Understanding Who Benefits from Parenting Interventions for Children's Conduct Problems: an Integrative Data Analysis

Predictors and Moderators Two Treatments of Oppositional Defiant Disorder in Children

OBJECTIVE

The aim of this study was to examine predictors and moderators of behavioral improvement in children with Oppositional Defiant Disorder (ODD) following treatment with Parent Management Training (PMT) and Collaborative and Proactive Solutions (CPS). Initial problem severity, inconsistent discipline, parental attributions of child misbehavior, and child lagging cognitive skills were examined.

METHOD

One hundred and forty-five children aged between 7 and 14 (103 males, M = 8.88 years, ethnicity representative of the wider Australian population) were randomly assigned to PMT and CPS. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semi-structured diagnostic interviews and parent-ratings of ODD symptoms. Using an intent-to-treat sample in this secondary analysis (Murrihy et al., 2022), linear regressions and PROCESS (Hayes, 2017) were used to examine these predictors and possible moderators of treatment.

RESULTS

Higher pre-treatment levels of conduct problems, lagging skills, and inconsistent discipline predicted poorer behavioral outcomes following both treatments. The only characteristic that moderated treatment outcome was child-responsible attributions - mothers who were more likely to attribute their child's problematic behaviors to factors in the child had significantly poorer outcomes in PMT than CPS at 6-month follow-up.

CONCLUSIONS

CPS may be a more beneficial treatment than PMT for families who have been identified as having higher levels of child-responsible attributions before commencing treatment for ODD. While tentative, this provides promising insights as to how treatment outcomes for children with ODD may be improved.

Searching for who benefits most and least: An analysis of moderators of the TRUE Dads fatherhood intervention

Evaluations of interventions to promote fathers' involvement in family life typically focus on whether or not the intervention has a positive impact. Some evaluations also attempt to describe mediators that explain how the intervention is linked to specific outcomes. An evaluation of TRUE Dads, a Randomized Clinical Trial of a couples-based fatherhood intervention for low-income families, reported results that addressed these two issues. Reporting new analyses, the present study addresses a question asked in only a very few fatherhood intervention studies: Are there moderator variables that define characteristics of participants who benefit most or least from the intervention? A total of 46 potential moderators of 2 significant intervention outcomes - reductions in personal distress and in negative evaluations of the parents' relationship with each other - were selected from a 5-domain risk/protective model of family functioning (Cowan & Cowan, 2018. Journal of Family Theory & Review, 92, 111) and from a set of demographic variables associated with these outcomes. An additional 24 potential moderators were tested on 4 outcomes that did not have direct intervention effects. Only 6 of the 70 moderator tests were statistically significant. The intervention provided greater reductions in parents' personal distress when fathers had more economic resources, co-parents had higher levels of education, and the parents were living in the same household on entering the study. There were greater reductions in negative aspects of their couple or co-parenting relationship when the parents at enrollment described more difficulties in the parent-child relationship, fathers were more involved in the children's daily care and were living in the household with their child. No other moderators were found. The results support the conclusion that TRUE Dads was equally effective for a relatively wide range of participants. This search for potential moderators of TRUE Dads outcomes is presented as an example of a needed direction in the evaluation of fatherhood interventions.

Moderators of the Effects of a Digital Parenting Intervention on Child Conduct and Emotional Problems Implemented During the COVID-19 Pandemic: Results From a Secondary Analysis of Data From the Supporting Parents and Kids Through Lockdown Experiences (SPARKLE) Randomized Controlled Trial

BACKGROUND

A smartphone app, Parent Positive, was developed to help parents manage their children's conduct and emotional problems during the COVID-19 pandemic. A randomized controlled trial, Supporting Parents and Kids Through Lockdown Experiences (SPARKLE), found Parent Positive to be effective in reducing children's emotional problems. However, app effectiveness may be influenced by a range of child, family, socioeconomic, and pandemic-related factors.

OBJECTIVE

This study examined whether baseline factors related to the child, family, and socioeconomic status, as well as pandemic-related disruption circumstances, moderated Parent Positive's effects on child conduct and emotional problems at 1- and 2-month follow-up.

METHODS

This study was a secondary exploratory analysis of SPARKLE data. The data set included 646 children (4-10 years of age) with parents randomized to either Parent Positive (n=320) or follow-up as usual (n=326). Candidate baseline moderators included child age, gender, attention-deficit/hyperactivity disorder symptoms, parental psychological distress, family conflict, household income, employment status, household overcrowding, and pandemic-related disruption risk (ie, homeschooling, lockdown status, and isolation status). Child conduct and emotional problem outcomes measured at 1- (T2) and 2-months (T3) post randomization were analyzed using linear mixed-effects analysis of covariance models adjusting for baseline (T1) measure of outcome and including intervention and intervention by time point interaction terms allowing for different effects at the 2 time points. Moderation of intervention effects by baseline factors was assessed by replacing the intervention by time interaction terms with intervention by time point by baseline moderator interaction terms.

RESULTS

Child gender was a significant moderator of the Parent Positive versus follow-up as usual effect on emotional problems (B=0.72, 95% CI 0.12-1.33; P=.02). Specifically, the effect of Parent Positive was close to significant (T2: B=-0.41, 95% CI -0.82 to 0.0004; P=.05) or significant (T3: B=-0.76, 95% CI -1.22 to -0.30; P<.001) in males only when compared with females, and males experienced a significantly larger reduction in emotional problems than females in the Parent Positive arm at the 2-month post randomization time point. None of the other investigated baseline factors moderated effects on emotional problems, and no factors moderated effects on conduct problems.

CONCLUSIONS

This study highlights Parent Positive's potential for effectively reducing emotional problems in primary school-aged male children across a wide range of families. However, due to limited variability in the demographic background of the families, cautious interpretation is required, and replications are necessary in diverse samples with longer follow-up times.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04786080; https://clinicaltrials.gov/ct2/show/NCT04786080.

The Effectiveness of GenerationPMTO During Sustained Implementation in the Public Mental Health System: A Single-Arm Open Trial Evaluation

To support families and reduce the burden of child mental, emotional, and behavioral problems, evidence-based parenting interventions must remain effective in real-world service delivery contexts. The purpose of the current study was to evaluate the effectiveness of the GenerationPMTO (GenPMTO) intervention during sustained implementation in the Michigan public mental health system using a single-arm open trial (pre-post) design. We also examined potential predictors of treatment response. A multilevel analysis framework was utilized to evaluate data from 365 caregivers who completed GenPMTO treatment. Results revealed significant positive improvements from pretest to posttest in all four outcome domains (i.e., parenting confidence, parenting practices, caregiver depressive symptoms, child behavior problems). When compared to group-based GenPMTO delivery, the individual delivery format was associated with significantly greater improvements in overall effective parenting practices, as well as in the subdomain of skill encouragement. Caregiver gender, caregiver educational level, and child age were all implicated as predictors of GenPMTO outcomes. These findings add to the literature by supporting the effectiveness of the GenPMTO intervention when fully integrated into mental health care practice and can inform continued efforts to provide families with evidence-based services in community settings.

Is internet-based parent training for everyone? Predictors and moderators of outcomes in group vs. internet-based parent training for children with disruptive behavior problems

Parent training is an effective treatment for disruptive behavior problems in children. However, as there is limited access to traditional face-to-face treatment, other delivery formats have been evaluated. This study aims to evaluate possible predictors and moderators of outcome, completion and engagement in parent training when delivered in group or through the internet. A recent randomized controlled non-inferiority trial (N = 161) demonstrated equal effectiveness of the parent training program Comet when delivered in group (gComet) and through the internet (iComet). Demographic, clinical and theory-driven variables were studied to find predictors and moderators of treatment effect, completion and engagement. Linear mixed effects models were used to determine predictors and moderators of change in disruptive behavior from baseline to the 3- and 12-month follow-up. Most variables did not have significant predictive or moderating effects. However, there were some variables that predicted or moderated outcomes that may have implications for practice (e.g., comorbid emotional problems, preferred treatment format, and ADHD). This trial can contribute to guiding clinical work with children with disruptive behavior and results indicate that parent training in both treatment formats can be offered regardless of a range of demographic and clinical factors. Taking patients' treatment preferences into account can increase treatment completion.

Disrupting Maternal Transmission of Depression: Using Integrative Data Analysis (IDA) to Examine Indirect Effects of the Family Check-Up (FCU) Across Three Randomized Trials

Maternal depression is a well-established risk factor for the development of depression in offspring. As such, reducing maternal depression may be key to effective prevention efforts to reduce offspring's depression. Based on the broad risk represented by maternal depression, examining cross-over effects of parent-focused interventions on maternal depression is important. The present study examined improvements in maternal depression as a mediator of the long-term effects of the Family Check-Up (FCU) prevention program on youth depression across three randomized controlled trials. The FCU is a family-focused intervention originally designed to reduce youth problem behaviors, particularly conduct problems and substance use, but has also been found to have cross-over effects on other youth problem behaviors, including internalizing symptoms. We utilized integrative data analysis that allows for powerful tests of prevention effects across trials, specifically moderated nonlinear factor analysis, to integrate data across three trials: one trial initiated in early childhood and two in early adolescence. Using a latent growth modeling approach, we first examined direct effects of the FCU on changes in maternal depression. Then we examined the mediating effect of maternal depression on changes in both parent and youth reports of youth depression. A significant intervention effect on maternal depression was observed across the three trials, with the FCU predicting improvements in maternal depression. In turn, such improvements predicted a reduction in the growth in both parent and youth reports of youth depressive symptoms across 10 years post baseline. These results demonstrate the utility in addressing cross-over effects of family-focused interventions in reducing the long-term development of depression in youth through mediating pathways.

Cost-Effectiveness a Parenting Skills Program Implemented in Public PreK Schools in Disadvantaged Urban Communities

BACKGROUND

Little is known about the cost-effectiveness of parent training programs when offered universally in U.S. elementary schools in disadvantaged urban communities.

OBJECTIVE

To estimate the cost-effectiveness of a universal school-based implementation study of the Chicago Parent Program (CPP).

METHODS

CPP was offered universally from 2014 to 2017 to parents of PreK students in 12 Baltimore City Title 1 schools (n = 380; 61.1% Black/African American, 24.1% Hispanic). CPP program implementation and operating costs were estimated using microcosting methods and data drawn from study records. A Complier Average Causal Effects (CACE) framework was used to estimate an Incremental Cost Effectiveness Ratio (ICER) for CPP's average cost per child per 1% decrease in conduct problem prevalence at follow-up. This ICER was then compared with comparable ICERs for four parenting interventions that have been implemented and evaluated in Europe: Connect, Incredible Years, COPE, and Comet.

RESULTS

CPP cost $937.51 per child (95% CI: $902.09 to $971.92). Adjusted CACE estimates indicated that CPP resulted in a 31.4% reduction (95% CI: -39.7% to -23.9%) in conduct problem prevalence at follow-up among children whose parents attended CPP. The mean ICER for CPP was $29.86 per each 1% reduction in prevalence (95% CI: $21.05 to $50.71). CPP's ICER was similar to ICERs for Connect ($25.50) and COPE ($29.72), and less than ICERs for Incredible Years ($50.36) and Comet ($59.69).

CONCLUSION

School-based CPP offered universally to parents of children transitioning to Kindergarten in extremely disadvantaged U.S. urban communities was found to offer relatively good value compared with similar parenting programs that are widely used in Europe.

Effect of incredible years autism spectrum and language delays (IY-ASD) program on stress and behavioral management skills among parents of children with autism spectrum disorder in Palestine

PURPOSE

This study purposed to evaluate the effect of the Incredible Years Autism Spectrum and Language Delays (IY-ASD) program in reducing parents' stress and improving aggressive and disruptive behaviors in the parents among parents of children with autism spectrum disorder in Palestine.

DESIGN AND METHODS

A one-group pre-posttest design was used. Thirty-four parents who enrolled in the Palestinian Child Institute in Nablus were recruited.

RESULTS

Findings revealed a significant difference between parents' total stress pre and post-IY-ASD (t = 1.2, p < 0.01 and parents' behavioral management skills toward their children with autism spectrum disorder. The study demonstrated that the IY-ASD program for 16 sessions reduced stress among parents of children with autism spectrum disorder in Palestine and improved aggressive and disruptive behaviors in the parents.

CONCLUSION

The IY-ASD program can be successfully implemented for parents of this cohort group.

PRACTICE IMPLICATIONS

Healthcare providers can adopt such a program for enhancing parenting roles with their children experiencing autism spectrum disorder.

Student Behavior Ratings and Response to Tier 1 Reading Intervention: Which Students Do Not Benefit?

Core reading instruction and interventions have differential effects based on student characteristics such as cognitive ability and pre-intervention skill level. Evidence for differential effect based on affective characteristics is scant and ambiguous; however, students with problem behavior are more often non-responsive to core reading instruction and intensive reading interventions. In this study, we estimated the range of students' behavior ratings in which a core reading instruction intervention was effective using a data set including 3,024 students in K-3. Data came from seven independent studies evaluating the Individualized Student Instruction (ISI) Tier 1 reading intervention and were pooled using integrative data analysis. We estimated Johnson-Neyman intervals of student behavior ratings that showed a treatment effect both at the within and between classroom level. ISI was effective in improving reading scores (b=0.51, p=.020, d = 0.08). However, students with very low or very high behavior ratings did not benefit from the approaches (range of behavior rating factor scores: -0.95 - 2.87). At the classroom level, students in classrooms with a higher average of problem behaviors did not benefit from ISI (average classroom behavior rating factor score: 0.05 - 4.25). Results suggest differentiating instruction alone is not enough for students with behavior problems to grow in reading ability.

Behavioural and nondirective parent training for children with externalising disorders: First steps towards personalised treatment recommendations

For children with externalising disorders, parent training programmes with different theoretical foundations are available. Currently, there is little knowledge concerning which programme should be recommended to a family based on their individual needs (e.g., single parenthood). The personalised advantage index (PAI) indicates the predicted treatment advantage of one treatment over another. The aim of the present study was to examine the usefulness of this score in providing individualised treatment recommendations. The analysis considered 110 parents (per-protocol sample) of children (4-11 years) with attention-deficit/hyperactivity (ADHD) or oppositional defiant disorder (ODD), randomised to either a behavioural or a nondirective telephone-assisted self-help parent training. In multiple moderator analyses with four different regression algorithms (linear, ridge, k-nearest neighbors, and tree), the linear model was preferred for computing the PAI. For ODD, families randomised to their PAI-predicted optimal intervention showed a treatment advantage of d = 0.54, 95% CI [0.17, 0.97]; for ADHD, the advantage was negligible at d = 0.35, 95% CI [-0.01, 0.78]. For children with conduct problems, it may be helpful if the PAI includes the treatment moderators single parent status and ODD baseline symptoms when providing personalised treatment recommendations for the selection of behavioural versus nondirective parent training. TRIAL REGISTRATION: The study was registered prospectively with ClinicalTrials.gov (Identifier NCT01350986).

Maternal mental-health treatment moderates the association between psychological distress and harsh parenting: A prospective cohort study

OBJECTIVE

Parental psychological distress (depression, anxiety) is detrimental to child mental health. A key reason for this is that depressed and anxious parents are at risk of engaging in more negative, reactive and harsh parenting. While treatment for psychological distress has a long history of success in adults, less is known about how treatment for parental psychological distress may positively influence parenting behaviours, particularly in the general population. We examined the moderating role of mothers receiving treatment for depression or anxiety on the longitudinal relationship between maternal psychological distress and the development of harsh parenting (smacking and shouting) across early childhood (ages 3 to 7).

METHOD

Using prospective data from 16,131 families participating in the UK's Millennium Cohort Study, we conducted moderator analysis within a multilevel repeated measures model to test whether receiving treatment for mental health problems could protect mothers with high psychological distress from engaging in harsh parenting.

RESULTS

In each wave, about 7% of mothers reported undergoing treatment for depression or anxiety at that time. Maternal psychological distress was associated with increased use of harsh parenting and that, adjusting for psychological distress, receiving psychological treatment was related to decreased use of harsh parenting. Importantly, receiving psychological treatment buffered the negative effect of psychological distress on harsh parenting.

CONCLUSION

In early-to-middle childhood, mental health treatment may help mothers with depression or anxiety to be less harsh toward their children, thereby benefiting their child's psychological adjustment.

Exploring the Mechanisms in Cognitive Behavioural Therapy for Anxious Children: Does Change in Emotion Regulation Explain Treatment Effect?

Cognitive behavioural therapy (CBT) for childhood anxiety has shown moderate effects. However, inconsistency in findings during the last decades of treatment research and lack of measurable treatment gains over time has led to a call for optimizing interventions by identifying the active mechanisms involved and for whom such interventions are effective. It has been suggested that the moderate effects may be explained by the fact that emotion regulation rarely is directly targeted in CBT-interventions and that interventions may be more effective for children with a certain level of problems with emotion regulation. Using data from a randomized controlled trial with 160 children and their mothers at baseline (t1) and posttreatment (t2), we examined whether being randomized to CBT predicted change in anxiety symptoms from t1 to t2 and whether this change was mediated by change in emotion regulation from t1 to t2. We also investigated whether the strength of this indirect pathway depended on the level of emotion regulation problems at baseline. Latent baseline target moderated mediation analyses within a structural equation modelling framework were conducted. Results showed a significant indirect pathway between receiving CBT to improved emotion regulation, which again was significantly associated with reductions in anxiety symptoms. The findings suggest that the effect of CBT is similar for children irrespective of initial levels of emotion regulation measured broadly, whereas there was some evidence of a baseline moderation effect of the subdomain emotional control. Emotion regulation, and especially emotional control, seems to be an underlying mechanism for positive effects of CBT for anxiety disorders in children, possibly indicating that a greater emphasis on emotion regulation may optimize the intervention.

Exploring Parenting Profiles to Understand Who Benefits from the Incredible Years Parenting Program

Behavioral parenting programs are a theory-driven and evidence-based approach for reducing disruptive child behavior. Although these programs are effective on average, they are not equally effective in all families. Decades of moderation research has yielded very few consistent moderators, and we therefore still have little knowledge of who benefits from these programs and little understanding why some families benefit more than others. This study applied a baseline target moderation model to a parenting program, by (1) identifying parenting profiles at baseline, (2) exploring their correlations with other family characteristics and their stability, and (3) assessing whether they moderate intervention effects on child behavior. Individual participant data from four Dutch studies on the Incredible Years (IY) parenting program were used (N = 785 caregiver-child dyads). Children (58.2% boys) were at risk of disruptive behavior problems and aged between 2 and 11 years of age (M = 5.85 years; SD = 1.59). Latent profile analyses indicated three distinct baseline parenting profiles, which we labeled as follows: Low Involvement (81.4%), High Involvement (8.4%), and Harsh Parenting (10.1%). The profiles caregivers were allocated to were associated with their education, minority status, being a single caregiver, and the severity of disruptive child behavior. We found neither evidence that baseline parenting profiles changed due to participation in IY nor evidence that the profiles predicted program effects on child behavior. Our findings do not support the baseline target moderation hypothesis but raise new questions on how parenting programs may work similarly or differently for different families.

Family Functioning in Hispanic Parents of Adolescents: Who Benefits Most from a Family-Based HIV and Substance Use Preventive Intervention?

To understand which families are likely to benefit most from resource-intensive family-based, evidence-based interventions (EBIs), we must examine the key, modifiable determinant of family functioning. The purpose of this study was to (1) identify whether there are subgroups of Hispanic parents that differ meaningfully based on their family functioning at baseline, (2) test whether the Familias Unidas preventive intervention was differentially effective across the baseline family functioning subgroups, and (3) understand the mechanisms of intervention effectiveness within each baseline family functioning subgroup. On a pooled data set of 4 completed efficacy and effectiveness trials of Familias Unidas (n = 1445 low-income, Hispanic immigrant origin, parents and their adolescent between the ages of 12-17), we conducted a series of secondary data analyses. Latent profile analyses revealed four significantly different profiles: (1) low family functioning (n = 210, 14.55%), (2) low-to-moderate family functioning (n = 554, 38.39%), (3) moderate-to-high family functioning (n = 490, 33.96%), and (4) high family functioning (n = 189, 13.10%). A structural equation modeling approach found there were significant differences in intervention effectiveness between the subgroups. The low family functioning subgroup experienced gains in family functioning, and in turn, lower levels of adolescent substance use, internalizing, and externalizing symptoms. The high family functioning subgroup showed significant direct effects of the intervention on adolescent substance use, internalizing, and externalizing symptoms, but no indirect effects through improvements in family functioning. Implications for screening, targeting, and adapting interventions are discussed.

Mindfulness and Imagery Enhanced Behavioral Parenting: Effectiveness Pilot of the Confident Carers Cooperative Kids Program

Mindfulness is increasingly offered to parents of children presenting with behavioral problems, either as a stand-alone intervention, or integrated within existing behavioral parenting interventions. There is relatively modest support for mindful parenting, with small to medium effect size improvements demonstrated across child and parent outcome measures. Here we introduce a mindfulness and imagery enhanced behavioral parenting program. We argue blending mindfulness, imagery and behavioral skills could produce improved parenting engagement and perseverance, leading to stronger outcomes. Pilot data is presented from two contrasting real world clinical settings. Parents attending the 8-week Confident Carers Cooperative Kids (CCCK) group program in a university clinic setting were invited to be included in the study (n = 20). Permission was also gained to use archival data from a community organisation offering CCCK groups to parents who were at risk of child welfare involvement (n = 14). Pre- and post-intervention measures were completed across both groups on parent-reported child behavior, parent wellbeing, adaptive parenting, and mindful parenting. Parents from both groups achieved significant pre- to post-intervention improvements in child behavior problems, parent wellbeing, adaptive parenting, and mindful parenting, with large effect sizes. Larger improvements in child behavior problems were reported by parents from the community group compared with the university group. The CCCK intervention appears beneficial across child and parent outcomes, including for families most in need. A larger sample is required to replicate and extend these promising findings.

Effectiveness of mindfulness-based intervention in the improvement of maternal role adaptation among first time mothers: A randomized controlled trial

BACKGROUND AND PURPOSE

Mindfulness-based intervention (MBI) has been suggested as a method to alleviate mental health difficulties during the perinatal period. However, few studies have examined its use in improving maternal role adaptation. This study aimed to investigate the effectiveness of mindfulness in maternal role adaptation among first-time mothers.

MATERIALS AND METHODS

This randomized controlled trial study was performed on 40 first-time mothers who were randomly assigned into experimental (n = 20) and control (n = 20) groups. Research instruments included a demographic questionnaire and a validated Maternal Role Adaptation Questionnaire (MRAQ). In addition to receiving routine care, mothers in the experimental group attended eight 90-min sessions of mindfulness-based intervention. The control group, however, received only routine care. Both groups completed MRAQ before intervention, and immediately, one month, and two months after it.

RESULTS

After intervention, there was a significant increase in the mean scores of MRAQ and its seven domains in the experimental group at all three follow-up intervals (P < 0.001). These domains included "support and strengthening of the couples' relationships", "hardship and dissatisfaction", "mother-infant attachment", "stress and anxiety", "emotional growth", "functionality" and "social adaptation development".

CONCLUSION

The intervention implemented in this study could be effective in promoting maternal role adaptation.

Changes in Prosocial Behaviors Among Children With Behavioral Problems Following Incredible Years Parenting Program

Parenting programs often train parents in improving their parenting practices and parent-child relationship to reduce behavioral problems in children. However, the children's prosocial behaviors are less examined as an intervention outcome in these programs. This study aimed to evaluate the effectiveness of the Incredible Years parenting program (IYPP) for Malaysian parents of school-going children and its sustainability in improving the children's prosocial behaviors. This randomized controlled study involved pre- and post-intervention assessments at 2 and 14 weeks. Mothers of children aged 6-12 years (n = 70) recruited through the pediatrics and the child and adolescent psychiatric clinics were randomly assigned to the parenting program or a waitlist control condition. The mothers rated their children's prosocial behaviors using a self-administered questionnaire. The program ran two to three hours weekly for 14 weeks. Several modifications were made to the program to accommodate public health control during the pandemic. Children in the intervention group showed a notable but non-significant increase in prosocial skills. However, subsequent score decline at follow-up may suggest a lack of evidence that the program is potentially effective in improving prosocial behaviors among school children who are at risk of or already having behavioral problems.

Annual Research Review: Cross-cultural similarities and differences in parenting

This article reviews contemporary research on cross-cultural similarities and differences in parenting. The article begins by providing a definition of culture and how both parenting and culture can change over historical time. The article then presents some classic theoretical frameworks for understanding culture and parenting before considering why parenting may be similar across cultures and why parenting may be different across cultures. The article next turns to a review of cross-cultural similarities and differences in several aspects of parenting, including physical caregiving, cognitive stimulation, warmth and acceptance, control and monitoring, and discipline. Cultural normativeness and beliefs on the legitimacy of parental authority are then considered as potential moderators that contribute to cross-cultural similarities and differences in relations between parenting and child outcomes. The article then considers implications for parenting interventions and laws and policies related to parenting. Finally, the article suggests directions for future research.

Parent Management Training Combined with Group-CBT Compared to Parent Management Training Only for Oppositional Defiant Disorder Symptoms: 2-Year Follow-Up of a Randomized Controlled Trial

Parent management training (PMT) is recommended treatment for children with oppositional defiant disorder (ODD) and child-directed cognitive behavior therapy (CBT) is also recommended for school-aged children. The current study examined 2-year follow-up effects of parent management training (PMT) combined with the CBT based group intervention Coping Power Program (CPP) compared to PMT only. Results showed long-term effectiveness of both PMT and PMT combined with CPP in reduced disruptive behavior problems and harsh parenting strategies, and increased emotion regulation- and social communication skills. The earlier reported increase in emotion regulation- and social communication skills in the PMT with CPP condition during treatment remained stable while the PMT condition showed continued improvement during the follow-up period. To conclude, PMT with CPP did generally not provide significant benefits at the 2-year follow-up compared to PMT, apart from an improvement earlier in time regarding emotion regulation- and social communication skills.Trial registration number ISRCTN10834473, date of registration: 23/12/2015.

Effectiveness of a Preventive Parenting Program Combining Attachment and Behavioral Approaches in an Arab Context: a Cluster-Based Randomized Control Trial

Parenting programs aim to help parents and carers enhance their skills and ameliorate infants' and toddlers' wellbeing. In Lebanon and other Arab countries, contextualized group-based parenting programs addressing parents' mental wellbeing, parenting styles, and child development are quite rare. Therefore, a Preventive Parenting Program consisting of 7 sessions has been designed by local experts for the local cultural context. This study aims to assess its effectiveness. Thirty-three sites were identified in Great Beirut: private firms, primary healthcare centers, and child daycares. Sixteen agreed to take part in the study and were randomly assigned to intervention and control arms. From these clusters, 191 mothers of typically developed children younger than three years were recruited to intervention (106) or control (85) groups. The Mental Health Inventory, Caregiver Knowledge about Child Development Inventory, Parent Authority Questionnaire, and a Demographic questionnaire were completed at pre-intervention and post-intervention and 3 months later by both groups of mothers. There were no significant differences between clusters with respect to all scales' scores at baseline as well as the 2 other data collection points. Despite the positive feedback collected from mothers who attended the sessions, no significant effects were detected. The design of the program, the expected outcomes, and the characteristics of the participants may have contributed to the limited results, hence the need for further research.

Clinical Presentation and Treatment of Early-Onset Behavior Disorders: The Role of Parent Emotion Regulation, Emotion Socialization, and Family Income

Parent emotion regulation and socialization have been linked to various aspects of child functioning. In the case of early-onset behavior disorders in particular, parent emotion regulation may be an important correlate of the coercive cycle implicated in early-onset behavior disorders thus, symptom presentation at baseline. Further, emotion socialization may be complicated by a pattern of parent-child interactions in which both supportive or unsupportive parenting behaviors in response to behavioral dysregulation may increase vulnerability for problem behavior in the future. Some work suggests standard Behavioral Parent Training may impact parent emotion regulation and socialization. Still little is known, however, about how such processes may vary by family income, which is critical given the overrepresentation of low-income children in statistics on early-onset behavior disorders. This study explored parent emotion regulation, socialization, and family income in a sample of socioeconomically diverse treatment-seeking families of young (3–8 years old) children. Findings suggest relations between parental emotion regulation, socialization, and child behavior although the pattern of associations differed at baseline and post-treatment and varied by family income. Clinical implications and future directions are discussed.

Teaching Parents to Be Responsive: A Network Meta-analysis

CONTEXT

Children who receive more responsive care during their early childhood tend to exhibit stronger cognitive development, mental well-being, and physical health across their life course.

OBJECTIVE

Determine how to design effective responsivity training programs for caregivers.

DATA SOURCES

We searched seven electronic databases through October 2020.

STUDY SELECTION

Randomized trials (k = 120) of programs training parents of children ages 0 to 6 to be more responsive.

DATA EXTRACTION

Two reviewers independently extracted data. Data were pooled by using random-effects pairwise and network meta-analyses.

RESULTS

Programs had, on average, a medium effect (d = 0.56; 95% confidence interval [CI]: 0.47 to 0.65). The most effective programs included didactic teaching and opportunities for parents to observe models, practice skills, and receive feedback (d = 1.07; 95% CI: 0.37 to 1.77), or all these instructional methods in addition to reflection (d = 0.86; 95% CI: 0.64 to 1.09). Programs that had participants observe examples of responsivity (d = 0.70; 95% CI: 0.57 to 0.83), used researchers as facilitators (d = 0.89; 95% CI: 0.66 to 1.12), assigned homework (d = 0.85; 95% CI: 0.66 to 1.02), and had a narrow scope (d = 0.72; 95% CI: 0.57 to 0.87) were more effective than those that did not.

LIMITATIONS

Most samples included only mothers from Western countries and lacked follow-up data.

CONCLUSIONS

Having parents observe examples of responsive caregiving and complete home-practice in short, focused programs may be an effective, scalable approach to enhancing responsivity in the general population and reducing inequalities in child development.

Technology-Assisted Parenting Interventions for Families Experiencing Social Disadvantage: a Meta-Analysis

Technology-assisted interventions have been identified as a means to increase accessibility and enhance engagement of parenting programs. The current meta-analytic review examines the effectiveness of these interventions in families experiencing social disadvantage. A literature search was conducted spanning March 2007-June 2019. Nine studies met inclusion criteria (total of 864 participants) which included an evaluation of a parenting intervention for families with at least one of the following demographic challenges, low socioeconomic status, single parenthood, and/or young parenthood. Interventions (or a component of the intervention) were delivered by computer, cell phone, smartphone, and/or tablet. Data were organized into three categories: parental psychological well-being (e.g., self-esteem, social support), parenting (e.g., observed or self-reported parenting behavior), and child behavior (e.g., disruptive behavior). Effect sizes (Hedges' g) were calculated and moderators (i.e., contact with an interventionist, intervention length, publication year, % female parents, mean parent age, parental education, % minority, and child age) were examined through Q-statistics and meta-regression, as appropriate. Intervention showed a near-significant impact on parental psychological well-being (g = .35, p = .051). Furthermore, interventions that did not include direct contact with an interventionist showed no evidence of effectiveness (g = - .02); interventions that incorporated contact were significantly more effective (g = .68). In addition, intervention length moderated intervention effectiveness; shorter interventions yielded greater improvements in well-being, compared with longer interventions. Interventions were also associated with significant improvements in parenting (g = .38) and child behavior (g = .39). These findings provide support for the use of technology-assisted parenting interventions in populations experiencing social disadvantage.

Patterns and Predictors of Different Youth Responses to Attachment-Based Parent Intervention

Objective: Few studies have evaluated attachment-based parent interventions for pre-teens and teens, and in particular, differential adolescent trajectories of response. This study examined distinct patterns, and multi-level predictors, of intervention response among youth with serious behavioral and mental health problems whose parents participated in Connect, an attachment- and trauma-informed parent program.Method: Participants included 682 parents (M_age = 42.83, 86% mothers) and 487 youth (M_age = 13.95, 53% female, 28.1% ethnic minority) enrolled in a community-based evaluation of Connect. Parents and youth reported on youth externalizing and internalizing problems (EXT and INT) at six time points from baseline through 18-months post-intervention. Demographic and youth and family level predictors were assessed at baseline.Results: Growth mixture modeling revealed three distinct trajectory classes in both the parent and youth models based on different patterns of co-occurring EXT and INT and degree of improvement over time. Youth with severe EXT showed the largest and fastest improvement, and, interestingly, were characterized by higher callous-unemotional traits and risk-taking at program entry. Youth with comorbid EXT/INT demonstrated a partial or moderate response to intervention in the parent and youth model, respectively, and were characterized by more attachment anxiety at baseline. Most youth showed relatively moderate/low levels of EXT/INT at baseline which gradually improved. Caregiver strain also predicted trajectory classes.Conclusions: These results have significance for tailoring and personalizing interventions for high-risk youth and provide new understanding regarding the profiles of subgroups of youth who show different responses to an attachment-based parent intervention.

Moderators of Psychosocial Intervention Response for Children and Adolescents with Conduct Problems

Objective: The purpose of this Brief Report is to synthesize the current evidence base examining moderators of psychosocial intervention response for children and adolescents with conduct problems (CP). We also provide directions for future research.Method: We focused on four categories of psychosocial interventions for the prevention and/or treatment of CP: (1) parent management training (PMT) for children, (2) other family-based interventions for adolescents, (3) youth skills training, and (4) multicomponent interventions (i.e., family-based intervention plus skills training). Emphasis is placed on findings from meta-analyses.Results: Moderation analyses have occurred more frequently for PMT than for other types of interventions. Variables for which there was consistent evidence for positive moderation included higher initial severity of CP, father engagement, higher maternal depressive symptoms, individual administration (vs. group), and treatment/targeted prevention approaches (vs. universal prevention). Variables where there was evidence for no moderation (demonstrating generalizability) included child diagnostic status and family risk in PMT, and diagnostic status and intervention setting for skills training. However, for some variables, evidence of moderation was dependent on intervention type.Conclusions: Future research should examine multiple moderators in combination; incorporate innovative techniques such as integrative data analyses, individual participant data, and class-based modeling, which may identify moderator effects that are undetected by more traditional variable-oriented moderation analyses; and conduct moderated mediation models for informing developmental theory on the interplay of risk and protective factors.

"Since his birth, I've always been old" the experience of being parents to children displaying disruptive behavior problems: a qualitative study

BACKGROUND

Being parents of children who display disruptive behavior problems (DBP) can pose several challenges. Interventions for children with DBP are primarily outpatient group parent training (PT) programs. The purpose of this study was to explore how parents of children with disruptive behavior problems, diagnosed with oppositional defiant disorder (ODD), describe the difficulties they face in their family and parenting situations.

METHODS

Nineteen parents of children aged 3 to 8 years who had searched for help and signed up for a parent training program provided by Child and Adolescent Mental Health Service participated in the study. Semi-structured diagnostic interviews and a modified background interview adapted for the purpose of the study were conducted before parents entered the program. All children included in the study met the DSM criteria for ODD. The interviews were audiotaped and transcribed. Thematic analysis was used to examine, identify, and report patterns of meaning in the data. The analysis was conducted inductively using a contextual approach.

RESULTS

Parents described their own vulnerability, how they were affected by the parent-child interaction, and the challenges they perceived in their parenting practices. The study contributes to an understanding of the complexity that parents of children with ODD perceive in everyday life.

CONCLUSIONS

The parents in the study highlight the need to address parents' own mental health problems, parental alliance, capacity for emotion regulation, perceived helplessness as parents, lack of parental strategies, sense of isolation, and absence of supportive social networks. All these factors could be important when tailoring interventions aimed to help and support parents of children who display DBP, and specifically ODD.

Individual Participant Data Meta-analysis: Impact of Conduct Problem Severity, Comorbid Attention-Deficit/Hyperactivity Disorder and Emotional Problems, and Maternal Depression on Parenting Program Effects

OBJECTIVE

There is concern whether established parenting programs for children's conduct problems meet the needs of families with severe and complex mental health problems. For example, many children with conduct problems show comorbid attention-deficit/hyperactivity disorder (ADHD) or emotional problems, or have parents who are depressed, but families with such complex mental health problems typically seen in real life are often underrepresented in evaluation trials. We tested whether children with more severe conduct problems, and those with more complex mental health problems, benefit less from the Incredible Years parenting program, using individual participant data meta-analysis of randomized trials in Europe.

METHOD

In 1,696 families from 13 children aged (child age 2-11 years; 37% girls; 58% low income; 30% ethnic minority; 98% mothers), we used moderator analysis within a multilevel model to test whether initial conduct problem severity, comorbid ADHD or emotional problems, and maternal depression would diminish intervention effects for children's conduct problems.

RESULTS

The Incredible Years program reduced children's conduct problems overall (Cohen's d = -0.35), but more so in children with more severe conduct problems. There was no evidence that children's comorbid ADHD and emotional problems changed the intervention benefits. Children of mothers with more depressive symptoms benefited more.

CONCLUSION

Children with more severe conduct problems derive greater, rather than lesser, benefits from a high-quality group parenting program, and comorbid ADHD and emotional problems do not reduce effects; maternal depression, rather than being linked to less child change, was associated with greater reductions in children's conduct problems.

Do Comorbid Oppositional Symptoms Predict ADHD Behavioral Treatment Outcomes?

Parent management training (PMT) is considered a best-practice for treating childhood ADHD. However, the magnitude of change in response to PMT differs across individuals. This study examined comorbid oppositional symptoms as a predictor of ADHD treatment outcomes. We predicted children with more severe baseline oppositionality would exhibit greater improvements in externalizing behaviors overall, including core ADHD symptoms. Participants consisted of 67 children aged 7-10 diagnosed with ADHD-Combined Type. Participants and their families received a manualized ten-session intervention, Family Skills Training for ADHD-Related Symptoms (Family STARS), combining PMT with a simultaneously occurring child skills training intervention. Pre- and post-treatment parent and teacher rating scales were collected to assess changes in ADHD and oppositional symptoms. Results demonstrated that children with more severe ratings of oppositional behaviors achieved commensurate ADHD symptom outcomes compared to those with less severe oppositionality. Implications are discussed with regard to the utilization of ADHD impairment-specific treatment targets.

Families Who Benefit and Families Who Do Not: Integrating Person- and Variable-Centered Analyses of Parenting Intervention Responses

OBJECTIVE

Families with disruptive child behavior are typically referred to services based on children's behavior alone, rather than on underlying mechanisms of disruptive behavior. Yet, the presence of the precise mechanisms targeted by services might be essential for intervention success. We integrated person- and variable-centered approaches to test whether families with combined disruptive child behavior and harsh/inconsistent parenting indeed benefit most from a behavioral parenting intervention in indicated prevention context, compared to families with disruptive child behavior but less harsh/inconsistent parenting, and families with less severe disruptive behavior.

METHOD

Families (N = 387) of children aged 4 to 8 years (disruptive behavior >75^th percentile) participated in a randomized trial of the Incredible Years parenting intervention (Trial NTR3594, www.trialregister.nl). We identified different response trajectories and tested whether families with combined child and parenting difficulties had a higher probability of responding well, compared to families with only child difficulties or less severe difficulties.

RESULTS

Most intervention group families (82%) showed a nonresponse trajectory. A minority (18%) showed a response trajectory with strong reductions in disruptive behavior (Cohen's d =1.45). As expected, families with both child and parenting difficulties were most likely to respond: 20% more than families with only child difficulties, and 40% more than families with less severe difficulties.

CONCLUSION

Incredible Years, as an indicated prevention program, benefits mainly families in which the mechanisms targeted by the intervention (ie, harsh/inconsistent parenting) is actually present, rather than all families. Careful matching of children to services based on assessments of both child and parenting behavior seems critical for intervention success.

CLINICAL TRIAL REGISTRATION INFORMATION

ORCHIDS: Study on Children's Genetic Susceptibility to Their Environment; https://www.trialregister.nl; 3594.

Parenting Programs for Underserved Populations in Low- and Middle-Income Countries: Issues of Scientific Integrity and Social Justice

Research suggests that parenting programs are effective for preventing behavioral and emotional difficulties in children, but a lot more attention needs to be paid to issues of context and culture during the development, testing and implementation of these interventions. The views and needs of underserved and disenfranchised communities in the US and the Global South are often not taken into account for the development and testing of interventions. The successful implementation of evidence-based interventions for vulnerable children and families in underserved and marginalized communities requires careful consideration of how existing paradigms of prevention, evaluation, and implementation science impact issues of social justice and equity. This paper will describe how a team of parenting program researchers has been collaborating with their partners globally in generating local knowledge by balancing the need for rigorous scientific methods with issues of power. Authors from the U.S., Latin America, Africa and Southeast Asia draw on their experiences regarding challenges and successes with issues regarding study design and measurement, the transferability and adaptation of interventions, and the dissemination and implementation of different parenting interventions while placing communities at the center of their efforts through participatory methods. We describe innovative approaches that span the continuum of intervention development, adaptation, optimization, evaluation, implementation, and scale up of different parenting programs for vulnerable children and families across the world. We conclude by offering specific and pragmatic recommendations to increase access of culturally relevant and effective parenting programs in these communities.

Healing through Parenting: An Intervention Delivery and Process of Change Model Developed with Low-Income Latina/o Immigrant Families

Low-income Latinas/os are exposed to widespread mental health disparities in the United States. Most recently, a resurgence of anti-immigration narratives has led vulnerable Latina/o immigrants to experience considerable contextual stressors with multiple deleterious consequences for their overall well-being, including significant disruptions to their parenting practices. Within this context of adversity and despite the multiple benefits associated with parent training (PT) prevention interventions, the availability of contextually and culturally relevant PT interventions remains limited in underserved Latina/o communities. This paper constitutes a contribution to this gap in knowledge by presenting a model of intervention delivery utilized in the dissemination of culturally adapted versions of the evidence-based intervention known as GenerationPMTO.^© The proposed model also describes a process of change that we have documented in empirical research with low-income Latina/o immigrant parents who have been exposed to the adapted interventions. The manuscript is organized in four sections. First, an overview of the model is discussed, along with a brief summary of major theories. Next, the core components of the model are described, complemented by the presentation of a case study. Finally, implications for prevention and clinical intervention are discussed.

Strengthening a Culture of Prevention in Low- and Middle-Income Countries: Balancing Scientific Expectations and Contextual Realities

Relevant initiatives are being implemented in low- and middle-income countries (LMICs) aimed at strengthening a culture of prevention. However, cumulative contextual factors constitute significant barriers for implementing rigorous prevention science in these contexts, as defined by guidelines from high-income countries (HICs). Specifically, disseminating a culture of prevention in LMICs can be impacted by political instability, limited health coverage, insecurity, limited rule of law, and scarcity of specialized professionals. This manuscript offers a contribution focused on strengthening a culture of prevention in LMICs. Specifically, four case studies are presented illustrating the gradual development of contrasting prevention initiatives in northern and central Mexico, Panamá, and Sub-Saharan Africa. The initiatives share the common goal of strengthening a culture of prevention in LMICs through the dissemination of efficacious parenting programs, aimed at reducing child maltreatment and improving parental and child mental health. Together, these initiatives illustrate the following: (a) the relevance of adopting a definition of culture of prevention characterized by national commitments with expected shared contributions by governments and civil society, (b) the need to carefully consider the impact of context when promoting prevention initiatives in LMICs, (c) the iterative, non-linear, and multi-faceted nature of promoting a culture of prevention in LMICs, and (d) the importance of committing to cultural competence and shared leadership with local communities for the advancement of prevention science in LMICs. Implications for expanding a culture of prevention in LMICs are discussed.

Moderators Influencing the Effectiveness of a Behavioral Teacher Program

Objective: This study assessed which moderators influenced the effectiveness of a low-intensive behavioral teacher program for children with symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD).

Methods: Primary school children (N = 114) with ADHD symptoms in the classroom were randomly assigned to the intervention program (n = 58; 91% male) or control group (n = 56; 77% male). Multilevel regression analyses assessed differential treatment gains of the intervention program in terms of ADHD symptoms and social skills. Moderators included demographic characteristics (gender, age, parental educational level), severity and comorbidity of problem behavior (ADHD symptoms, conduct and internalizing problems), social functioning, and classroom variables (teaching experience, class size).

Results: Results revealed larger program effects for older children and children from highly educated families and smaller beneficial effects for children with comorbid conduct or anxiety problems.

Conclusion: The intervention program seems more beneficial for highly educated families and children without comorbid problem behavior, but more intensive treatments appear necessary for children facing additional challenges.

ClinicalTrials.gov registration number: NCT02518711