Programs for Prevention of Externalizing Problems in Children: Limited Evidence for Effect Beyond 6 Months Post Intervention

The Effectiveness of Preventative Interventions to Reduce Mental Health Problems in at-risk Children and Young People: A Systematic Review of Reviews

Mental health problems are the leading cause of childhood disability worldwide, resulting in poor outcomes for children and young people that persist into adulthood. It is essential that those young people most at risk of developing mental health problems receive effective preventative interventions. Whilst there have been a number of systematic reviews which have examined the effectiveness of secondary prevention interventions for specific groups of children and young people, or to address identified mental health concerns, no review has engaged with the breadth of this literature. We conducted a systematic review of systematic reviews to map this complex field of secondary preventative interventions and identify effective interventions to prevent mental health problems in children and adolescents aged 3-17 years. The review protocol was registered on PROSPERO. We searched five electronic databases from inception to February 2023. The certainty of the evidence was appraised using the AMSTAR 2. We included 49 unique systematic reviews each including between 2 and 249 (mean 34) unique studies; the majority of which were reviews which included only or mostly randomised controlled trials (70%). The reviews examined selective interventions (defined as interventions which are delivered to sub-group populations of young people at increased risk of mental health problems) (n = 22), indicated interventions (defined as interventions which target young people who are found to have pre-clinical symptoms) (n = 15) or a synthesis of both (n = 12). The certainty of the evidence in the reviews was rated as high, (n = 12) moderate (n = 5), low (n = 9) and critically low (n = 23). We found evidence to support both selective and indicated interventions in a range of populations and settings, with most of this evidence available for children and young people in their mid-years (6-10 years) and early adolescence (11-13 years). There was a large body of evidence suggesting that resilience enhancing, cognitive behaviour therapy-based and psychoeducational interventions for children who experience adversity, or those with subclinical externalising problems may offer promise. Early selective interventions for a subpopulation of children and young people who have experienced adversity which combines risk reduction and resilience enhancing approaches directed at children and their families may be effective at reducing mental health problems.

Child behaviour is a main concern for parents of 3-year-olds

AIM

The aim of this study was to describe parental concerns about child health and behaviour and their sociodemographic predictors in 3-year-olds, in relation to the national guidelines of well-baby clinics.

METHODS

The study included parents of 33 526 children in Stockholm who had completed a questionnaire prior to a routine visit to a well-baby clinic at age 3 years. Multivariate regression was used to analyse predictors for concerns.

RESULTS

Child behaviour problems, defined as defiance and problem with adherence to daily routines, were the most common parental concerns (36.4%), with poor social skills and relations being second (21.8%). Regarding development, 9.6% had concerns about speech and 4.7% about motor development. Screen use (9.5%) and being underweight (6.3%) were other common parental concerns, while lifestyle concerns regarding physical activity and overweight were rare. Parents raised about twice as many concerns for first-born children compared with younger siblings. Child behaviour and developmental concerns were more frequent in families where the mother had primary education only and attended a well-baby clinic with a high Care Need Index.

CONCLUSION

Parents' concerns reflected the national guidelines about child development and behaviour, but not its emphasis on a healthy lifestyle.

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Swedish parents' satisfaction and experience of facilitators and barriers with Family Check-up: A mixed methods study

Family Check-up (FCU) was introduced in Sweden more than a decade ago. Little is known about what parents experience as FCU's key mechanisms leading to changes in parenting. The aim of this study was to investigate Swedish parents' satisfaction with FCU, and their experiences of facilitators and barriers for making changes in their parenting. A mixed methods approach was employed using a parent satisfaction questionnaire (n = 77) and focus groups (n = 15). General satisfaction with FCU was adequate, with an average rating of 4 on a five-point scale (range 3.1-4.6). The analysis of quantitative and qualitative data resulted in eight themes representing facilitators and four themes representing barriers, organized into three categories: (1) access and engagement; (2) therapeutic process; and (3) program components. Ease of access to FCU facilitated initial engagement. Individual tailoring and access to FCU during different phases of change facilitated sustained engagement and change. Therapeutic process facilitators were a meaningful, supportive relationship with the provider, psychological benefits for parents and benefits for the whole family. Program components that facilitated change in parenting were new learning of parenting strategies and use of helpful techniques such as videotaping and home practice. Negative experiences with service systems prior to starting FCU, parent psychological barriers, and parent-provider mismatch were described as potential barriers. Some parents desired other program formats that were not offered, and some felt that new learning was insufficient to improve child behavior. Understanding the parent perspective can contribute to successful future work with implementing FCU.

Maternal Functioning and Child's Externalizing Problems: Temperament and Sex-Based Driven Effects

This study examines how maternal adverse parenting (hostility, neglect, low warmth) and psychological distress explain the associations between child temperament factors and externalizing problems. It also examines if these associations differ according to the child's biological sex. The sample consists of 339 school-age children receiving in-school services for conduct problems. Data were collected through questionnaires completed by mothers at 3 time points, at one-year intervals. Results from path analyses revealed that maternal psychological distress partly explained the associations between each child temperamental factors (negative affectivity, surgency/extraversion, effortful control) and levels of externalizing problems. Specifically, the indirect effect of psychological distress between child negative affectivity and externalizing problems was only significant for boys, not girls. Maternal hostility, on the other hand, mediated the association between child surgency/extraversion and externalizing problems in both boys and girls. Interestingly, neglectful parenting and maternal warmth did not explain the association between child temperamental factors and externalizing problems. The findings suggest small but significant temperament child-driven effects on maternal psychological distress and hostility, in turn, translating into higher levels of externalizing problems. These findings support the relevance of temperament-based interventions for children with conduct problems and of increased mental health support for their mothers. By aiding mothers in developing a larger repertoire of parenting strategies, mothers may be better equipped to respond appropriately to their child's various temperamental characteristics, hence, reducing their psychological distress and hostile behaviors and limiting the development of child externalizing problems.

Non-Pharmaceutical Interventions for Self-Regulatory Failures in Adolescents Suffering from Externalizing Symptoms: A Scoping Review

Introduction: Deficits of self-regulation (SR) are a hallmark of externalizing (EXT: offending or aggressive behaviors) symptoms in adolescence. Objectives: This scoping review aims (1) to map non-pharmaceutical interventions targeting SR processes to reduce EXT symptoms in adolescents and (2) to identify research gaps, both of which will provide recommendations for future studies. Methods: Systematic searches were carried out in eight bibliographic databases up to March 2021, combining the following concepts: self-regulation, externalizing symptoms, adolescents, and non-pharmaceutical interventions. Results: We identified 239 studies, including 24,180 youths, mainly from North America, which described a plethora of non-pharmaceutical interventions targeting SR to alleviate EXT symptoms in adolescents (10–18 years of age). The majority of studies (about 70%, k = 162) represent samples with interventions exposed to “selective” or “indicated” prevention. Curriculum-based (i.e., multiple approaches targeting several domains such as emotion, cognition, and social) interventions (31.4%) were the most common type of intervention. Moreover, studies on cognitive-based interventions, mind-based interventions, and emotional-based interventions have increased over the last decades. Network analyses allowed us to identify several hubs between curriculum-based interventions, cognitive SR processes, as well as aggressiveness, conduct problems, and irritability/anger dysregulation. In addition, we identified gaps of studies concerning the physiological SR processes and on some types of interventions (i.e., body-based interventions and externally mediated interventions) or, more specifically, on promising tools, such as biofeedback, neurofeedback, as well as programs targeting neuropsychological processes (e.g., cognitive remediation). Conclusions: This scoping review stresses the plethora of interventions, identified hubs, and emerging fields, as well as some gaps in the literature, which together may orient future studies.

Improving multicultural parenting program for children with emotional and behavioral problems: An integrated review

Children with emotional and behavioral problems are often managed using medications or behavioral therapy, but in some countries, there is no structured parenting intervention to equip parents from different cultural backgrounds with adequate parenting skills to help these children. This paper aims to synthesize key findings from previous research on multicultural parenting programs and produce a comprehensive integrated view by looking into three separate themes: effective multicultural parenting programs, ethnocultural groups and cultural adaptation process. Literature search through Scopus and Google Scholar from 1999 to 2019 was conducted using the terms "effective parenting program", "effective parenting intervention", "effective multicultural parenting program", "effective multicultural parenting intervention", "multicultural parenting program", "multicultural parenting intervention", "parenting program and ethnic groups", "parenting intervention and ethnic groups", "adapted parenting program", "adapted parenting intervention", "cultural adaptation of parenting program'' and "cultural adaptation of parenting intervention". By applying the "Literature Review Synthesis Process", authors conducted cross-analysis, integrated possibilities, and prioritized the synthesized information gearing towards highly probable solutions for improving multicultural parenting programs to manage emotional and behavioral problems in children better. Development of a culturally fit parenting intervention and its implications on existing parenting programs are also discussed. The findings highlight the need 1) to engage with ethnocultural groups of parents during development of a new multicultural parenting program, and 2) to incorporate specific measures for engaging with parents during multicultural parenting program implementation. This paper contributes in acknowledging cultural components in future parenting intervention programs. Finally, recommendations are made for future directions of research.

How can adolescent aggression be reduced? A multi-level meta-analysis

Aggressive behaviour among adolescents has significant social and economic costs. Numerous attempts have been made to intervene to reduce aggression in adolescents. However, little is known about what factors enhance or diminish intervention effectiveness. The present systematic review and meta-analysis, therefore, seeks to quantify the effectiveness of interventions to reduce aggressive behaviour in adolescents and to identify when and for whom such interventions work best. Sixteen databases were searched for randomised controlled trials that assessed interventions to reduce aggression among adolescents. After screening 9795 records, 95 studies were included. A multi-level meta-analysis found a significant overall small-to-medium effect size (d = 0.28; 95% CI [0.17, 0.39]). More effective interventions were of shorter duration, were conducted in the Middle East, were targeted at adolescents with higher levels of risk, and were facilitated by intervention professionals. Potentially active ingredients were classified using the Behaviour Change Technique Taxonomy. Behavioural practice and problem solving were components of more effective interventions targeted at the general population. Overall the findings indicate that psychosocial interventions are effective in reducing adolescent aggression. Future trials need to assess the effect of individual techniques and their combination to identify the key components that can reduce aggression in adolescents.

Socioeconomic inequalities and the equity impact of population-level interventions for adolescent health: an overview of systematic reviews

OBJECTIVES

Despite robust evidence on health inequalities in adulthood, less attention has been paid to inequalities in adolescence. The aim of this overview was to examine systematic review (SR) evidence on the equity impact of population-level interventions intended to improve health, happiness and wellbeing for adolescents.

STUDY DESIGN

An overview (review of systematic reviews).

METHODS

Eleven electronic databases were systematically searched to identify SRs of population-level interventions for adolescent health. A secondary data analysis of socioeconomic inequality was conducted to identify whether SRs reported on primary studies in terms of disadvantage, by measures of socioeconomic status (SES) and by differential effects.

RESULTS

35,310 review titles were screened; 566 full texts were retrieved and 140 SRs met the predefined selection criteria. Differential intervention effects were considered in 42/140 (30%) SRs, 18/140 (13%) reported primary studies using an SES measure and 16/140 (11%) explicitly reported differential effects. 15/140 SRs (11%) explicitly focused on socioeconomic inequalities; of these 4/15 reported differential intervention effects in more detail, 7/15 concluded there was insufficient primary evidence to identify the impact of interventions on socioeconomic inequalities and 4/15 planned to examine differential effects by SES, but this was not reported further.

CONCLUSIONS

Our overview identifies that there is limited SR evidence on the equity impact of population-level interventions for adolescent health. Strengthening the evidence on whether interventions narrow or widen inequalities for adolescents must be a priority for public health research.

Frühkindliche Prädiktoren externalisierender Verhaltensauffälligkeiten

Zusammenfassung. Externalisierende Verhaltensauffälligkeiten sind mit hohen gesellschaftlichen Kosten verbunden. Damit wirksame Präventions- und frühe Therapieprogramme entwickelt werden können, ist es notwendig, bereits in den ersten Lebensjahren Risiken für einen externalisierenden Entwicklungsverlauf zu identifizieren. In einer systematischen Literaturrecherche konnten aus 21 Publikationen zu 12 längsschnittlichen Geburtskohorten mit insgesamt 55 077 Kindern frühe Risiken bezogen auf eine elterliche Psychopathologie, einen niedrigen sozio-ökonomischen Status und ungünstige Eltern-Kind-Interaktionen identifiziert werden. Insbesondere eine mütterliche Depression, ein niedriger sozio-ökonomischer Status und ein harsches Erziehungsverhalten in den ersten Lebensjahren waren prädiktiv für externalisierende Verhaltensauffälligkeiten im Kindergarten und bei Schuleintritt. Implikationen für die klinische Praxis werden vorgestellt.

Design and implementation of RESCUR in Sweden for promoting resilience in children: a study protocol

Background

This research program aims to investigate the implementation and effects of a theoretically promising prevention method. It is being developed in a European research collaboration within a Comenius project (2012–2015) between 6 European universities (in Malta, Italy, Greece, Croatia, Portugal and Sweden) with the purpose of enhancing European children’s resilience.

Methods/design

RESCUR in Sweden consists in a RCT study of the Resilience Curriculum (RESCUR) that is taking place in Sweden 2017–2019. The study is being performed by Junis, IOGT-NTO’s Junior Association, part of IOGT International, in conjunction with researchers at Göteborg, Umeå and Stockholm universities, and is being funded by the Public Health Agency of Sweden.

Around 1000 children of the ages 7–12 will, through their schools and associations, or via groups in social services, be acquainted with the material. Children will learn and practice mindfulness, storytelling, group discussions and much more, all designed to strengthen protective factors and increase their resilience. The program also involves parents, who are taking part in the work to reinforce children’s protective factors.

Based on the work with groups of children, an effectiveness study including children aged 7–12 in school classes, with randomized and controlled pre- and post-measurements, self-rating questionnaires and group observations is being performed. The program will also be implemented in a non-governmental organization and in groups in social services. The study also investigates forms of implementation.

Discussion

The design of the study will enable the researchers to answer five research questions by using a mixed-methods approach. Implementation will be studied, which is a necessary prerequisite for an effect study. Moreover, the research procedure has been tailored to the target group, with age-appropriate measures as well as multiple informants, which will produce high-quality data for analysis. A special ethical challenge is the study of young children, and efforts to give children a voice have been included in the program. This project is regarded as having good potential to benefit children in general, and particularly children in vulnerable positions.

Trial registration

National Institute of Health, ClinicalTrials.gov identifier NCT03655418. Registered August 31, 2018.

Effectiveness of a Positive Parental Practices Training Program for Chilean Preschoolers' Families: A Randomized Controlled Trial

Background: Evidence for the effectiveness of parental training as a strategy for promotion of positive parental practices and prevention of child behavior problems in low and middle income countries is not conclusive. This study aims to assess the effectiveness of a universal positive parental training program designed for this context, “Día a Día” UdeC © (“Day by Day” University of Concepción), in Chilean preschoolers’ families (3–6 years old children).

Methods: A cluster randomized controlled trial (cRCT) was carried out in 19 preschool education centers. There were two treatment arms: 10 centers (including 178 families) were randomly assigned to the intervention group and nine centers (including 154 families) were assigned to the waiting list control condition. Intervention groups received Day by Day UdeC, a six group sessions program for parents, including two group sessions for preschool educators, focused in affective communication; daily and child-directed play; directed attention; routines and transitions; reinforcement and incentive programs; planned inattention-ignore and time out; and logical consequences. Parental practices, parental satisfaction, and presence of children behavioral problems were examined at two-time points: T1 (4 weeks before intervention) and T2 (5–6 weeks after intervention).

Results: Intention-to-treat analysis shows a reduction in physical punishment and an increase in parental involvement, as well as a reduction in children behavioral problems. A per-protocol analysis revealed an additional effect: increase in observed parental practices.

Conclusion: This cRCT provided evidence for the effectiveness of a parental training program for the promotion of positive parental practices in low and middle income countries. The observed effects of the program in decreasing physical punishment and children’s behavioral problems make it a promising strategy for prevention purposes.

Trial Registration: This study was registered under ISRCTN.com (ISRCTN90762146; https://doi.org/10.1186/ISRCTN90762146).

Randomized effectiveness Trial of the Family Check-Up versus Internet-delivered Parent Training (iComet) for Families of Children with Conduct Problems

We investigated the effectiveness of the Family Check-Up (FCU) and an Internet-based parent-training program (iComet), along with moderators and mediators of outcome. Families (N = 231) with a child with conduct problems were randomized to one of the conditions for 10 weeks of treatment. The drop-out rate was significantly higher in the iComet (39%) compared to FCU (23%). At post-treatment, both conditions resulted in significant improvement, based on parent-report, but no significant interaction between time and condition, with the exception of conduct problem subscale of the Strengths and Difficulties Questionnaire, slightly favoring the FCU. Neither child, nor teacher reports indicated any significant changes on any of the investigated variables. At 1-, and 2-years follow-up, the gains from the treatment were maintained in both conditions, with basically no significant time X condition interactions. A significantly larger proportion of children in the FCU recovered at post-treatment with regard to opposition defiant behavior, inattention, and conduct problems, compared to the iComet, but almost none of these differences remained significant at 1-, and 2-years follow-up. None of the moderators (child age, parental income or education, or pre-treatment level of motivation) or mediators (limit setting, and appropriate or harsh parenting) of outcome turned out to be significant.

Childhood aggression: A synthesis of reviews and meta-analyses to reveal patterns and opportunities for prevention and intervention strategies

This study provides a synthesis of meta-analyses and systematic reviews on non-pharmacological treatments for childhood aggression. Treatments referred to universal prevention, selective prevention, indicated prevention, or intervention (Mrazek and Haggerty, 1994). Seventy-two meta-analyses and systematic reviews met the inclusion criteria. We describe their characteristics, effect sizes across types of treatments, and the effects of various moderators. For universal and selective prevention, effects were mostly absent or small; for indicated prevention and interventions, effects were mostly small or medium. Only two moderators had a positive effect on treatment effectiveness, namely pre-test levels of aggression and parental involvement. These results identified similarities between indicated prevention and intervention treatments, on the one hand, and universal prevention and selective prevention, on the other. Our findings suggest that research distinguishing between targets of treatments (i.e., factors associated with childhood aggression vs. present aggressive behaviors) would be promising. Moreover, to further increase effectiveness of treatments for childhood aggression, individual differences warrant scientific attention.

Mental health in adolescence and subsequent receipt of medical benefits in young adulthood: The mediating role of upper secondary school completion

BACKGROUND

Mental health problems in adolescence are associated with impaired function in young adulthood. Our aim was to assess how a hypothetical reduction in mental health problems in adolescence was related to medical benefits in young adulthood and to examine the mediating role of completion of upper secondary school.

METHODS

We used a population-based sample of more than 10,000 10th-grade adolescents with self-reported data on internalizing and externalizing mental health problems. The sample was linked to the Norwegian national registers of education and medical benefits. The mediation analysis was based on a causal inference framework.

RESULTS

During a three-year period in young adulthood, 6.4% of men and 5.9% of women received medical benefits. A two-point hypothetical reduction in externalizing problems was related to a lower probability of receiving medical benefits of 1.5 (95% confidence interval (CI) 1.0-2.1) percentage points in young men and 1.8 (95% CI 1.3-2.3) percentage points in young women. The proportion mediated by the completion of upper secondary school was 52% (95% CI 36-76) among boys and 42% (95% CI 29-60) among girls. The corresponding reduction in the probability of receiving medical benefits was 1.8 percentage points for internalizing problems in both sexes (95% CI boys 1.2-2.4 and girls 1.4-2.2). The proportion mediated was lower for internalizing problems and was only significant among girls (19%). CONCLUSIONS INTERVENTION AND PREVENTION STRATEGIES TARGETING INTERNALIZING AND EXTERNALIZING PROBLEMS IN ADOLESCENTS MAY HAVE THE POTENTIAL TO REDUCE THE RECEIPT OF MEDICAL BENEFITS IN YOUNG ADULTHOOD THE COMPLETION OF UPPER SECONDARY SCHOOL SEEMS TO BE A MECHANISM FOR THIS ASSOCIATION, ESPECIALLY FOR EXTERNALIZING PROBLEMS.