Distance-Delivered Parent Training for Childhood Disruptive Behavior (Strongest Families™): a Randomized Controlled Trial and Economic Analysis

Evidence for investing in parenting interventions aiming to improve child health: a systematic review of economic evaluations

A comprehensive review of the economic evidence on parenting interventions targeting different aspects of child health is lacking to support decision-making. The aim of this review is to provide an up to date synthesis of the available health economic evidence for parenting interventions aiming to improve child health. A systematic review was conducted with articles identified through Econlit, Medline, PsychINFO, and ERIC databases. Only full economic evaluations comparing two or more options, considering both costs and outcomes were included. We assessed the quality of the studies using the Drummond checklist. We identified 44 studies of varying quality that met inclusion criteria; 22 targeting externalizing behaviors, five targeting internalizing problems, and five targeting other mental health problems including autism and alcohol abuse. The remaining studies targeted child abuse (n = 5), obesity (n = 3), and general health (n = 4). Studies varied considerably and many suffered from methodological limitations, such as limited costing perspectives, challenges with outcome measurement and short-time horizons. Parenting interventions showed good value for money in particular for preventing child externalizing and internalizing behaviors. For the prevention of child abuse, some programs had the potential of being cost-saving over the longer-term. Interventions were not cost-effective for the treatment of autism and obesity. Future research should include a broader spectrum of societal costs and quality-of-life impacts on both children and their caregivers.

Engaging Parents in Technology-Assisted Interventions for Childhood Adversity: Systematic Review

BACKGROUND

Youth mental health problems are a major public health concern and are strongly associated with adverse childhood experiences (ACEs). Technology-assisted parenting programs can intervene with ACEs that are within a parent's capacity to modify. However, engagement with such programs is suboptimal.

OBJECTIVE

This review aims to describe and appraise the efficacy of strategies used to engage parents in technology-assisted parenting programs targeting ACEs on the behavioral and subjective outcomes of engagement.

METHODS

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines, we conducted a systematic review of peer-reviewed papers that described the use of at least 1 engagement strategy in a technology-assisted parenting program targeting ACEs that are within a parent's capacity to modify. A total of 8 interdisciplinary bibliographic databases (CENTRAL, CINAHL, Embase, OVID MEDLINE, OVID PsycINFO, Scopus, ACM, and IEEE Xplore) and gray literature were searched. The use of engagement strategies and measures was narratively synthesized. Associations between specific engagement strategies and engagement outcomes were quantitatively synthesized using the Stouffer method of combining P values.

RESULTS

We identified 13,973 articles for screening. Of these, 156 (1.12%) articles were eligible for inclusion, and 29 (18.2%) of the 156 were associated with another article; thus, 127 studies were analyzed. Preliminary evidence for a reliable association between 5 engagement strategies (involving parents in a program's design, delivering a program on the web compared to face-to-face, use of personalization or tailoring features, user control features, and provision of practical support) and greater engagement was found. Three engagement strategies (professional support features, use of videos, and behavior change techniques) were not found to have a reliable association with engagement outcomes.

CONCLUSIONS

This review provides a comprehensive assessment and description of the use of engagement strategies and engagement measures in technology-assisted parenting programs targeting parenting-related ACEs and extends the current evidence with preliminary quantitative findings. Heterogeneous definition and measurement of engagement and insufficient engagement outcome data were caveats to this synthesis. Future research could use integrated definitions and measures of engagement to support robust systematic evaluations of engagement in this context.

TRIAL REGISTRATION

PROSPERO CRD42020209819; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=209819.

Economic Evaluations of Digital Health Interventions for Children and Adolescents: Systematic Review

BACKGROUND

Digital health interventions (DHIs) are defined as digital technologies such as digital health applications and information and communications technology systems (including SMS text messages) implemented to meet health objectives. DHIs implemented using various technologies, ranging from electronic medical records to videoconferencing systems and mobile apps, have experienced substantial growth and uptake in recent years. Although the clinical effectiveness of DHIs for children and adolescents has been relatively well studied, much less is known about the cost-effectiveness of these interventions.

OBJECTIVE

This study aimed to systematically review economic evaluations of DHIs for pediatric and adolescent populations. This study also reviewed methodological issues specific to economic evaluations of DHIs to inform future research priorities.

METHODS

We conducted a database search in PubMed from 2011 to 2021 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. In total, 2 authors independently screened the titles and abstracts of the search results to identify studies eligible for full-text review. We generated a data abstraction procedure based on recommendations from the Panel on Cost-Effectiveness in Health and Medicine. The types of economic evaluations included in this review were cost-effectiveness analyses (costs per clinical effect), cost-benefit analyses (costs and effects expressed in monetary terms as net benefit), and cost-utility analyses (cost per quality-adjusted life year or disability-adjusted life year). Narrative analysis was used to synthesize the quantitative data because of heterogeneity across the studies. We extracted methodological issues related to study design, analysis framework, cost and outcome measurement, and methodological assumptions regarding the health economic evaluation.

RESULTS

We included 22 articles assessing the cost-effectiveness of DHI interventions for children and adolescents. Most articles (14/22, 64%) evaluated interventions delivered through web-based portals or SMS text messaging, most frequently within the health care specialties of mental health and maternal, newborn, and child health. In 82% (18/22) of the studies, DHIs were found to be cost-effective or cost saving compared with the nondigital standard of care. The key drivers of cost-effectiveness included population coverage, cost components, intervention effect size and scale-up, and study perspective. The most frequently identified methodological challenges were related to study design (17/22, 77%), costing (11/22, 50%), and economic modeling (9/22, 41%).

CONCLUSIONS

This is the first systematic review of economic evaluations of DHIs targeting pediatric and adolescent populations. We found that most DHIs (18/22, 82%) for children and adolescents were cost-effective or cost saving compared with the nondigital standard of care. In addition, this review identified key methodological challenges directly related to the conduct of economic evaluations of DHIs and highlighted areas where further methodological research is required to address these challenges. These included the need for measurement of user involvement and indirect effects of DHIs and the development of children-specific, generic quality-of-life outcomes.

A tornado in the family: fetal alcohol spectrum disorder and aggression during childhood and adolescence: a scoping review

Background

Aggression exhibited by children and youth with Fetal Alcohol Spectrum Disorder (FASD) toward family members is a major cause of stress and anxiety for caregivers, but relatively little attention has been directed toward designing interventions specific to this phenomenon. In light of the serious negative impact of this issue for families, a scoping review was undertaken to summarize the evidence available on psychosocial interventions that may mitigate the frequency and severity of aggression exhibited by children and youth with FASD toward family members.

Methods

This review was designed using PRISMA-SCR and JBI scoping review guidelines. Three databases were searched in August 2021: EMBASE, PsychINFO, and Medline.

Results

A total of 1,061 studies were imported for screening with only five studies meeting full eligibility criteria. None of the interventions were aimed at specifically targeting aggression and instead reported on broader constructs of externalizing behaviors such as hyperactivity. The interventions were limited to school-aged children. Studies reported primarily on child outcomes while only one reported on family related outcomes.

Conclusion

Following from this review of the literature, we argue that aggression is a related but separate construct from other behavioral problems most frequently targeted by parenting interventions. Given the often dire consequence of aggression displayed by children and youth with FASD and the limited number of studies, there is an urgent need for research on how to support families to manage this specific type of behavior in this population.

Online Behavioral Parenting Interventions for Disruptive Behavioral Disorders: A PRISMA Based Systematic Review of Clinical Trials

Behavioral parenting interventions (BPIs) are efficacious, evidence-based interventions for disruptive behavioral disorders in children. Technological advances have seen online adaptations of BPIs further increase efficacy and expand program reach. This systematic review examined the treatment outcomes of online BPIs. Our secondary aim was to examine which components of online BPIs are associated with beneficial child outcomes. Electronic databases were searched to identify randomized controlled trials of online BPIs for children with disruptive behavioral difficulties published between 2000 and 2020. Ten studies, reporting on nine different interventions, met inclusion criteria. The review indicated online BPIs are a viable treatment for disruptive behavioral disorders with nine of ten reporting significant improvements post-treatment. Effective interventions had clearly defined program structure and included content based on operant learning principles. Future research would benefit from greater detail when reporting intervention content, and regular assessment of progress through treatment against the delivery of specific program components.

Digital health interventions to support family caregivers: An updated systematic review

Objective

Chronic diseases are the leading causes of death and disability in the U.S., and disease management largely falls onto patients' family caregivers. The long-term burden and stress of caregiving negatively impact caregivers' well-being and ability to provide care. Digital health interventions have the potential to support caregivers. This article aims to provide an updated review of interventions using digital health tools to support family caregivers and the scope of the Human-Centered Design (HCD) approaches.

Methods

We conducted a systematic search on July 2019 and January 2021 in PubMed, CINAHL, Embase, Cochrane Library, PsycINFO, ERIC, and ACM Digital Library, limiting to 2014-2021 to identify family caregiver interventions assisted by modern technologies. The Mixed Methods Appraisal Tool and the Grading of Recommendations Assessment, Development and Evaluation were used to evaluate the articles. Data were abstracted and evaluated using Rayyan and Research Electronic Data Capture.

Results

We identified and reviewed 40 studies from 34 journals, 10 fields, and 19 countries. Findings included patients' conditions and relationships with family caregivers, how the technology is used to deliver the intervention, HCD methods, theoretical frameworks, components of the interventions, and family caregiver health outcomes.

Conclusion

This updated and expanded review revealed that digitally enhanced health interventions were robust at providing high-quality assistance and support to caregivers by improving caregiver psychological health, self-efficacy, caregiving skills, quality of life, social support, and problem-coping abilities. Health professionals need to include informal caregivers as an essential component when providing care to patients. Future research should include more marginalized caregivers from diverse backgrounds, improve the accessibility and usability of the technology tools, and tailor the intervention to be more culturally and linguistically sensitive.

A randomized controlled trial evaluating the effect of an internet-based cognitive-behavioral program on anxiety symptoms in a community-based sample of adolescents

Adolescents' use of online resources to self-manage anxiety is growing. The objective of the current trial was to assess the effectiveness of an online, primarily self-led cognitive behavioral therapy (CBT) program in reducing anxiety symptoms compared to an active comparator, access to anxiety resources on a static website. A total of 563 adolescents (13-19 years) with self-identified anxiety concerns were enrolled. Self-reported anxiety symptoms were assessed pre- and post-intervention (6 weeks). Adolescents were further assessed 3 months post-intervention. Other outcomes assessed at the three time-points were quality of life (QOL) and healthcare utilization. Both interventions reduced anxiety symptoms after use. Group differences in symptom change were not significant post-intervention (p = 0.16), but were at 3 months (favouring online CBT; p = 0.04) with male participants reporting more symptom change (p = 0.03). Across time-points, as anxiety symptoms decreased, QOL increased (p < 0.001). Among participants that provided healthcare utilization before and after intervention use, the greatest changes in use were among online CBT users particularly for mental health provider visits (psychiatrist, -41.0 % vs. +18.5 %; social worker, -42.5 % vs. -22.1 %), hospital-based care (emergency department visits, -80.0 % vs. +79.4 %; hospital admissions, -76.1 % vs. +42.9 %), and use of self-help or alternative treatments (-60.0 % vs. +6.6 %). Results suggest that, over time, use of online CBT by adolescents can result in improved anxiety symptoms and fewer use of other healthcare resources compared to traditional online information seeking.

Parenting Programme Structure, Potential Barriers, and Facilitators: A Scoping Review

Becoming a parent is a challenging transition, and stress factors may arise. This scoping review aims to map, from the literature, the structure, potential barriers, and facilitators to be considered when conducting a parenting programme for parents of children up to 3 years old. It followed the JBI methodology and included studies with parents of children up to 3 years old (Participants), studies about parenting programme structure, its potential barriers, and facilitators (Concept) in the healthcare or community setting (Context). Qualitative and/or quantitative study designs and grey literature publications between 2016 and 2021 were eligible. The search was performed in three stages in CINAHL Plus with Full Text, MEDLINE with Full Text, and PubMed databases. It was also conducted in OpenGrey, ProQuest, Portuguese Open Access Scientific Repository, and Google Scholar. Fourteen articles were selected. The following aspects were identified regarding parenting programmes: benefits; structuring elements to be considered; facilitating factors and possible barriers to its development, and measurement instruments to assess the programme. Parenting programmes are important ways to contribute to a healthy, sustainable, and resilient society. It should be adapted to individuals, groups, and communities. They add value to parents, children, and society and should be carefully adapted to the group's needs.

Family-based treatments for disruptive behavior problems in children and adolescents: An updated review of rigorous studies (2014-April 2020)

Disruptive behavior problems in youth are common and costly, lead to adverse outcomes, and are often left untreated. This article builds on previous work by providing an updated evaluation of family-based treatments based on results from randomized controlled trials (RCTs) for three populations: (1) children with disruptive behavior, (2) adolescents with disruptive behavior, and (3) adolescents with juvenile justice involvement. Using a comprehensive process, 28 new reports on 27 RCTs were identified for the 2014-April 2020 period, which when combined with the prior evidence base of all rigorous RCTs, resulted in 3 well-established, 11 probably efficacious, and 7 possibly efficacious family-based treatment categories. Many of the RCTs lent further support to existing treatment categories, more countries were represented, and several RCTs incorporated technology. Notable issues that remain include a limited number of family-based treatments for adolescents and for youth with juvenile justice involvement, as well as methodological concerns.