction with the HOT DOCS program was significantly better in smaller groups compared to recommended and larger size groups. Overall effect sizes suggested a medium effect for parenting stress and a large effect for child disruptive behavior. Notably, average score changes on the ECBI from pre- to post-intervention suggested clinical improvements, meaning that participants in HOT DOCS were no longer rating challenging behaviors above and beyond what is typically expected by the end of the group. These results have significant implications for intervention planning and implementation. While we categorized group size for this study using theoretical recommendations (Waterman & Walker, 2009 ), results suggested that consistent improvements in parenting stress and child disruptive behaviors can be achieved regardless of group size. This is of particular interest when planning and facilitating large groups, as bigger cohorts allow for more families to access services, which may reduce time spent waiting for intervention and offset the burden of waitlists for individualized interventions like Parent-Child Interaction Therapy. Further, the group intervention format may offer more opportunities for participants to receive validation in their experience and access support from others with similar concerns (Douma et al., 2020 ). In a study of HOT DOCS adapted for Australian caregivers, participants reported clinically significant improvements in parenting self-efficacy after the group intervention (groups of 6–10 participants) and these effects were maintained through a 2-month follow up (Dunlop et al., 2021 ). While group size did not significantly affect parenting stress or child behavior changes, smaller group size demonstrated significantly greater satisfaction with the intervention. However, differences in the average score between groups was less than two points, possibly suggesting a less meaningful clinical change. Nevertheless, this finding may be reflective of the increased individualized attention a family receives in a smaller group compared to a larger group. Thus, when planning group size, factors such as the caregiver’s expectation for individualized attention and support from the facilitator may be considered. This could be accomplished using a simple needs assessment before group assignment. These findings should not discourage clinicians from running recommended or larger size groups. There were some notable strengths regarding the demographic makeup of this sample. In particular, the sample was either representative or over-representative of the local population. The study population closely matched county US Census Bureau area demographics for individuals from Hispanic/Latino (27.3% current study compared to 30.4% county population), American Indian and Alaska Native (0.3% current study compared to 0.6% county population), Asian (4.8% current study compared to 4.9% county population), and two or more race (5.9% current study compared to 3.2% county population) backgrounds. In addition, males (fathers, grandfathers, etc.) represented 28.4% of the study sample, which is considerably better than other studies, which have included fewer than 10% male caregivers (Weeland, 2017). Further, males are represented between 19% and 32% in HOT DOCS research (Agazzi et al., 2021 ; Childres et al., 2011 ; Dunlop et al., 2021 ; Ogg et al., 2014 ). Limitations and Directions for Future Research There are some limitations pertinent to this study. Data were derived from a non-random sample. Future research would be enhanced by a trial wherein participants are randomly assigned group size. Data also were collected using parent self-report, which increases risk of social desirability and expectancy bias. Future researchers may consider other objective measurements of parenting stress and child disruptive behavior such as cortisol levels and direct observation, respectively. Future researchers also may consider a regression analysis to identify whether there is a point of diminishing returns regarding group size. Data were collected over a period of six years, and in that time, significant modifications to program delivery were forced with the COVID-19 pandemic. The present sample included various groups that occurred both in person and virtually. The extent to which in-person compared to virtual group size was not investigated; however, prior HOT DOCS research indicated no significant differences in outcomes between in-person and virtual parent training groups (Agazzi et al., 2021 ). Further research is warranted to determine whether group size and group format impact parenting stress, child behavior, and satisfaction outcomes. Conclusion Little is known about the extent to which group size affects parenting stress, child behavior, and satisfaction outcomes among participants in group formatted BPMTs. To the best of our knowledge, this is the first empirical study exploring the impact of group size on parent training outcomes. Results from the current study suggest that group size does not significantly affect the positive impact of group BPMT on parenting stress or child behavior outcomes. However, group size does significantly affect intervention satisfaction such that smaller group size is associated with better satisfaction. Still, these differences in reported satisfaction are marginal and not clinically meaningful enough to warrant change to the current practices in BPMT group size. Ultimately, these results suggest that larger group sizes should not be a deterrent when planning BPMT groups, and given the dearth of accessible behavioral health services, larger groups sizes may increase access to care. Declarations Author Contribution HC wrote introductory and results section, and further edited the paper as a whole. HC additionally built the dataset and completed the analyses. SD wrote introductory and discussion sections, and further edited the paper as a whole. DT wrote the method section and edits the paper.TT wrote the abstract.HA wrote the discussion and conclusion sections, and further edited the paper as a whole. HA is the senior author on this paper. 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Indian J Psychiatry , 60 (Suppl 4), S514–s521. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_42_18 Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S. M., & Donnelly, M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database Systematic Review , (2), CD008225. https://doi.org/10.1002/14651858.CD008225.pub2 Gopalan, G., Dean-Assael, K., Klingenstein, K., Chacko, A., & McKay, M. M. (2010). Caregiver depression and youth disruptive behavior difficulties. Social Work in Mental Health , 9 (1), 56–70. Hong, J. S., Tillman, R., & Luby, J. L. (2015). Disruptive behavior in preschool children: Distinguishing normal misbehavior from markers of current and later childhood conduct disorder. The journal of pediatrics , 166 (3), 723–730. Jones, H. A., Putt, G. E., Rabinovitch, A. E., Hubbard, R., & Snipes, D. (2017). Parenting stress, readiness to change, and child externalizing behaviors in families of clinically referred children. Journal of Child and Family Studies , 26 , 225–233. Kazdin, A. E. (1997). Parent management training: Evidence, outcomes, and issues. Journal of the American Academy of Child & Adolescent Psychiatry , 36 (10), 1349–1356. Kouros, C. D., Cummings, E. M., & Davies, P. T. (2010). Early trajectories of interparental conflict and externalizing problems as predictors of social competence in preadolescence. Development and Psychopathology , 22 (3), 527–537. Leijten, P., Gardner, F., Melendez-Torres, G., Van Aar, J., Hutchings, J., Schulz, S., Knerr, W., & Overbeek, G. (2019). Meta-analyses: Key parenting program components for disruptive child behavior. Journal of the American Academy of Child & Adolescent Psychiatry , 58 (2), 180–190. Long, P., Forehand, R., Wierson, M., & Morgan, A. (1994). Does parent training with young noncompliant children have long-term effects? Behaviour Research and Therapy , 32 (1), 101–107. Mackler, J. S., Kelleher, R. T., Shanahan, L., Calkins, S. D., Keane, S. P., & O'Brien, M. (2015). Parenting stress, parental reactions, and externalizing behavior from ages 4 to 10. Journal of Marriage and Family , 77 (2), 388–406. MacNair-Semands, R. (2021). The Theory and Practice of Group Psychotherapy: by Irvin D. Yalom and Molyn Leszcz. New York, NY: Basic Books, 2020. 818 pp. In: Taylor & Francis. McLaughlin, S. P., Barkowski, S., Burlingame, G. M., Strauss, B., & Rosendahl, J. (2019). Group psychotherapy for borderline personality disorder: A meta-analysis of randomized-controlled trials. Psychotherapy , 56 (2), 260. Neece, C. L., Green, S. A., & Baker, B. L. (2012). Parenting stress and child behavior problems: A transactional relationship across time. Am J Intellect Dev Disabil , 117 (1), 48–66. https://doi.org/10.1352/1944-7558-117.1.48 Niec, L. N., Barnett, M. L., Prewett, M. S., & Shanley Chatham, J. R. (2016). Group parent–child interaction therapy: A randomized control trial for the treatment of conduct problems in young children. Journal of Consulting and Clinical Psychology , 84 (8), 682. Niec, L. N., Hemme, J. M., Yopp, J. M., & Brestan, E. V. (2005). Parent-child interaction therapy: The rewards and challenges of a group format. Cognitive and Behavioral Practice , 12 (1), 113–125. Ogg, J., Shaffer-Hudkins, E., Childres, J., Feldman, M., Agazzi, H., & Armstrong, K. (2014). Attendance and Implementation of Strategies in a Behavioral Parent-Training Program: Comparisons between English and Espanol Programs. Infant Mental Health Journal , 35 (6), 555–564. https://doi.org/10.1002/imhj.21470 Roskam, I., Brassart, E., Loop, L., Mouton, B., & Schelstraete, M. (2015). Stimulating parents' self-efficacy beliefs or verbal responsiveness: Which is the best way to decrease children's externalizing behaviors? Behaviour Research and Therapy , 72 , 38–48. Sanders, M. (1999). Triple P-positive parenting program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child and Family Psychology Review , 2 , 71. Sandler, I. N., Schoenfelder, E. N., Wolchik, S. A., & MacKinnon, D. P. (2011). Long-term impact of prevention programs to promote effective parenting: Lasting effects but uncertain processes. Annual Review of Psychology , 62 , 299–329. https://doi.org/10.1146/annurev.psych.121208.131619 Sayal, K., Washbrook, E., & Propper, C. (2015). Childhood behavior problems and academic outcomes in adolescence: Longitudinal population-based study. Journal of the American Academy of Child & Adolescent Psychiatry , 54 (5), 360–368. Shaffer, A., Kotchick, B. A., Dorsey, S., & Forehand, R. (2001). The past, present, and future of behavioral parent training: Interventions for child and adolescent problem behavior. The Behavior Analyst Today , 2 (2), 91. Silva, L. M., & Schalock, M. (2012). Autism parenting stress index: Initial psychometric evidence. Journal of Autism and Developmental Disorders , 42 (4), 566–574. https://doi.org/10.1007/s10803-011-1274-1 Tanner, J., Wilson, P., Wight, D., & Thompson, L. (2024). The importance of group factors in the delivery of group-based parenting programmes: A process evaluation of Mellow Babies. Frontiers in Child and Adolescent Psychiatry , 3 , 1–13. Waterman, J., & Walker, E. (2009). Helping at-risk students: A group counseling approach for grades 6–9 . Guilford Press. Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: Intervention outcomes for parent, child, and teacher training. Journal of Clinical Child & Adolescent Psychology , 33 (1), 105–124. Weeland, J., Chhangur, R., van der Giessen, D., Matthys, W., Orobio de Castro, B., & Overbeek, G. (2017). Intervention Effectiveness of The Incredible Years: New Insights Into Sociodemographic and Intervention-Based Moderators. Behavior Therapy , 48 (1), 1–18. https://doi.org/https://doi.org/10.1016/j.beth.2016.08.002 Yalom, I. D., & Crouch, E. (1990). The theory and practice of group psychotherapy. The British Journal of Psychiatry , 157 (2), 304–306. Tables Table 1. Participant characteristics by size of group attended. smaller group, n (%) recommended group, n (%) larger group, n (%) p -value Total, N (%) Sex 0.51 Female 79 (71.8) 175 (73.2) 196 (69.5) 450 (71.3) Male 30 (27.3) 63 (26.4) 86 (30.5) 179 (28.4) Refused 1 (.9) 1 (.4) 0 (0) 2 (.3) Relationship to Child 0.01 Biological Parent 91 (82.7) 226 (94.6) 257 (91.2) 574 (91) Grandparent 7 (6.4) 6 (2.5) 8 (2.8) 21 (3.3) Adoptive Parent 5 (4.5) 1 (.4) 10 (3.5) 18 (2.9) Other 2 (1.8) 4 (1.7) 4 (1.5) 10 (1.6) Foster Parent 4 (3.6) 0 (0) 3 (1.1) 7 (1.1) Race 0.17 White 75 (68.2) 176 (73.6) 217 (77) 468 (74.2) Two or more races 11 (1) 10 (4.2) 16 (5.7) 37 (12.9) Refused 9 (8.2) 15 (6.3) 16 (5.7) 40 (6.3) Black or African American 7 (6.4) 13 (5.4) 17 (6) 37 (5.9) Asian 5 (4.5) 16 (6.7) 9 (3.2) 30 (4.8) Not available 1 (.9) 7 (2.9) 5 (1.8) 13 (2.1) American Indian or Alaska Native 1 (.9) 1 (.4) 0 (0) 2 (.3) Native Hawaiian or other Pacific Islander 1 (.9) 1 (.4) 2 (.7) 4 (.6) Ethnicity 0.09 Non-Hispanic/Latino 65 (59.1) 168 (70.3) 198 (70.2) 431 (68.3) Hispanic/Latino 40 (36.4) 57 (23.8) 75 (26.6) 172 (27.3) Refused 4 (3.6) 14 (5.9) 9 (3.2) 27 (4.3) Not Available 1 (.9) 0 (0) 0 (0) 1 (.2) Table 2. Intervention Outcomes by Group Size Sample Smaller Recommended Larger Mean ( SD) Mean (SD) Mean (SD) Pre-Intervention Stress N = 574 22.54 (12.83) 21.22 (10.72) 21.97 (12.36) Post-Intervention Stress N = 574 18.89 (11.12) 17.61 (10.31) 18.16 (10.36) Pre-Intervention Intensity of Behavior n = 529 139.46 (34.82) 131.52 (31.75) 131.98 (32.41) Post-Intervention Intensity of Behavior n = 529 118.01 (32.33) 113.33 (32.93) 111.66 (30.83) Post-Intervention Therapy Attitude N = 584 44.48 (4.79) 42.66 (5.21) 42.91 (5.22) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6882775","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":538490578,"identity":"399a0137-e40b-4eac-96b3-f0e58587c83a","order_by":0,"name":"Hannah Cooper","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Cooper","suffix":""},{"id":538490579,"identity":"ae4f7960-4cee-475a-9231-f5028d78c0cd","order_by":1,"name":"Sarah Dickinson","email":"","orcid":"","institution":"University of South 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16:18:50","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158696,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6882775/v1/c46bf366a4ad0f79c3d1d0f7.html"},{"id":95229847,"identity":"c305f4d2-25d5-41bb-9217-3945fb2bb2e9","added_by":"auto","created_at":"2025-11-05 16:36:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":677835,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6882775/v1/6390ac53-defb-4dec-9ad5-c9d6e0701525.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does Size Matter? Determining Differences in Family Outcomes Based on Cohort Size of HOT DOCS Parent Behavior Management Groups","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003eHOTDOCS is an effective intervention at reducing parenting stress and disruptive behaviors in children\u003c/li\u003e\n \u003cli\u003eThe size of the parenting group cohort does not impact the benefit of the intervention on parenting stress or disruptive behavior\u003c/li\u003e\n \u003cli\u003eCaregiver attitudes toward the intervention were slightly more positive from those in smaller groups; this effect was small and lacks clinical meaningfulness\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eClinicians should not be deterred from delivering group parent management interventions to larger cohort sizes\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"Introduction","content":"\u003cp\u003eDisruptive behavior in childhood is a common parenting challenge and a frequent concern that caregivers discuss with their children’s medical providers (Duncan et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). In fact, disruptive behavior is developmentally appropriate for young children as they learn to navigate their world. Subclinical patterns of disruptive behavior are common, with caregivers of one in six children reporting developmental or behavioral challenges (Canino et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Cree et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Egger \u0026amp; Angold, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). However, the intensity and frequency of symptoms are what differentiates normative disruptive behaviors from those that are of clinical concern (American Psychiatric Association, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Egger \u0026amp; Angold, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), childhood disruptive behavior is transdiagnostic and presents in a variety of ways including oppositionality, aggression, irritability, vindictiveness, and argumentativeness (American Psychiatric Association, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hong et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe DSM-5-TR offers several ways of categorizing distinct presentations of disruptive behaviors of clinical concern, including Oppositional Defiant Disorder, Intermittent Explosive Disorder, and Conduct Disorder (American Psychiatric Association, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), each with a prevalence rate of 3.3%, 4%, and 4%, respectively (Canino et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Coccaro \u0026amp; McCloskey, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Costello et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Studies have demonstrated that clinically significant disruptive behavior in young children is linked to poor academic achievement (Brennan et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Sayal et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and social development (Kouros et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), as well as internalizing disorders such as depression and anxiety (Boylan et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Childhood disruptive behavior is also related to adverse consequences in caregivers, including depression, marital challenges, and high levels of stress (Blacher \u0026amp; Baker, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Calzada et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Gopalan et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Jones et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The impact of disruptive behaviors in youth is cyclical: child disruptive behaviors are linked to parenting stress, and parenting stress is related to increased negative parenting practices and greater behavioral problems in children (Mackler et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Neece et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Interrupting this problematic cycle is pivotal for healthy family functioning.\u003c/p\u003e\u003cp\u003eEarly prevention and intervention strategies aimed at refining parenting practices are highly effective at improving behavior in youth and creating long term, positive adjustment into adulthood (Kazdin, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Long et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Sandler et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). These practices are known generally as behavioral parent management training (BPMT) and include teaching caregivers techniques such as positive reinforcement and logical consequences to either encourage favorable behaviors or extinguish inappropriate ones (Leijten et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). BPMT interventions have been shown to increase a caregiver’s ability to confidently and effectively manage their child’s disruptive behaviors (Roskam et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Not only do BPMT interventions positively impact child behavior, they also effectively reduce parenting stress and strengthen the parent-child relationship (Kazdin, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e1997\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere are numerous curricula for parenting interventions such as the Positive Parenting Program (Sanders, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e1999\u003c/span\u003e), the Incredible Years (Webster-Stratton et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), and Parent-Child Interaction Therapy (Eyberg \u0026amp; Funderburk, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Intervention formats vary; a common delivery method is one-on-one (i.e., provider to single family). However, when considering the high level of need in the population, clinicians must question whether providing care on a single-family basis is the most effective intervention for problematic behavior of childhood.\u003c/p\u003e\u003cp\u003eAn alternate form of service delivery is group BPMT. Not only are group BPMTs highly effective at reducing behavioral challenges in children (Agazzi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Barlow et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Chacko et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), but they also decrease depression, anxiety, and stress in caregivers (Furlong et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Group BPMT is a particularly appealing option for many families due to accessibility. Individual BPMTs can be costly and time-intensive, lasting 12 or more sessions (Shaffer et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Group BPMTs can increase accessibility by serving multiple families at one time at regular increments throughout the year. Thus, in the time it takes to serve one family in individual treatment, up to 15 families can be served in a group format, which increases access to care. Group BMPT has further benefits in terms of peer support, vicarious learning opportunities, and reduced stigma, making groups an attractive option for many families (Niec et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Niec et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne accessible and short-term group BPMT, and the intervention used in the present study, is Helping Our Toddlers, Developing Our Children’s Skills (HOT DOCS; (Agazzi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The HOT DOCS program is a six-week intervention for caregivers of children ages birth to five years. Each session ranges from 1.5 to two hours and includes opportunities for individualized problem-solving. Group size ranges from two to 17 individuals. Prior research with HOT DOCS has shown significant pre- to post-intervention improvements in parenting stress and parent-reported child disruptive behaviors, regardless of group format (in-person vs. telehealth; (Agazzi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Armstrong, 2006). More rigorous waitlist control studies have shown improvements in parent-reported child disruptive behaviors and parent-reported knowledge of positive parenting practices in comparison to waitlist (Childres et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Additionally, HOT DOCS has been effective when adapted for Spanish-speaking families and for families of children with autism (Agazzi et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Childres et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConsidering the effectiveness and efficiency of group BPMTs such as HOT DOCS, clinicians must rely on best practices to inform implementation with regard to group size, opportunities to respond, and session length. Of particular interest to these authors is the impact of group factors on outcomes, namely cohort size. Tanner and colleagues interviewed members of attachment-based parenting intervention groups for caregivers with children under 18 months of age (Tanner et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Although opinions between group members differed, the researchers concluded that groups of three participants were found to be less impactful when compared to groups of five to seven. In smaller groups, interpersonal differences interfered with the group process. Additionally, the groups engaged in more off-topic conversation due to having fewer members to support consistent on-topic conversation. This derailing interfered with treatment fidelity. Members of this program shared that groups of five to 10 would be a preferable cohort size to maximize group cohesion and helpful discussion. Generally, groups of six to 10 participants have been recommended by other authors as an ideal size for therapeutic groups, though this recommendation may vary from four to nine participants or eight to 12 participants (Ezhumalai et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; MacNair-Semands, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; McLaughlin et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Waterman \u0026amp; Walker, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Yalom \u0026amp; Crouch, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). Current research from adult group therapies suggests mixed results when considering group size and symptom reduction, with some studies demonstrating better outcomes with smaller groups and others suggesting better outcomes with larger groups (Dueweke et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Altogether, the literature is surprisingly limited in its detailing of the best group size for optimal outcomes in group therapies as a whole; it is even more limited when considering this same factor in group BPMT.\u003c/p\u003e\n\u003ch3\u003ePurpose of the Current Study\u003c/h3\u003e\n\u003cp\u003eWhile many clinicians may rely on their personal and institutional preference to inform the number of individuals they enroll, there is little data to inform what is best practice when it pertains to sizing groups in BPMTs. The purpose of the current study was to determine whether group size affected self-reported parenting stress, parent-reported child disruptive behaviors, and overall satisfaction with the parent training program known as HOT DOCS. To our knowledge, this is the first quantitative study focused on BPMT and group size. We developed the following research questions:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat HOT DOCS group size is associated with greatest improvements in the intensity of child problematic behavior from pre- to post-intervention?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat HOT DOCS group size is associated with greatest improvements in parenting stress from pre- to post-intervention?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e What HOT DOCS group size is associated with greatest level of participant satisfaction in the program?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Method","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eParticipants were caregivers (\u003cem\u003eN\u003c/em\u003e = 631) who attended HOT DOCS sessions between 2019 and 2024. The program was implemented over six weeks using both in-person and virtual formats to meet the needs of diverse families. Eligible participants included caregivers (biological parents, foster or adoptive parents, grandparents, babysitters, etc.) with children ages birth to five years who attended at least four of the six sessions.\u003c/p\u003e\n\u003ch3\u003eMaterials\u003c/h3\u003e\n\u003cp\u003eThe HOT DOCS Demographic Form was used to collect information about the program participants at pre-intervention and is described in Table\u0026nbsp;1.\u003c/p\u003e\n\u003ch3\u003eEyberg Child Behavior Inventory (ECBI)\u003c/h3\u003e\n\u003cp\u003eThe ECBI (Eyberg \u0026amp; Pincus, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) is a 36-item measure for children ages 2 to 16 years designed to assess the intensity of disruptive behaviors using a 7-point Likert scale (1\u0026thinsp;=\u0026thinsp;Never to 7\u0026thinsp;=\u0026thinsp;Always). The ECBI scale has demonstrated reliability coefficients from .86 (test-retest) to .98 (internal consistency), indicating the inventory is stable and homogeneous. Inter-item correlations and factor analyses have suggested the ECBI measures a single construct and, thus, is an internally valid measure (Eyberg \u0026amp; Pincus, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). The child behavior intensity score on the ECBI ranges from 36 to 252 with a clinical cutoff score of 131 indicating more significant child behavior challenges than is typical. Child behavior intensity score was measured using the ECBI at pre- and post-intervention for all children ages 2 to 5 years.\u003c/p\u003e\n\u003ch3\u003eDOCS Parenting Stress Measure (DOCS PSM)\u003c/h3\u003e\n\u003cp\u003eThe DOCS PSM is a 17-item Likert scale assessing parenting stress associated with daily living and adaptive skills, as well as social-communication skills. It was adapted from the Autism Parenting Stress Index (APSI; (Silva \u0026amp; Schalock, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) by modifying the wording of several items (e.g., changing \u003cem\u003eyour child\u0026rsquo;s diet\u003c/em\u003e to \u003cem\u003eyour child\u0026rsquo;s feeding difficulties\u003c/em\u003e). Also, four items assessing the time, effort, and finances involved in parenting were added to the scale. Scores range from 0 to 68 and the DOCS PSM demonstrated excellent internal consistency (α\u0026thinsp;=\u0026thinsp;.90; (Agazzi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The APSI has good internal consistency and test-retest reliability (Silva \u0026amp; Schalock, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The DOCS PSM was used to assess caregiver parenting stress at pre- and post-intervention for all participants.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTherapy Attitude Inventory (TAI)\u003c/h2\u003e\u003cp\u003eThe TAI (Eyberg, 1993) is a 10-item questionnaire designed to measure satisfaction with treatment as well as the impact of therapy on parenting skills and child behavior. Caregivers rate items on a scale from 1 (dissatisfaction with treatment, or a worsening of problems) to 5 (maximum satisfaction with treatment, or improvement of problems). External validity was demonstrated by moderate correlations (.36 to .49) between TAI scores (total and factor) and changes during treatment measured by pre- to posttreatment difference scores on the ECBI (Brestan et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) and on behavioral observations of compliance. Likewise, reliability of the measure using Cronbach's alpha was excellent (.91) and the internal consistency was acceptable (.85; (Brestan et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). The TAI was used to measure caregiver satisfaction with program participation at post-intervention.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board at the authors\u0026rsquo; institution and a written or electronic informed consent was collected for all participants. Participants completed the ECBI, DOCS PSM, and demographic form at pre-test. The TAI, ECBI, and DOCS PSM were administered the last week of intervention (post-test).\u003c/p\u003e\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eThe present study used quantitative, archival data collected via convenience sampling. Data were collected at pre- and post-intervention for each participant. Post intervention data were used to capture group differences in parent satisfaction with the course, as captured by the TAI. Data included repeated measures of child behavior intensity and parental stress, measured through the Intensity score on the ECBI and overall score on the DOCS PSM, respectively.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS version 30.0. All participants in the current sample attended at least four of the six HOT DOCS sessions. A variable was created to indicate the number of participants in their respective cohort. This variable was transformed into one of three categorical variables representing the participant's group size: smaller group (two to five participants), recommended group (six to 10 participants), or larger group (over 10 participants). Group sizes were developed based on theoretical recommendations for group size described above. Participants were also assigned a value for their change scores from pre- to post-test on repeated measures (ECBI Intensity and DOCS PSM).\u003c/p\u003e\u003cp\u003eListwise deletion for missing values was used during analyses by SPSS default. Means and standard deviations were calculated for each variable. Sample descriptives and frequencies were used to describe the sample\u0026rsquo;s demographic features. Chi square tests were run to determine any demographic differences between the three groups. Repeated measures ANOVAs were used to measure differences between groups in ECBI Intensity and DOCS PSM scores from pre- to post-intervention, as a function of participants\u0026rsquo; group size. Post hoc pairwise comparisons were used to identify group differences on outcome scores. Independent samples ANOVA was used to compare post-test scores on the TAI between groups scores. Post hoc Bonferroni test for multiple comparisons was used to identify differences in TAI scores across groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe sample\u0026rsquo;s demographic breakdown as a whole and by group category is illustrated in Table\u0026nbsp;1. Participants were primarily female (71.3%), biological parent caregivers (91%), of white race (74.2%) and non-Hispanic/Latino ethnicity (68.3%) with a mean age of 38.14 \u003cem\u003e(SD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.57\u003cem\u003e).\u003c/em\u003e Participants were predominantly caregivers in two-parent households (84.5%). Most of these caregivers\u0026rsquo; children were not yet in school or pre-kindergarten (62.7%). Mean age of the child for whom caregivers were reporting was 3.69 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.05).\u003c/p\u003e\u003cp\u003eFrom the sample of 631 participants, 110 participants were in a cohort of the smaller size group, 239 participants were in a cohort of the recommended size, and 282 participants were in a cohort of the larger size. A total of 93, 205, and 239 children were included in the ECBI analysis from the smaller, recommended, and larger samples, respectively. This represents the number of children who were ages 2 years or older at pre- and post-intervention and therefore were eligible for their caregiver to complete the ECBI. Analyses were conducted for the total sample for parenting stress and group satisfaction. A chi square test demonstrated no significant differences between the groups based on their demographic makeup (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05) beyond the participants\u0026rsquo; relationship to the child (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05); most participants reported being the biological caregiver of the rated child.\u003c/p\u003e\u003cp\u003e The first repeated-measures ANOVA was used to determine the effect of the HOT DOCS intervention and group size on caregiver reported child ECBI Intensity scores. The analysis demonstrated a main effect of HOT DOCS on ECBI Intensity scores (\u003cem\u003eF\u003c/em\u003e(1,526)\u0026thinsp;=\u0026thinsp;240.89, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.314), such that scores decreased over time. There was no main effect of group size on ECBI Intensity scores (\u003cem\u003eF\u003c/em\u003e(2,526)\u0026thinsp;=\u0026thinsp;1.98, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.14, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.01). There was no significant interaction between the HOT DOCS intervention and group size on ECBI Intensity from pre- to post-intervention (\u003cem\u003eF\u003c/em\u003e(1,571)\u0026thinsp;=\u0026thinsp;80.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.12).\u003c/p\u003e\u003cp\u003eThe next repeated-measures ANOVA identified the effect of HOT DOCS intervention and group size on caregiver DOCS PSM stress scores. The analysis showed a main effect of HOT DOCS on DOCS PSM (\u003cem\u003eF\u003c/em\u003e(1,571)\u0026thinsp;=\u0026thinsp;80.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.123), such that scores decreased over time. There was no main effect of group size on DOCS PSM scores (\u003cem\u003eF\u003c/em\u003e(2,571)\u0026thinsp;=\u0026thinsp;.61, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.55, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.01). There was no significant interaction between HOT DOCS and group size on ECBI Intensity scores (\u003cem\u003eF\u003c/em\u003e(2,526)\u0026thinsp;=\u0026thinsp;.54, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.57, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.01) or between HOT DOCS and group size on DOCS PSM scores (\u003cem\u003eF\u003c/em\u003e(2,571)\u0026thinsp;=\u0026thinsp;.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.97, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.00).\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;2 includes the breakdown of outcomes of interest by group membership. Following Bonferroni\u0026rsquo;s adjustment for multiple comparisons, mean change in ECBI Intensity scores from pre- to post-intervention was \u0026minus;\u0026thinsp;19.99 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.31). Average pre-test ECBI scores were 139, 132, and 132 for smaller, recommended, and larger group sizes respectively. These scores are above the clinical cutoff of 131 for disruptive behaviors, meaning all groups reported more challenging behavior than is typical for children at pre-test. Average post-test scores were below the clinical cutoff of 131 with smaller, recommended, and larger group sizes reporting 118, 113, and 112, respectively. Mean change in parenting stress scores from pre- to post-intervention was \u0026minus;\u0026thinsp;3.69 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.12).\u003c/p\u003e\u003cp\u003eLevene\u0026rsquo;s test demonstrated homogeneity of variances between group sizes on mean intervention satisfaction (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). Independent samples ANOVA confirmed differences in TAI scores between the three groups (\u003cem\u003eF\u003c/em\u003e(2,583)\u0026thinsp;=\u0026thinsp;4.66, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.01, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.02). Post Hoc, Bonferroni tests confirmed significant differences in TAI scores between the smaller group and the recommended size group (mean difference\u0026thinsp;=\u0026thinsp;1.82, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.01) and the smaller group and the larger group (mean difference\u0026thinsp;=\u0026thinsp;1.56, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.03), with the smaller group reporting higher satisfaction than other groups. No difference was found when comparing TAI scores between the larger and the recommended group (\u003cem\u003ep\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChallenging behaviors early in life are common and can play a role in a child\u0026rsquo;s social, academic, and psychological development if left unaddressed (Duncan et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Kouros et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Sayal et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Challenging behaviors are particularly impactful to the parent-child relationship, where challenging behaviors increase parenting stress, thereby increasing coercive parenting practices and further exacerbating existing concerns (Blacher \u0026amp; Baker, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Best practice recommendations for treating challenging behaviors include individual and group BPMT, and HOT DOCS is one such effective group BPMT (Agazzi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Childres et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Despite group BPMT being an effective intervention avenue, very little is known about the effect of group size on participant outcomes. Some studies from adult group therapy literature suggest mixed results when considering group size on outcomes, and no quantitative studies to the current researchers\u0026rsquo; knowledge explore the effect of group size on parent training outcomes.\u003c/p\u003e\u003cp\u003eThe purpose of this study was to determine whether parenting stress, child behavior, and participant satisfaction with HOT DOCS differed between groups of three sizes. While groups of six to 10 participants are theoretically recommended for ideal group size, results suggested no significant differences across smaller, recommended, and larger group sizes for parenting stress and child disruptive behaviors. However, post hoc Bonferoni tests showed that satisfaction with the HOT DOCS program was significantly better in smaller groups compared to recommended and larger size groups. Overall effect sizes suggested a medium effect for parenting stress and a large effect for child disruptive behavior. Notably, average score changes on the ECBI from pre- to post-intervention suggested clinical improvements, meaning that participants in HOT DOCS were no longer rating challenging behaviors above and beyond what is typically expected by the end of the group.\u003c/p\u003e\u003cp\u003eThese results have significant implications for intervention planning and implementation. While we categorized group size for this study using theoretical recommendations (Waterman \u0026amp; Walker, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), results suggested that consistent improvements in parenting stress and child disruptive behaviors can be achieved regardless of group size. This is of particular interest when planning and facilitating large groups, as bigger cohorts allow for more families to access services, which may reduce time spent waiting for intervention and offset the burden of waitlists for individualized interventions like Parent-Child Interaction Therapy. Further, the group intervention format may offer more opportunities for participants to receive validation in their experience and access support from others with similar concerns (Douma et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In a study of HOT DOCS adapted for Australian caregivers, participants reported clinically significant improvements in parenting self-efficacy after the group intervention (groups of 6\u0026ndash;10 participants) and these effects were maintained through a 2-month follow up (Dunlop et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile group size did not significantly affect parenting stress or child behavior changes, smaller group size demonstrated significantly greater satisfaction with the intervention. However, differences in the average score between groups was less than two points, possibly suggesting a less meaningful clinical change. Nevertheless, this finding may be reflective of the increased individualized attention a family receives in a smaller group compared to a larger group. Thus, when planning group size, factors such as the caregiver\u0026rsquo;s expectation for individualized attention and support from the facilitator may be considered. This could be accomplished using a simple needs assessment before group assignment. These findings should not discourage clinicians from running recommended or larger size groups.\u003c/p\u003e\u003cp\u003eThere were some notable strengths regarding the demographic makeup of this sample. In particular, the sample was either representative or over-representative of the local population. The study population closely matched county US Census Bureau area demographics for individuals from Hispanic/Latino (27.3% current study compared to 30.4% county population), American Indian and Alaska Native (0.3% current study compared to 0.6% county population), Asian (4.8% current study compared to 4.9% county population), and two or more race (5.9% current study compared to 3.2% county population) backgrounds. In addition, males (fathers, grandfathers, etc.) represented 28.4% of the study sample, which is considerably better than other studies, which have included fewer than 10% male caregivers (Weeland, 2017). Further, males are represented between 19% and 32% in HOT DOCS research (Agazzi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Childres et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Dunlop et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ogg et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Directions for Future Research\u003c/h2\u003e\u003cp\u003eThere are some limitations pertinent to this study. Data were derived from a non-random sample. Future research would be enhanced by a trial wherein participants are randomly assigned group size. Data also were collected using parent self-report, which increases risk of social desirability and expectancy bias. Future researchers may consider other objective measurements of parenting stress and child disruptive behavior such as cortisol levels and direct observation, respectively. Future researchers also may consider a regression analysis to identify whether there is a point of diminishing returns regarding group size.\u003c/p\u003e\u003cp\u003eData were collected over a period of six years, and in that time, significant modifications to program delivery were forced with the COVID-19 pandemic. The present sample included various groups that occurred both in person and virtually. The extent to which in-person compared to virtual group size was not investigated; however, prior HOT DOCS research indicated no significant differences in outcomes between in-person and virtual parent training groups (Agazzi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Further research is warranted to determine whether group size and group format impact parenting stress, child behavior, and satisfaction outcomes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLittle is known about the extent to which group size affects parenting stress, child behavior, and satisfaction outcomes among participants in group formatted BPMTs. To the best of our knowledge, this is the first empirical study exploring the impact of group size on parent training outcomes. Results from the current study suggest that group size does not significantly affect the positive impact of group BPMT on parenting stress or child behavior outcomes. However, group size does significantly affect intervention satisfaction such that smaller group size is associated with better satisfaction. Still, these differences in reported satisfaction are marginal and not clinically meaningful enough to warrant change to the current practices in BPMT group size. Ultimately, these results suggest that larger group sizes should not be a deterrent when planning BPMT groups, and given the dearth of accessible behavioral health services, larger groups sizes may increase access to care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHC wrote introductory and results section, and further edited the paper as a whole. HC additionally built the dataset and completed the analyses. SD wrote introductory and discussion sections, and further edited the paper as a whole. DT wrote the method section and edits the paper.TT wrote the abstract.HA wrote the discussion and conclusion sections, and further edited the paper as a whole. HA is the senior author on this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgazzi, H., Childres, J., \u0026amp; Armstrong, K. (2020). \u003cem\u003eHelping Our Toddlers, Developing Our Children\u0026rsquo;s Skills (HOT DOCS)\u003c/em\u003e (4th ed.). University of South Florida, Department of Pediatrics.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgazzi, H., Hayford, H., Thomas, N., Ortiz, C., \u0026amp; Salinas-Miranda, A. (2021). 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(2015). Stimulating parents' self-efficacy beliefs or verbal responsiveness: Which is the best way to decrease children's externalizing behaviors? \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e72\u003c/em\u003e, 38\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSanders, M. (1999). Triple P-positive parenting program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. \u003cem\u003eClinical Child and Family Psychology Review\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e, 71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSandler, I. N., Schoenfelder, E. N., Wolchik, S. A., \u0026amp; MacKinnon, D. P. (2011). 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The theory and practice of group psychotherapy. \u003cem\u003eThe British Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e157\u003c/em\u003e(2), 304\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eParticipant characteristics by size of group attended.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"821\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003esmaller group, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003erecommended group, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003elarger group, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003eTotal, \u003cem\u003eN\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e79 (71.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e175 (73.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e196 (69.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e450 (71.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e30 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e63 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e86 (30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e179 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Refused\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e2 (.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003eRelationship to Child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Biological Parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e91 (82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e226 (94.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e257 (91.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e574 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Grandparent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e7 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e6 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e21 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Adoptive Parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e5 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e10 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e18 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e10 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Foster Parent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e4 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e7 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e75 (68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e176 (73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e217 (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e468 (74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Two or more races\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e11 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e10 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e16 (5.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e37 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Refused\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e9 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e15 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e16 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e40 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Black or African American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e7 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e13 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e17 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e37 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e5 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e16 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e30 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Not available\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e7 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e13 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; American Indian or Alaska Native\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e2 (.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; Native Hawaiian or other Pacific Islander\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4 (.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003eEthnicity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Non-Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e65 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e168 (70.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e198 (70.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e431 (68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e40 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e57 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e75 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e172 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Refused\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e4 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e14 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e27 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp; Not Available\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1 (.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Intervention Outcomes by Group Size\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"821\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSmaller\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003eRecommended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLarger\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMean (\u003cem\u003eSD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003eMean \u003cem\u003e(SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMean \u003cem\u003e(SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003ePre-Intervention Stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003eN\u003c/em\u003e = 574\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e22.54 (12.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003e21.22 (10.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e21.97 (12.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003ePost-Intervention Stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003eN\u003c/em\u003e = 574\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.89 (11.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003e17.61 (10.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e18.16 (10.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003ePre-Intervention Intensity of Behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003en =\u0026nbsp;\u003c/em\u003e529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e139.46 (34.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003e131.52 (31.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e131.98 (32.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003ePost-Intervention Intensity of Behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003en =\u0026nbsp;\u003c/em\u003e529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e118.01 (32.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003e113.33 (32.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e111.66 (30.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003ePost-Intervention Therapy Attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003eN\u003c/em\u003e = 584\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e44.48 (4.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 127px;\"\u003e\n \u003cp\u003e42.66 (5.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e42.91 (5.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Disruptive behavior, child, caregivers, group, behavior management","lastPublishedDoi":"10.21203/rs.3.rs-6882775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6882775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cdiv class=\"SectionHeadings\"\u003e\u003cdiv class=\"SectionHeading\"\u003e\u003cdiv class=\"Paragraphs\"\u003e\u003cp\u003eDisruptive behavior in youth is a common challenge for caregivers. Behavioral parent management training (BPMT) is an effective way to intervene with disruptive behaviors of childhood. Dissemination of BPMT is needed considering the prevalence of disruptive behavior. Group formatted BPMT is one way to provide efficacious strategies for managing challenging behaviors to wider audiences. Still, questions remain as to the impact of group factors, namely cohort size, on group outcomes. The purpose of this study was to examine whether group size was related to self-reported parenting stress, the intensity of parent-reported child disruptive behaviors, and overall satisfaction amongst caregivers who completed the Helping Our Toddlers, Developing Our Children\u0026rsquo;s Skills (HOT DOCS) BPMT. Participants (N = 631) were grouped by cohort size (smaller, recommended, or larger size). Analyses compared pre- to post-intervention change across groups on parenting stress and disruptive behavior. Additional analyses evaluated post-test program satisfaction between groups. The results demonstrated that HOT DOCS was effective at reducing parent stress and the intensity of problematic behavior in children. There was no effect of group size on outcomes, nor was there an interaction between HOT DOCS participation and group size on these outcomes. Still, participants from smaller groups had greater satisfaction with the program, albeit this difference lacked clinical meaningfulness. These results indicated that group size neither enhanced nor detracted from the success of caregivers in managing their own stress and their child\u0026rsquo;s behaviors. Findings from this study may inform the implementation of similar behavior-focused parent training programs.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e","manuscriptTitle":"Does Size Matter? Determining Differences in Family Outcomes Based on Cohort Size of HOT DOCS Parent Behavior Management Groups","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-03 11:29:03","doi":"10.21203/rs.3.rs-6882775/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ce476208-584b-4aea-8b78-0775a89f4cc4","owner":[],"postedDate":"November 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T11:29:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-03 11:29:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6882775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6882775","identity":"rs-6882775","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}