A crucial goal of mental health care for adolescents is to provide treatment in the least restrictive environment, ideally in the community and at home. However, the least restrictive environment does not always provide the intensive care that some children require. In these cases, therapeutic residential treatment (RT) may be necessary. Therapeutic RT programs serve high-risk youth through the use of a “multi-dimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs in partnership with their families and in collaboration with a full spectrum of community-based formal and informal helping resources” (Whittaker, Del Valle, & Holmes, 2016, p. 24). Much of the research to date has focused on the effects of RT programs (e.g., readmission, placement disruption) and whether treatment gains are maintained in the long term (Lanier et al., 2020). While this is an important area of inquiry, other external factors such as the family and home environment are likely to underpin the effects of RT.

Parenting and Adolescent Behavior Problems

A critical component of understanding the barriers and facilitators to treatment gain maintenance for adolescents’ post-discharge from RT is understanding the family’s role and the strengths and challenges families face. Parents with a high sense of competence (i.e., high satisfaction with parenting and perceive their parenting as effective; Ohan et al., 2000) are motivated to learn and apply knowledge, persist in implementing effective parenting practices and persevere despite adversity (Albanese et al., 2019). A low parental sense of competence can result in poor outcomes rather than positive outcomes when implementing behavior management strategies (Albanese et al., 2019). Preyde and colleagues (2015) examined relationships between parental sense of competence and child internalizing and externalizing behaviors. They found that parental sense of competence was moderate among caregivers and negatively associated with adolescent externalizing behaviors but not internalizing behaviors (Preyde et al., 2015). While the literature supports an inverse relationship between parental sense of competence and externalizing behaviors (Preyde et al., 2015), relationships between parental sense of competence and inattention behaviors are unknown.

Adolescents admitted to RT display disruptive behaviors that can challenge parents’ sense of competence (Preyde et al., 2015). When parents feel confident about managing child behaviors, they develop resilience and are more likely to use effective parenting practices such as supervision and praise (Ziv et al., 2020). On the contrary, when adolescents are impulsive or inattentive, parents may feel powerless about their parenting ability and are more likely to display negative parenting behaviors such as inconsistent discipline (Glatz & Stattin, 2013). When Ringle and colleagues (2015) tested an aftercare intervention, they assessed parenting practices. They found that parents displayed moderate levels of supervision, low levels of inconsistent discipline, and low levels of positive parenting. These findings converged with administrative data on family characteristics of youth in RT in which parents displayed few positive parenting practices (e.g., limited participation in youth activities and consistent discipline; Griffith et al., 2009). Specific challenges in this population were poor supervision and monitoring and controlling their emotions when parenting (Griffith et al., 2009).

A coercive relationship can develop between parents and adolescents exhibiting behavior problems that may reinforce the problem behavior (Capaldi et al., 1997; Patterson, 1982). Adolescents may receive inconsistent consequences in which they may be ignored by their parents or punished harshly. Because of the inconsistency, adolescents cannot determine what response they will get from their behavior (Capaldi et al., 1997; Dwairy, 2007; Therriault et al., 2021). In the pediatric inpatient population, inconsistent discipline and corporal punishment predict higher externalizing behaviors even after discharge (Blader, 2006). A permissive parenting style and specific parenting practices (i.e., harsh discipline and parental involvement) increase the risk of readmission in the pediatric psychiatric population (Blader, 2004; Fite et al., 2009).

Home Environment and Adolescent Behavior Problems

Before the adolescent enters RT, parents describe a breaking point characterized by tension in the home, fear, and an inability to plan family activities or socialize with others because of the adolescent’s behaviors (Tahhan et al., 2010). Upon discharge, adolescents often return to the same household they were admitted from (Trout et al., 2010). Preyde and colleagues (2011) compared family function and parent-child relationships between families with children in RT to families in a home-based alternative. They found that at admission, the child’s behaviors towards others in the home (e.g., complying with rules) were moderately impaired on average (Preyde et al., 2011) according to the Child and Adolescent Functional Assessment Scale (CAFAS) home subscale (Hodges, 2000). They also found that their child’s behaviors tended to affect the entire family’s quality of life, and parent-child interactions were consistently negatively impacted by the perceptions of the child’s behaviors (Preyde et al., 2011). Parents with children in RT have self-reported their homes as chaotic and stressful (Herbell & Breitenstein, 2021). Because of the severity of the behaviors, parents described needing to devise homemade safety plans that included having physical protections (e.g., locks on the doors), hiding potential weapons, and involving all family members when a crisis occurred (Herbell & Breitenstein, 2021).

In addition, larger household size is associated with more significant behavior problems, including aggression (Grinde & Tambs, 2016). The link between the home environment and behavior problems may be partly due to household chaos in that larger households tend to be more chaotic (Dumas et al., 2005). Household chaos refers to disorganization in the home, including lack of routine, unpredictability, and high levels of stimulation (Ackerman & Brown, 2010). Household chaos also tends to be heightened in households where the total household income and education are low (Dumas et al., 2005); however, the effect of household chaos on adolescent behaviors problems remains even after controlling for the effects of socioeconomic status (Deater-Deckard et al., 2009). Household chaos also affects parenting. According to a scoping review, household chaos was associated with many parenting practices, including less effective discipline, warmth, responsiveness, and routine (Marsh et al., 2020). Greater household chaos was also associated with greater parent-child conflict and less parent-child closeness, positive parenting, and emotional availability (Marsh et al., 2020). Further, household chaos moderated the relationship between parenting and adverse child and family outcomes (Marsh et al., 2020). While a relatively large body of literature displays a link between household chaos and child outcomes, the specific concept of household chaos has been investigated in a limited way in the RT population.

Study Purpose

Little is known about the household environments in which adolescents in RT are admitted from and discharged to. Nor is there an explanation of how the home environment and adolescent behavior problems interact, specifically in adolescents admitted to RT. Second, there is scant available literature regarding how modifiable factors beyond the home environment, such as parenting, may be bi-directionally associated with adolescent behavior problems. Investigating relationships among the home environment, parenting, and adolescent behavior problems, specifically in the RT population is warranted because the home environment and parenting are modifiable and amenable to intervention. Therefore, this study aims to describe the relationships among parenting (sense of competence, practices), household chaos, and adolescent behavior problems (i.e., inattention, internalizing, externalizing) in a sample of parents with adolescents admitted to RT. It should be noted that this exploratory study did not have a priori hypotheses. Assessing these relationships could pinpoint potential intervention targets should there be strong relationships among parenting, household chaos, and adolescent behavior problems.

Method

Design and Sample

This study used a cross-sectional design with data collected from parents with adolescents currently admitted and recently discharged from RT. Using convenience sampling, parents were recruited through Facebook because this population has been shown to use Facebook for informal support (Herbell et al., 2020). Eligibility criteria included being a parent (biological, kin, adoptive, foster, step) who was at least 18 years old, a resident of the United States, and self-report that their adolescent was aged 12 to 17 with mental, emotional, or behavioral challenges and that their adolescent recently (past year) or at the time of the study accessed a RT program. The research team created a Facebook page for the study. The study team asked moderators of mental health or parenting-oriented Facebook groups to post a study recruitment flyer to recruit participants. The recruitment flyer contained a link that redirected parents to a study landing page that housed study information, eligibility questions, consent form, and surveys. Parents who completed the survey received a $20 gift card. The Ohio State University Institutional Review Board approved this study (Protocol # 2019B0455), and all parents provided informed consent.

Data Collection and Measures

If deemed eligible through the screening questions, parents then viewed the consent form to provide informed consent. Parents completed a demographic questionnaire (e.g., age, sex) followed by a series of surveys using Qualtrics (Qualtrics, 2021).

Adolescent behavior problems were assessed using the Brief Problem Monitor (BPM) for ages 6 to 18 (Achenbach et al., 2011). The BPM is an abbreviated form of the 113-item Child Behavior Checklist (CBCL) (Achenbach & Ruffle, 2000). The BPM consists of 19 items in which parents respond on a 3-point scale (0 = not true to 2 = very true) to the degree to which each symptom is present in their adolescent. Three behavior subscales, attention, internalizing, and externalizing, can be summed to create a total behavior problems score. Higher total scores are indicative of greater behavior problems. The BPM’s internal consistency for total behavior problems is high (α = 0.91), and the subscales were acceptable: internalizing (α = 0.78), attention (α = 0.87), and externalizing (α = 0.86) (Achenbach et al., 2011). The BPM and CBCL were also highly correlated (r = 0.95) in psychometric testing (Achenbach et al., 2011). While raw scores can be converted to t-scores, we opted only to use raw scores in this study because they are more precise, and our purpose was not to guide clinical decisions or make inferences about the population. Further, the developers advocate using raw scores in research (Achenbach & Rescorla, 2001).

Parental sense of competence was assessed with the Parenting Sense of Competence Scale (PSOC) (Ohan et al., 2000). The PSOC consists of 17-items and is designed for parents with children aged birth to 17. Parents rate each item on a 6-point scale (1 = strongly disagree to 6 = strongly agree). The two subscales in the PSOC consist of parenting satisfaction and parental self-efficacy, and higher total scores indicate a greater parental sense of competence. Internal consistency is acceptable (α = 0.80), and total scores have been correlated with adolescent externalizing behavior and family function (Ohan et al., 2000).

Parenting practices were assessed using the Alabama Parenting Questionnaire (APQ) (Frick, 1991; Shelton et al., 1996). The APQ consists of 42-items and is designed for parents with children aged 6 to 18. Parents rate each item on a 5-point scale (1 = never to 5 = always). There are five subscales: involvement, positive parenting, poor supervision and monitoring, inconsistent discipline, and corporal punishment. To obtain total scores for subscales, items are summed together. Higher scores on the involvement and positive parenting subscales indicate higher parental involvement and positive parenting, respectively. Higher scores on the poor monitoring and supervision and inconsistent discipline subscales indicate less monitoring and supervision and consistent discipline. Finally, higher scores on the corporal punishment subscale indicate that corporal punishment is used more frequently. Internal consistency across scales is acceptable (α = 0.68) and demonstrates criterion validity in clinical and non-clinical samples (Dadds et al., 2003).

The Confusion, Hubbub, and Order Scale (CHAOS) (Matheny et al., 1995) was administered to evaluate household chaos. The CHAOS consists of 14-items in which parents rate each item on a 4-point scale (1 = often to 4 = never). Higher total scores are indicative of more chaotic home environments. Internal consistency across scales is acceptable (α = 0.79) and is highly correlated with observer-reported household chaos (Matheny et al., 1995).

Data Integrity

Following Pozzar and colleagues (2020) guidance, a conservative data integrity protocol was developed to screen survey responses for low data quality. Each survey response was screened for “fraudulent” or “suspicious” data quality indicators in the following domains: (1) evidence of inattention, (2) duplicate or unusual responses to open-ended items, and (3) inconsistent responses to verifiable items (Pozzar et al., 2020). To determine if there was evidence of inattention, we first determined the average time the survey took to complete (30 min). Response times were then reviewed and flagged as fraudulent if the survey was completed in less than five minutes, and responses were flagged as suspicious if the survey was completed in less than fifteen minutes. A second method of assessing data quality was by examining open-ended items. For example, there was an open-response question about helpful parenting strategies, and several respondents copied and pasted the study purpose from the study recruitment flyer. Responses such as these were flagged as suspicious. Responses were flagged as fraudulent if the same response was provided on multiple separate participant surveys.

The third data quality metric assessed was inconsistent responses to verifiable items. For example, responses were flagged as fraudulent if the survey timestamp time zone indicated that the survey was completed outside of the United States. Responses were flagged as suspicious if the reported a treatment program type did not match the description of RT. The present study omitted survey responses with one fraudulent indicator or at least three suspicious indicators (Pozzar et al., 2020). Qualtrics-enabled features such as reCAPTCHA and ballot box stuffing prevention were also used as added protection. Before implementing the data integrity protocol, there were 100 responses. Twenty-nine responses were removed, of which eighteen had three or more suspicious indicators, and eleven responses had at least one fraudulent indicator. After removing suspected illegitimate responses, the final sample size was 71 parents. This response rate is considered average for online survey studies (Pozzar et al., 2020; Griffin et al., 2021).

Data Analysis

Data were described using frequency (percent) for categorical variables and median (range or interquartile range, as stated) for continuous variables. Box plots with violin plots overlaid were used to visualize the distribution of adolescent behavior and parenting scores among respondents. Univariable linear regression models were fit for each BPM subscales and total scale, using parenting practices, parental sense of competence, and household chaos variables as predictors. A multivariable model was fit for each BPM outcome using scores for total parenting practices, parental sense of competence, and household chaos. Multivariable models adjusted for potential confounding with child gender and RT discharge status. Model estimates were presented with 95% confidence intervals. Pearson correlation coefficients were also calculated. Two-sided p-values < 0.05 were considered statistically significant. All statistical analyses were performed in R version 4.0 (R Core Team, Vienna, Austria).

Results

Sample Description

Parents (n = 71) were a median age of 48 years old with an interquartile range from 40 to 51 years old. Three-quarters of parents identified as female (n = 53, 75%), with the majority (n = 60, 85%) identifying as biological parents. Most parents were white (n = 50, 70%) and non-Hispanic or Latinx (n = 65, 92%). Most parents earned a bachelor’s degree or higher (n = 56, 79%). Adolescents were a median age of 15 years old, with an interquartile range from 13 to 17. The median age problematic behaviors began was ten years old with an interquartile range from 5 to 13. Most adolescents were white (n = 42, 59%), non-Hispanic (n = 65, 92%) females (n = 37, 52%). At the time of the study, adolescents were residing in the home (n = 29, 41%), RT (n = 26, 37%), group home (n = 2, 3%), inpatient psychiatric treatment (n = 2, 3%), and other settings such as college, shelter care, detention (n = 12, 17%).

Dispersion of Scores

Total behavior problem scores ranged from 2 to 38, with a median score of 20.5. The median internalizing behavior score was 7, with a range of 0 to 12, and the median externalizing behavior score was 5, with a range of 0 to 14. Finally, the median inattention behavior score was 6, ranging from 0 to 12. The dispersion of parenting practice subscale scores included involvement (median = 37, range = 16–50), positive parenting (median = 23, range = 11–30), poor monitoring and supervision (median = 22, range = 10–41), inconsistent discipline (median = 14, range = 8–23), and corporal punishment (median = 5, range = 3–12). The dispersion of scores related to household chaos (median = 34, range = 25–46) and parental sense of competence (median = 58, range = 46–91).

Inattention Behaviors, Parenting, and Household Chaos

Adolescent inattention behaviors were positively associated with inconsistent discipline (Beta = 0.34, 95% CI = 0.11 to 0.57, p = 0.004), corporal punishment (Beta = 0.65, 95% CI = 0.17 to 1.10, p = 0.009), total parenting practices (Beta = 0.11, 95% CI = 0.05 to 0.17, p < 0.001), and parental sense of competence (Beta = 0.13, 95% CI = 0.01 to 0.25, p = 0.040) in univariable linear regression models. We then entered total parenting practices, household chaos, and parental sense of competence into a multiple linear regression model controlling for adolescent discharge status (i.e., admitted to RT vs. discharged) and adolescent gender. After controlling for these variables, total parenting practices remained positively associated with inattention behaviors; for each one-point increase in total parenting practices score, the estimated mean increase in attention behaviors score was 0.11 points after adjusting for these other factors (Beta = 0.11, 95% CI = 0.02 to 0.20, p = 0.021).

Internalizing Behaviors, Parenting, and Household Chaos

Adolescent internalizing behaviors were positively associated in univariable models with parental involvement (Beta = 0.16, 95% CI = 0.06 to 0.27, p = 0.002), positive parenting (Beta = 0.25, 95% CI = 0.08 to 0.41, p = 0.004), and total parenting practices (Beta = 0.07, 95% CI = 0.01 to 0.13, p = 0.025). Adolescent internalizing behaviors were negatively associated with household chaos (Beta = -0.25, 95% CI = -0.42 to -0.09, p = 0.003). When total parenting practices, parental sense of competence, discharge status, and adolescent gender were controlled for, there was a significant negative relationship between household chaos and adolescent internalizing behaviors; for each one-point increase in household chaos score, the estimated mean decrease in internalizing behaviors scores was 0.20 points after adjusting for the other variables (Beta = -0.20, 95% CI = -0.37 to -0.02, p = 0.029).

Externalizing Behaviors, Parenting, and Household Chaos

Adolescent externalizing behaviors were positively associated with inconsistent discipline (Beta = 0.41, 95% CI = 0.16 to 0.67, p = 0.002), corporal punishment (Beta = 0.68, 95% CI = 0.12 to 1.20, p = 0.017), and total parenting practices (Beta = 0.10, 95% CI = 0.03 to 0.17, p = 0.006) in univariable regression models. Adolescent externalizing behaviors were also positively associated with parental sense of competence (Beta = 0.19, 95% CI = 0.05 to 0.32, p = 0.007). Adolescent externalizing behaviors were negatively associated with household chaos (Beta = -0.23, 95% CI = -0.44 to -0.01, p = 0.038). When discharge status and adolescent gender were controlled for, aside from child gender, there were no significant relationships among total parenting practices, household chaos, parental sense of competence, and adolescent externalizing behaviors.

Total Behaviors, Parenting, and Household Chaos

Total adolescent behavior problems were associated with each parenting subscale except for poor monitoring/supervision. Total adolescent behavior problems were positively associated with parental sense of competence (Beta = 0.36, 95% CI = 0.09 to 0.63, p = 0.011) and negatively associated with household chaos (Beta = -0.63, 95% CI = -1.00 to -0.22, p = 0.004). When household chaos, parental sense of competence, discharge status, and adolescent gender were controlled, there was a significant positive relationship between total parenting practices and total behavior problems; for each one-point increase in total parenting practices scores, the estimated mean increase in total behavior problems score was 0.22 points after controlling for these variables (Beta = 0.22, 95% CI = 0.03 to 0.42, p = 0.023).

Relationships Between Parenting and the Home Environment

Household chaos was strongly negatively correlated with parental involvement (r = -0.579, p < 0.001) and positive parenting (r = -0.595, p < 0.001) and moderately negatively correlated with inconsistent discipline (r = -0.332, p = 0.017) and parental sense of competence (r = -0.387, p = 0.005). Except for monitoring/supervision, parental sense of competence was correlated with each parenting practice subscale.

Discussion

This exploratory study described relationships among parenting (i.e., parental sense of competence, parenting practices), household chaos, and adolescent behavior problems in a sample of parents whose adolescents were currently admitted or recently discharged from RT. Parents reported numerous strengths, including moderate to high involvement and a moderate level of positive parenting practices and monitoring and supervision. Parents also self-reported relatively low levels of inconsistent discipline and corporal punishment. Regarding adolescent behaviors, the study sample reported relatively low behavior problems, considering that the literature often describes severe behavior problems and trauma exposure in this population (Briggs et al., 2012; Connor et al., 2004; Farley et al., 2020). We suspect the moderate level of adolescent behavior problems was because 41% of adolescents were post-discharge and residing in the community.

According to the univariable linear regression results, inconsistent discipline and corporal punishment were positively associated with inattention, externalizing, and total behavior problems, meaning that as inconsistent discipline scores increased (i.e., discipline became less consistent), behavior problems tended to increase. Similarly, inattention, externalizing, and total behavior problem scores increased as corporal punishment scores increased. Further, when discharge status and child gender were controlled, total parenting practices were associated with inattention and total behavior problems. These findings are consistent with previous research that documents that when there is inconsistent discipline, adolescents may be challenged to anticipate the reaction their behavior will elicit, resulting in increased behavior problems (Capaldi et al., 1997; Dwairy, 2007; Therriault et al., 2021). Further, corporal punishment consistently predicts behavior problems and is associated with worsening behavior problems over time (Heilmann et al., 2021), further contextualizing these results.

Parents reported a relatively high sense of competence, consistent with a previous study of caregivers with youth in RT (Preyde et al., 2011). While there is only a small amount of literature regarding parents’ sense of competence in the RT population, our results converge with another study and suggest that parents’ sense of competence is moderate in caregivers (Preyde et al., 2011). However, our study also expands upon previous literature because parental sense of competence was positively associated with parental involvement, positive parenting, corporal punishment, and inconsistent discipline. Except for internalizing behaviors, parental sense of competence was positively associated with adolescent behavior problems in the univariable models. This finding diverges from a previous study (Preyde et al., 2015) that examined relationships among parental sense of competence, marital status, and adolescent behavior problems (internalizing, externalizing). Their results suggested that externalizing behavior problems decreased as parental sense of competence increased (Preyde et al., 2015). Other factors, such as relationship quality and caregiver strain, may be relevant to explore in relation to adolescent behavior problems in the RT population. However, the study sample comprised mothers who, on average, reported a high level of involvement with their children. Previous research demonstrates that parents with children with mental health needs, including RT, are highly motivated to get their children the help they need (Herbell & Banks, 2020; Tahhan et al., 2010). Therefore, even if behavior problems are severe, the parent may feel competent because they know that they are doing everything they can to get their child help. Further, the adolescents in this study had longstanding mental health issues. Parents may have developed resilience over time that bolstered their sense of competence regardless of their child’s behavior problems (Ziv et al., 2020). Examining how parental sense of competence is developed and maintained through studying other phenomena, such as resilience and caregiver strain, warrants further examination in this population.

Parents in our study reported a moderate level of household chaos. Except for inattention behaviors, household chaos was negatively associated with adolescent behavior problems, indicating that higher levels of household chaos were related to lower adolescent behavior problems. In the multivariate regression models, household chaos was negatively associated with internalizing behaviors. Specific factors in the home environment may contribute to the negative association between chaos and behavior problems. For example, the number of household members and the characteristics of these members may play a vital role because more members in the household are associated with a higher degree of chaos (Dumas et al., 2005). Similarly, a higher level of chaos may be observed if there are multiple children in the home with special needs (Marsh et al., 2020). Recruiting a large sample in which modeling and subsequently controlling for these additional variables (e.g., number of children, household membership) is a future direction for research.

In addition, our study results support that parental sense of competence and parenting practices were highly correlated with household chaos. Specifically, as the home environment became more chaotic, parental sense of competence, involvement, positive parenting decreased, and discipline became less consistent. Our study was only powered to examine associations among these variables. However, future research should examine how modifiable parenting variables and factors in the home environment contribute to chaos and adolescent behaviors. To understand these complex relationships, future studies should examine this interplay to understand what specific factors in the home environment contribute to the development and maintenance of behavior problems in the RT population. Overall, household chaos is a critical component of adolescent behavior problems. Understanding the specific factors in the home environment that contribute to chaos and potentially adolescent behaviors is a crucial area of study that can lead to intervention.

The univariable results suggested that parental involvement and positive parenting were positively associated with internalizing behaviors and total behavior problems. This finding should be interpreted as meaning that as involvement and positive parenting scores increased, so did internalizing and total behavior problem scores. While this relationship dissipated when discharge status and child gender were controlled for in the internalizing model, total parenting practices remained negatively associated with total adolescent behavior problems. The research is clear that involved and responsive parents are protective factors against behavior problems, with less involved parents reporting greater exacerbations in behavior problems (Fritz et al., 2018; Temmen & Crockett, 2021).

There is also abundant research regarding the effects of negative parenting behaviors (e.g., parental harshness, corporal punishment) on adolescent behaviors (Mackenbach et al., 2014; Orri et al., 2019). However, there is a balance with parental involvement. There are two types of supportive parental behavior: positive control (e.g., instructing, explaining) and following the child’s lead (e.g., monitoring, supervising; Obradović et al., 2021). Parents who are overly engaged and display more positive control behaviors (e.g., “helicopter parent” (Segrin et al., 2012); can undermine a child’s ability to self-regulate and be independent (Obradović et al., 2021). This parenting style can affect the adolescent’s long-term development by promoting less autonomy, competence, and prosocial behaviors in adulthood (Schiffrin et al., 2019, 2021). Our study sample had a relatively high level of parental involvement. While we are not suggesting that parents with adolescents in RT should be less involved in their adolescent’s life, overly involved parents who exhibit more positive control behaviors rather than letting the child take the lead may contribute to greater behavior problems.

Given these findings, a key area of future research may be testing behavioral parent training interventions in this population. Behavior parent training is a class of evidence-based behavior management interventions that reinforces many parenting skills, including appropriate involvement, monitoring, and supervision. Behavioral parent training has a large evidence base, and a meta-meta-analysis suggests behavioral parent training is effective in improving positive parent practices and parents’ perceptions that their parenting is effective (Weber et al., 2019). While behavioral parent training programs are a promising strengths-based approach, few have tested this class of programming in parents with adolescents in RT. There is some urgency in testing this type of intervention in the RT population, given that recent federal legislation, the Family First Prevention Services Act, now mandates that parent training be implemented in RT programs (National Conference of State Legislatures, 2020). However, there are several gaps in the research, including whether parent training is perceived as acceptable in this population and how this population prefers to receive this type of newly mandated intervention regarding delivery (e.g., online vs. in-person, group vs. individual), timing (e.g., during RT vs. post-discharge), and content (e.g., which parenting skills). The findings of the present study, coupled with others (e.g., Griffith et al., 2009; Preyde et al., 2011;2015; Sunseri, 2020), provide some insight into the parenting strengths that behavioral parent training programs may build upon to support parents with adolescents in RT.

Limitations

This was a cross-sectional study without a priori hypotheses, and therefore the results should only be interpreted as exploratory. In addition, because of the exploratory nature coupled with the small sample size, the analysis was limited to examining associations among parenting variables and adolescent behavior problems at one-time point rather than over time. This is an essential next step in research and could illuminate the ideal time to deliver intervention. Second, additional variables such as adolescent diagnosis, geographic region, length of stay, and treatment history were not collected in the study, which could have been important variables to control for in the analysis. The missing data also prevented modeling relationships while controlling for other variables; however, this remains a future direction for research.

Parents were eligible to participate in the study if their child was currently admitted or recently discharged from RT. While it is important to understand parenting during both timeframes, there are likely different stressors and distinct differences between these timeframes that warrant separate examination in future studies. Recruitment through Facebook was another limitation because we could not verify participants’ identities. While we instituted a data integrity protocol and the fraudulent response rate was consistent with prior studies, this is still a limitation. Facebook recruitment could have introduced selection bias, and participants may have shared characteristics (e.g., sex, income) compared to individuals who did not participate. For example, most parents identified as biological mothers, limiting the generalizability to non-kin caregivers and fathers. An important next step is to employ various recruitment methods that could yield a more diverse sample. Finally, all measures were parent self-report. While we selected valid and reliable instruments, including objective measures could be the next step in understanding how parenting, household chaos, and adolescent behaviors interact.

Conclusion

Overall, this study suggests that household chaos and parenting are associated with adolescent behavior problems in the RT population. The next steps include more comprehensively studying the home environment beyond self-report to understand environmental factors that may promote or inhibit adolescent behavior problem exacerbations. In addition, a better understanding of how these factors interact and identifying specific intervention targets is a future direction to understanding modifiable factors in the adolescent’s environment that may promote treatment gains in the community.