Intervention Effectiveness of The Incredible Years: New Insights Into Sociodemographic and Intervention-Based Moderators

Incredible years parenting program buffers prospective association between parent-reported harsh parenting and epigenetic age deceleration in children with externalizing behavior

Harsh parenting has been shown to increase the risk of physical and mental health problems in later life. To improve our understanding of these risks and how they can be mitigated, we investigated associations of harsh parenting with a clinically relevant biomarker, epigenetic age deviation (EAD), using data from a randomized-control trial of the Incredible Years (IY) parenting program. This study included 281 children aged 4-8 years who were screened for heightened externalizing behavior and whose parents were randomly allocated to either IY or care-as-usual (CAU). Parents reported on their own parenting practices and their child's externalizing behavior at baseline and at a follow-up assessment approximately three years later. Epigenetic age, based on the Pediatric Buccal Epigenetic (PedBE) clock, was estimated from child DNA methylation derived from saliva collected at the follow-up assessment. PedBE clock estimates were regressed on chronological age as a measure of EAD. Moderation analyses using multiple regression revealed that harsher parenting at baseline predicted epigenetic age deceleration in children that received CAU (b = -.21, 95% CI[-0.37, -0.05]), but no association was found in children whose parents were allocated to IY (b = -.02, 95% CI [-0.13, 0.19]). These results highlight a prospective association between harsh parenting and children's EAD and indicate a potential ameliorating effect of preventive intervention. Future work is needed to replicate these findings and understand individual differences in children's responses to harsh parenting in relation to epigenetic aging.

DNA methylation variation after a parenting program for child conduct problems: Findings from a randomized controlled trial

This study investigated associations of the Incredible Years (IY) parenting program with children's DNA methylation. Participants were 289 Dutch children aged 3-9 years (75% European ancestry, 48% female) with above-average conduct problems. Saliva was collected 2.5 years after families were randomized to IY or care as usual (CAU). Using an intention-to-treat approach, confirmatory multiple-regression analyses revealed no significant differences between the IY and CAU groups in children's methylation levels at the NR3C1 and FKBP5 genes. However, exploratory epigenome-wide analyses revealed nine differentially methylated regions between groups, coinciding with SLAMF1, MITF, FAM200B, PSD3, SNX31, and CELSR1. The study provides preliminary evidence for associations of IY with children's salivary methylation levels and highlights the need for further research into biological outcomes of parenting programs.

Parent training for 842 families experiencing disruptive child behavior across 19 Danish community sites: A benchmark effectiveness study

Interactional processes between child and parents, in particular harsh and coercive parenting practices, have been established as important factors maintaining and shaping the developmental trajectory of disruptive child behavior. The Incredible Years Parent Training (IYPT) is a well-established evidence-based program targeting negative parent-child interactions in families with children exhibiting high levels of disruptive behaviors. There are, however, few studies investigating the effectiveness of the IYPT when implemented in established practice settings independently from research environments. Also, very little evidence exists for the program's effectiveness for school-aged children. The IYPT was administered to consecutive groups of parents (N = 842) across 19 Danish community sites during the period from 2012 to 2019. Pre and post data were collected using the Eyberg Child Behavior Inventory (ECBI). By means of a benchmark approach, the effectiveness of the intervention was compared with that of two European effectiveness randomized controlled trials. Large effect sizes were seen from pre to post for both parent-reported number of problematic disruptive child behaviors (ECBI Problem subscale; d = 1.51, p = 0.000, 95% CI [9.06-10.01]) and frequency of these behaviors (ECBI Intensity subscale; d = 1.15, p = 0.000, 95% CI [29.33-32.73]). Treatment effects found in this study are comparable to or larger than those found in previous effectiveness studies and show the IYPT to be an effective intervention when implemented across a range of different community settings in a large community sample of children across an age span of 2 to 12 years.

Does Social and Economic Disadvantage Predict Lower Engagement with Parenting Interventions? An Integrative Analysis Using Individual Participant Data

There is a social gradient to the determinants of health; low socioeconomic status (SES) has been linked to reduced educational attainment and employment prospects, which in turn affect physical and mental wellbeing. One goal of preventive interventions, such as parenting programs, is to reduce these health inequalities by supporting families with difficulties that are often patterned by SES. Despite these intentions, a recent individual participant data (IPD) meta-analysis of the Incredible Years (IY) parenting program found no evidence for differential benefit by socioeconomic disadvantage (Gardner et al. in Public Health Resesearch 5, 1-144, 2017). However, it did not examine whether this was influenced by engagement in the intervention. Using intervention arm data from this pooled dataset (13 trials; N = 1078), we examined whether there was an SES gradient to intervention attendance (an indicator of engagement). We ran mixed-effects Poisson regression models to estimate incidence rate ratios (IRRs) for program attendance for each of five (binary) markers of SES: low income; unemployment; low education status; teen parent; and lone parent status. The multilevel structure of the data allowed for comparison of within-trial and between-trial effects, including tests for contextual effects. We found evidence that low SES was associated with reduced attendance at parenting programs-an 8-19% reduction depending on the SES marker. However, there was no evidence that this association is impacted by differences in SES composition between trials or by the attendance levels of higher-SES families. The findings underscore the importance of developing and prioritizing strategies that enable engagement in parenting interventions and encourage program attendance by low-SES families.

Cross-cultural adaptability of parenting interventions designed for childhood behavior problems: A meta-analysis

The dissemination of parenting interventions is one of the advised approaches to globally counteract childhood behavior problems, delinquency, and future criminal careers. Many of these interventions are developed in Anglosphere countries and transported to other contexts with distinct cultural backgrounds. However, there are no meta-analyses evaluating the overall effectiveness of these Anglosphere parenting programs in non-Anglosphere settings. This meta-analysis aimed to examine the effectiveness of parenting interventions developed in Anglosphere countries when transported to non-Anglosphere countries, as well as compare effectiveness levels between Anglosphere and non-Anglosphere trials; and analyze the impact of research and contextual factors in the dissemination of these interventions. Parenting interventions were included if they were: created in an Anglosphere setting; tested in non-Anglosphere countries; focused on reducing childhood behavioral problems; designed for children ranging from two to 12 years old; and tested in an experimental randomized trial. A random-effects model was selected for our meta-analysis. Standardized mean differences, confidence intervals and prediction intervals were also computed. Twenty studies were included, and results suggest that parenting interventions designed for childhood behavior problems can be transported to non-Anglosphere countries and potentially maintain effectiveness. This study is a relevant contribution to the evidence of cross-cultural transportability of parenting interventions.

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.

Behavioral Parent Training for Preschool ADHD: Family-Centered Profiles Predict Changes in Parenting and Child Outcomes

OBJECTIVE

Behavioral parent training (BPT) is the first line of treatment for preschool-aged children with attention-deficit hyperactivity disorder (ADHD); however, clinically significant improvements are not universal. In the current study, we employ a person-centered approach to create subgroups of families based on the intersection of multiple parent, child, and family pre-treatment factors. Further, we explore the utility of pre-treatment family profiles in predicting post-treatment differences in observed parenting behavior (i.e., behavioral control, parental warmth) and clinically significant change in child ADHD and oppositional symptoms.

METHOD

Longitudinal data were collected using observational and parent-, teacher- and clinician-reported assessments from 130 parent-child dyads (Mage= 3.57, range = 3.0- 4.11, 73.8% male, 69.2% White, 25.6% Hispanic) participating in BPT.

RESULTS

Findings from the current study suggest three distinct family profiles, which consisted of one profile with high family stress (HFS) as evidenced by elevated symptomatology across parent, child, and family-level domains, a second profile with elevated parental anxiety (PA), and a final profile with elevated parental depression (PD). These family-centered profiles were differentially associated with changes in observed parenting practices. Specifically, the PD profile (39%) demonstrated minimal improvements in behavioral control and warmth following treatment. In contrast, the HFS profile (30%) only improved in behavioral control and the PA profile (31%) improved in both parenting domains following treatment. In addition, marginally significant differences in child oppositional and ADHD symptoms were observed across profiles.

CONCLUSIONS

Family-centered approaches may be useful for selecting and implementing interventions.

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.

Predictors and moderators of treatment efficacy in reducing custodial grandmothers' psychological distress

It is increasingly recommended that hypothesis-generating studies be conducted after initial RCTs in order to identify moderators of differential treatment efficacy on individual outcomes. Such analyses are important because they help clarify the best inclusion and exclusion criteria or choice of stratification for maximizing power in subsequent RCTs, reduce the chances of discarding interventions that may appear to lack efficacy when only average treatment effects are taken into consideration, and facilitate the matching of individual clients to treatment alternatives. We identified predictors and moderators of treatment-related change in psychological distress among custodial grandmothers (n = 343) assigned within a prior RCT to behavior parent training (BPT), cognitive behavior therapy (CBT), or information only control (IOC) conditions. Latent change scores in psychological distress were estimated for each grandmother across pre-test to post-test and pre-test to six months, as indicated by self-reported and clinical ratings of depression and anxiety symptoms. These estimates served as outcomes in classification and regression tree analyses conducted separately within the CBT and BPT conditions to identify predictors of treatment efficacy. Matched groups based upon identified predictors were then formed across all RCT conditions, and Predictor × RCT Condition interactions were computed to test for moderation of differential treatment efficacy. Grandmother age was the only predictor and moderator of BPT efficacy at both measurement points, whereas multifaceted predictors and moderators emerged for CBT which varied by time since treatment.

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.

Evaluating the Effect of Parent-Child Interactive Groups in a School-Based Parent Training Program: Parenting Behavior, Parenting Stress and Sense of Competence

The Exploring Together program is a group-based parent training program that comprises separate parent, child, and teacher components, and a combined parent-child interactive component. A cluster-randomized trial design was used to compare the Exploring Together program with (Exploring Together; ET) and without (Exploring Together-Adapted; ET-Adapted) the parent-child interactive component. One hundred and thirty-six parents and their children (aged 5-10 years) with externalizing and/or internalizing problems participated in the trial, recruited from primary schools. There was a significant reduction in negative parenting behavior across both treatment groups (ET and ET-Adapted) but no significant improvement in positive parenting behaviors. Parenting self-efficacy improved significantly across both treatment groups however there was no significant change in parenting satisfaction or parenting stress. There was no consistent evidence of superiority of one version of the Exploring Together program over the other. Further investigation regarding treatment dosage and mastery of parenting skills associated with the program is warranted.

"Sometimes I think my frustration is the real issue": A qualitative study of parents' experiences of transformation after a parenting programme

Introduction

Parenting programmes help to alleviate conduct problems in children, but ensuring that all parents feel supported to attend, complete and learn from these programmes has proven difficult. Parents can feel overwhelmed and struggle to change their parenting. This article aims to inform the future refinement of parenting programmes by examining parents’ narratives of how programmes motivated them to change and enabled them to put changes into practice.

Method and results

Forty-two parents, most of whom had attended Incredible Years group sessions, were interviewed about their views and experiences of parenting programmes that focused on positive parenting practices. Analysis of interview transcripts drew on thematic approaches. Parents perceived that parenting programmes helped them to better understand their child and themselves and to let go of anxieties surrounding their child’s behaviour. Better understanding included greater awareness of emotions and of behaviours their child could and could not control. Parents believed this awareness helped them to change the ways that they interacted with their child, which, in turn, helped them and their child to feel calmer. With greater understanding and calmness parents believed they became more able to see for themselves the changes that they could make in their parenting and everyday lives, and to feel more confident in putting these into practice.

Discussion

By supporting parents to reflect on their own and their child’s situation, parents perceived that programmes enabled them to improve interactions with their children without getting stuck in self-blame or feeling overwhelmed. Parents of children whose behaviour remained challenging believed that programmes led to beneficial changes in the way they felt about their child’s behaviours. Enhanced support for reflection by parents could potentially help more families to benefit from parenting programmes.

Caregiver-mediated interventions to support self-regulation among infants and young children (0-5 years): a protocol for a realist review

INTRODUCTION

Self-regulation is a modifiable protective factor for lifespan mental and physical health outcomes. Early caregiver-mediated interventions to promote infant and child regulatory outcomes prevent long-term developmental, emotional and behavioural difficulties and improve outcomes such as school readiness, educational achievement and economic success. To harness the population health promise of these programmes, there is a need for more nuanced understanding of the impact of these interventions. The aim of this realist review is to understand how, why, under which circumstances and for whom, early caregiver-mediated interventions improve infant and child self-regulation. The research questions guiding this review were based on consultation with families and community organisations that provide early childhood and family services.

METHODS AND ANALYSIS

Realist reviews take a theory-driven and iterative approach to evidence synthesis, structured around continuous refinement of a programme theory. Programme theories specify context-mechanism-outcome configurations to explain what works, for whom, under which circumstances and how. Our initial programme theory is based on prior work in this field and will be refined through the review process. A working group, comprising service users, community organisation representatives, representatives from specific populations, clinicians and review team members will guide the evidence synthesis and interpretation, as well as the development and dissemination of recommendations based on the findings of the review. The review will involve searching: (i) electronic databases, (ii) connected papers, articles and citations and (iii) grey literature. Decisions to include evidence will be guided by judgements about their contribution to the programme theory and will be made by the research team, with input from the working group. Evidence synthesis will be reported using the Realist and MEta-narrative Evidence Synthesis: Evolving Standards guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a review. Findings will be disseminated to our working group and through peer-reviewed publications and conference presentations.

REVIEW REGISTRATION NUMBER

The protocol is registered with Open Science Framework https://osf.io/5ce2z/registrations.

Longer-Term Outcomes of the Incredible Years Parenting Intervention

Conduct problems can develop into behavior disorders and put children at risk for other mental health problems. Parenting interventions have been shown to successfully reduce conduct problems and are often expected to prevent the development of broader mental health problems. Few studies have evaluated the longer-term and broader effects of these interventions. To what extent are parenting intervention effects sustained in the years after the intervention? And do effects pertain to conduct problems specifically, or do they also affect broader aspects of children's mental health? We used a randomized controlled trial to assess the longer-term (2.5 years) effects of the Incredible Years parenting intervention on children's conduct problems in an indicated prevention setting (N = 387; 79% retention rate). Using a multi-method (survey and computerized tasks) and multi-informant (parents, teachers, and children) approach, we tested whether initial effects on conduct problems were sustained, and whether Incredible Years had broader effects on children's peer problems, emotional problems, attention-deficit/hyperactivity disorder (ADHD) symptoms, attention and inhibition deficits, and service use. Incredible Years, relative to control (no intervention), led to sustained reductions in parent-reported conduct problems (Cohen's d = 0.31), but not teacher- and child-reported conduct problems. There were no broader benefits: Incredible Years did not reduce children's peer problems, emotional problems, ADHD-symptoms, attention and inhibition deficits, or their service use. Improvements in parents' perceptions of child conduct problems sustained until 2.5 years later. Our findings do not show benefits of Incredible Years as a preventive intervention for children's broader mental health.

Parental attendance in two early-childhood training programmes to improve nurturing care: A randomized controlled trial

Parent training programmes have significant potential to improve the quality of children's early environments and thereby their development and life-course outcomes. The aim of this study was to identify and explain the extent to which parents engaged in two group-based training programmes, offered to high-risk families enrolled in a randomized controlled trial study called PIÁ in Southern Brazil. The programmes were: (1) ACT: Raising Safe Kids, a 9-week programme aiming to reduce harsh parenting and maltreatment and improve positive parenting practices; (2) Dialogic book-sharing (DBS), an 8-week programme aiming to promote parental sensitivity and improve child cognitive development and social understanding. Of the 123 mothers randomly allocated to the ACT programme, 64.2% (n = 79) completed the course, and of 124 mothers allocated to DBS, 76.6% (n = 95) completed the course. After the interventions, mothers were very positive about the experience of both programmes but highlighted practical difficulties in attending. In adjusted regression analyses, only two variables significantly predicted ACT course completion (maternal age and distance between the intervention site and household); no significant predictor was found for DBS attendance. We conclude that although high completion rates are possible, there are important challenges to engaging parents of young children in training programmes, and practical difficulties occurring during training courses may be more important for attendance than baseline participant characteristics.

Parental and Familial Predictors and Moderators of Parent Management Treatment Programs for Conduct Problems in Youth

Despite the established efficacy of Parent Management Training (PMT) for conduct problems in youth, evidence suggests that up to half of all treated youth still display clinical levels of disruptive behavior post-treatment. The reasons for these unsatisfactory outcomes are poorly understood. The aim of the present review was to provide an updated analysis of studies from the past 15 years that examined parental and familial predictors and moderators of improvement in PMT for conduct problems. A systematic literature review of indicated prevention (children with conduct problem symptoms) and intervention (children with clinical diagnoses) studies published between 2004 and 2019 was conducted. This 15-year time period was examined since the last systematic reviews were reported in 2006 and summarized studies completed through mid-2004 (see Lundahl et al. in Clin Psychol Rev 26(1):86-104, 2006; Reyno and McGrath in J Child Psychol Psychiatry 47(1):99-111, 2006). Risk of bias indices was also computed (see Higgins et al. in Revised Cochrane risk of bias tool for randomized trials (RoB 2.0), University of Bristol, Bristol, 2016) in our review. A total of 21 studies met inclusion criteria. Results indicated that a positive parent-child relationship was most strongly associated with better outcomes; however, little additional consistency in findings was evident. Future PMT research should routinely examine predictors and moderators that are both conceptually and empirically associated with treatment outcomes. This would further our understanding of factors that are associated with poorer treatment outcome and inform the development of treatment components or modes of delivery that might likely enhance evidence-based treatments and our clinical science. Protocol Registration Number: PROSPERO CRD42017058996.

Informing the personalisation of interventions for parents of children with conduct problems: a qualitative study

BACKGROUND

Parenting programmes aim to alleviate behavioural problems in children, including conduct disorder. This study was part of a multi-phase mixed-methods project seeking to extend the reach of parenting programmes for the treatment of conduct problems through developing an evidence base to inform a personalised approach. It explored the narratives of parents of children with behavioural and conduct problems about parenting programmes to identify how such programmes could be personalised in order to extend their reach to parents and children who do not currently benefit.

METHODS

Face-to-face semi-structured interviews with a purposive sample of 42 parents, who had different experiences of parenting programmes. Interviews were conversational and informed by a topic guide. Analysis of transcripts of audio-recorded interviews drew on inductive thematic approaches and was framed largely within a phenomenological perspective.

RESULTS

Parents' accounts demonstrated three themes: 1) a personalised approach needs to include the child; 2) a supportive school matters; and, 3) the programme needs to feel personal. Parents were more likely to have a positive experience at a parenting programme, and for their child to demonstrate positive behavioural changes, when they felt their concerns were validated within the group and they also felt supported by the child's teachers. Parents whose children had been assessed prior to undertaking the programme were also more likely to perceive the programme to be beneficial, compared to parents who felt their child's individual issues were never considered.

CONCLUSIONS

Our findings point to the potential for personalised approaches to extend the reach of parenting programmes to parents and children who do not currently benefit from such programmes. Important in personalising parenting programmes is assessing children before parents are referred, to directly work with children as well as parents, and to work collaboratively with parents and children to identify which families are most suited to group support or one-to-one support and how this may change depending on circumstances.

When mummy and daddy get under your skin: A new look at how parenting affects children's DNA methylation, stress reactivity, and disruptive behavior

Child maltreatment is a global phenomenon that affects the lives of millions of children. Worldwide, as many as one in three to six children encounter physical, sexual, or emotional abuse from their caregivers. Children who experience abuse often show alterations in stress reactivity. Although this alteration may reflect a physiological survival response, it can nevertheless be harmful in the long run-increasing children's disruptive behavior and jeopardizing their development in multiple domains. But can we undo this process in at-risk children? Based on several lines of pioneering research, we hypothesize that we indeed can. Specifically, we hypothesize that highly dysfunctional parenting leads to an epigenetic pattern in children's glucocorticoid genes that contributes to stress dysregulation and disruptive behavior. However, we also hypothesize that it is possible to "flip the methylation switch" by improving parenting with known-effective parenting interventions in at-risk families. We predict that improved parenting will change methylation in genes in the glucocorticoid pathway, leading to improved stress reactivity and decreased disruptive behavior in children. Future research testing this theory may transform developmental and intervention science, demonstrating how parents can get under their children's skins-and how this mechanism can be reversed.

Moderators of treatment effects in a child maltreatment prevention programme in South Africa

BACKGROUND

Previous research has found mixed results on whether the most disadvantaged families benefit as much as less disadvantaged families from parenting interventions designed to reduce child maltreatment, and little in known in low-income settings.

OBJECTIVE

In this study, we test the effects of child, caregiver, household, and community characteristics as treatment moderators of intervention outcomes - child maltreatment and parenting practices. We test characteristics previously examined elsewhere as well as factors relevant to the South African context.

PARTICIPANTS AND SETTING

This analysis includes adolescents (ages 10-18) and their caregivers (N = 552 pairs) who participated in a randomised trial of a parenting programme in the Eastern Cape Province of South Africa.

METHODS

Data from the caregiver and adolescent standardised questionnaires collected at baseline, post-test (1-month post-intervention), and follow-up (5-9 months) were analysed using longitudinal multilevel analyses. We tested seven hypothesised moderators for each of the primary outcomes through interactions of treatment effect with baseline moderators.

RESULTS

No moderator effects were statistically significant after correcting for multiple comparisons testing. Hence, in line with several recent studies examining moderation effects in parenting programmes, our study suggests that parenting interventions aiming to reduce child maltreatment and promote parenting skills in low- and middle-income countries may be similarly effective for families facing various levels of economic, social, and health risk factors.

CONCLUSIONS

It may be useful to explicitly power trials for testing moderator effects, study different types of moderators and use person-centred analyses to further understand variations in treatment effects.

Evidence Base Update for Measures of Social Skills and Social Competence in Clinical Samples of Youth

Social skills and social competence are key transdiagnostic processes in developmental psychopathology and are the focus of an array of clinical interventions. In this Evidence Base Update, we evaluated the psychometric properties of measures of social skills and social competence used with clinical samples of children and adolescents. A systematic literature search yielded eight widely used measures of social skills and one measure of social competence. Applying the criteria identified by Youngstrom et al. (2017), we found that, with some exceptions, these measures had adequate to excellent norms, internal consistency, and test-retest reliability. There was at least adequate evidence of construct validity and treatment sensitivity in clinical samples for nearly all measures assessed. Many of the scales included items assessing constructs other than social skills and competence (e.g., emotion regulation). Development of updated tools to assess youth's effectiveness in key interpersonal situations, including those occurring online, may yield clinical dividends.

Preventing child mental health problems through parenting interventions in Southeastern Europe (RISE): Protocol for a multi-country cluster randomized factorial study

BACKGROUND

Child mental health problems continue to be a major global concern, especially in low- and middle-income countries (LMICs). Parenting interventions have been shown to be effective for reducing child behavior problems in high-income countries, with emerging evidence supporting similar effects in LMICs. However, there remain substantial barriers to scaling up evidence-based interventions due to limited human and financial resources in such countries.

METHODS

This protocol is for a multi-center cluster randomized factorial trial of an evidence-based parenting intervention, Parenting for Lifelong Health for Young Children, for families with children ages 2-9 years with subclinical levels of behavior problems in three Southeastern European countries, Republic of Moldova, North Macedonia, and Romania (8 conditions, 48 clusters, 864 families, 108 per condition). The trial will test three intervention components: length (5 vs. 10 sessions), engagement (basic vs. enhanced package), and fidelity (on-demand vs. structured supervision). Primary outcomes are child aggressive behavior, dysfunctional parenting, and positive parenting. Analyses will examine the main effect and cost-effectiveness of each component, as well as potential interaction effects between components, in order to identify the most optimal combination of program components.

DISCUSSION

This study is the first factorial experiment of a parenting program in LMICs. Findings will inform the subsequent testing of the optimized program in a multisite randomized controlled trial in 2021.

TRIAL REGISTRATION

NCT03865485 registered in ClinicalTrials.gov on March 5, 2019.

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.

What Affects Attendance and Engagement in a Parenting Program in South Africa?

Parenting programs are a promising approach to improving family well-being. For families to benefit, programs need to be able to engage families actively in the interventions. Studies in high-income countries show varying results regarding whether more disadvantaged families are equally engaged in parenting interventions. In low- and middle-income countries (LMICs), almost nothing is known about the patterns of participation in parent training. This paper examines group session attendance and engagement data from 270 high-risk families enrolled in the intervention arm of a cluster-randomized controlled trial in South Africa. The trial evaluated a 14-week parenting intervention aiming to improve parenting and reduce maltreatment by caregivers. The intervention was delivered in 20 groups, one per study cluster, with 8 to 16 families each. Overall, caregivers attended 50% of group sessions and children, 64%. Using linear multilevel models with Kenward-Roger correction, we examined child and caregiver baseline characteristics as predictors of their attendance and engagement in the group sessions. Variables examined as predictors included measures of economic, educational, and social and health barriers and resources, as well as family problems and sociodemographic characteristics. Overall, the study yielded no evidence that the level of stressors, such as poverty, was related to attendance and engagement. Notably, children from overcrowded households attended on average 1.2 more sessions than their peers. Our findings suggest it is possible to engage highly disadvantaged families that face multiple challenges in parenting interventions in LMICs. However, some barriers such as scheduling, and alcohol and substance use, remain relevant.

Co-occurring change in children's conduct problems and maternal depression: Latent class individual participant data meta-analysis of the Incredible Years parenting program

Children vary in the extent to which they benefit from parenting programs for conduct problems. How does parental mental health change if children benefit less or more? We assessed whether changes in conduct problems and maternal depressive symptoms co-occur following participation in the Incredible Years parenting program. We integrated individual participant data from 10 randomized trials (N = 1280; children aged 2–10 years) and distinguished latent classes based on families' baseline and post-test conduct problems and maternal depressive symptoms, using repeated measures latent class analysis (RMLCA) and latent transition analysis (LTA). Classes differed mainly in severity of conduct problems and depression (RMLCA; 4 classes). Conduct problems reduced in all classes. Depressive symptoms did not change in most classes, except in a class of families where conduct problems and depression were particularly severe. Incredible Years led to a greater likelihood of families with particularly severe conduct problems and depression moving to a class with mild problems (LTA; 3 classes). Our findings suggest that for the majority of families, children's conduct problems reduce, but maternal depressive symptoms do not, suggesting relative independence, with the exception of families with severe depression and severe conduct problems where changes for the better do co-occur.

Equity effects of parenting interventions for child conduct problems: a pan-European individual participant data meta-analysis

BACKGROUND

Childhood conduct problems are a costly public health problem and are five times more common in socially disadvantaged groups than they are in advantaged groups. Untreated, conduct problems have a poor prognosis, with increasing gaps between socioeconomic groups, and high rates of subsequent criminality. Incredible Years is a high quality parenting programme for reducing conduct problems and is widely disseminated in Europe. Many trials have shown Incredible Years to be effective but the potential effects of parenting interventions on social inequality are unknown. Some behavioural interventions (eg, smoking cessation programmes), although beneficial overall, can widen inequality gaps. Because single trials and aggregate-level meta-analyses are ill equipped for examining differential intervention (moderator) effects, we pooled individual-level trial data to assess the effects of Incredible Years on social equity.

METHODS

We did a systematic review and individual participant data meta-analysis by searching CINAHL, Embase, Global Health, Medline, and PsycINFO, for studies published from inception to March 15, 2019. We also searched the Incredible Years website library and consulted with experts, including the European Incredible Years mentors' network. We included data from all completed randomised trials of the Incredible Years parenting intervention in Europe that included children aged 1-12 years, including unpublished trials, without restriction on publication year or outcome measures. We included prevention (selective or universal) and treatment or indicated prevention trials (for children diagnosed or above the clinical cutoff for conduct problems). We excluded trials or conditions within trials that were not randomised, included additional non-parenting material (eg, child-focused interventions), or were abbreviated, non-standard versions of the usual Incredible Years intervention of 12-14 weekly sessions. We requested individual participant data from the study authors. The primary outcome was child conduct problems, assessed using the Eyberg Child Behavior Inventory Intensity (ECBI-I) scale. Moderators were analysed using multilevel modelling with multiple imputation.

FINDINGS

Of 15 European trials of Incredible Years parenting programmes (n=1696 children), individual participant data were unavailable for one trial and one trial did not assess the primary outcome. Children were aged 2-10 years (median 5·1), 492 (30%) of 1651 children were from an ethnic minority and 931 (58%) of 1614 were from low-income families. Families who received the Incredible Years intervention reported an overall reduction in child conduct problems (13·5 points on the ECBI-I scale, 95% CI 10·9-16·1). There were no differential effects by family disadvantage (indicated by poverty, lone parenthood, teenage parenthood, household joblessness, or low education), or ethnic minority status.

INTERPRETATION

We found no evidence for differential effects by social disadvantage, suggesting that Incredible Years is unlikely to widen socioeconomic inequalities in conduct problems. Furthermore, the programme might be an important tool for reducing social disparities and improving poor long-term outcomes in disadvantaged families because follow-up studies indicate that benefits persist. Clinicians and commissioners can be reassured that the programme is similarly effective for families from different backgrounds.

FUNDING

UK National Institute for Health Research.

Evasão em Intervenções Psicológicas com Pais de Crianças e Adolescentes: Relato de Experiência

Resumo A evasão de participantes em pesquisas que avaliam efeitos de intervenções com pais de crianças e adolescentes tem sido pouco investigada pelos pesquisadores brasileiros, que enfrentam dificuldades para concluir estudos-piloto, frequentemente realizados com recursos escassos e amostras pequenas. Este estudo propõe uma análise crítica sobre experiências com a evasão de participantes em quatro pesquisas que avaliaram programas de intervenção, conduzidas pelos autores do presente artigo, à luz da literatura recente. A análise das experiências revelou percentuais de 40% a 80% de abandono após o recrutamento ou início da intervenção. Entre os motivos elencados para justificar o abandono estão: o desinteresse, a discordância entre os cônjuges sobre a adesão, a distância entre residência e local da intervenção e a incompatibilidade de horários. Conclui-se que a maior aproximação entre os pesquisadores e a comunidade pode resultar em aumento de confiança e adesão aos estudos, o que pode ampliar o potencial de inserção social e divulgação científica das pesquisas realizadas com essa população.

Behavioral Versus Nonbehavioral Guided Self-Help for Parents of Children With Externalizing Disorders in a Randomized Controlled Trial

Self-help interventions for parents, which have a behavioral basis, are considered to be an effective treatment option for children with externalizing disorders. Nonbehavioral approaches are widely used but have little empirical evidence. The main objective of this trial was to compare the efficacy of a behavioral and a nonbehavioral guided self-help program for parents. Families of children (aged 4-11 years) diagnosed with attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) were randomized to either a behavioral or a nonbehavioral guided self-help program including 8 parenting booklets and 10 counseling telephone calls. The analyses considered the ratings of 5 informants: blinded clinician, therapist, participant, (her or his) partner, and teacher. Of the 149 families randomized to treatment (intention-to-treat sample [ITT]), 110 parents completed the intervention (per-protocol sample [PP]). For the 4 primary outcome measures (blinded clinician- and participant-rated ADHD and ODD) at post-assessment, the analysis revealed a treatment advantage for the behavioral group in blinded clinician-rated ODD symptoms (ITT: d = 0.37; PP: d = 0.35). Further treatment differences, all in favor of the behavioral group (ITT and PP), were detected in therapist ratings (i.e., ODD) and participant ratings (e.g., parental self-efficacy [only PP], negative parenting behavior, parental stress). In both samples, no differences were found at post-assessment for ratings of the partner and the teacher, or at the 12-month follow-up (only participant ratings available). Behavioral guided self-help shows some treatment advantage in the short term. No superiority over nonbehavioral therapy was detected 12 months after treatment termination.

What changes when? A reply to Beauchaine and Slep

In their commentary, Beauchaine and Slep (2018) raise important issues regarding research on behavioral parenting training (BPT). In this reply we highlight key points of agreement and respond to issues that we feel require clarification. BPT has been repeatedly proven effective in decreasing disruptive child behavior (also in the work of our research team). Yet, there is much to learn about for whom and how BPT is effective. Specifically, assessing the how (i.e., mediation) comes with many challenges. One of these challenges is taking into account the timeline of change, and being able to infer causal mechanisms of change. We argue that cross-lagged panel models (which we, and many other scholars, used) are a valid and valuable method for testing mediation. At the same time, our results raise important questions, specifically about the timing and form of expected changes in parenting and child behavior after BPT. For example, are these changes linear and gradual or do they happen more suddenly? To select the appropriate design, assessment tools, and statistical models to test mediation, we need to state detailed hypotheses on what changes when. An important next step might be to assess multiple putative mediators on different timescales, not only before and after, but specifically also during BPT.

In the Eye of the Beholder? Parent-Observer Discrepancies in Parenting and Child Disruptive Behavior Assessments

This study examined parent-observer discrepancies in assessments of negative child behavior and negative parenting behavior to shed more light on correlates with these discrepancies. Specifically, we hypothesized that informant discrepancy between observers and parents on child behavior would be larger when parents reported high levels of negative parenting (and vice versa) because high levels of these behaviors might be indicators of negative perceiver bias or patterns of family dysfunctioning. Using restricted correlated trait-models, we analyzed cross-sectional observation (coded with the Dyadic Parent-Child Interaction Coding System) and survey data (Eyberg Child Behavior Inventory and Parenting Practices Interview) of 386 Dutch parent-child dyads with children aged 4-8 years (Mage = 6.21, SD = 1.33; 55.30% boys). Small associations between parent-reported and observed child and parenting behavior were found, indicating high discrepancy. In line with our hypothesis, this discrepancy was higher when parents self-reported more negative parenting or more negative child behavior. Parent-observer discrepancy on negative child behavior was also predicted by child gender. For boys parents reported higher levels of negative child behavior than were observed, but for girls parents reported lower levels of negative child behavior than were observed. These findings suggest that informant discrepancies between observers and parents might provide important information on underlying, problematic family functioning and may help to identify those families most in need of help.

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

Parenting interventions are an effective strategy to reduce children's conduct problems. For some families, that is, not all families benefit equally. Individual trials tend to be underpowered and often lack variability to differentiate between families how benefit less or more. Integrating individual family level data across trials, we aimed to provide more conclusive results about often presumed key family (parental education and ethnic background) and child characteristics (problem severity, ADHD symptoms and emotional problems) as putative moderators of parenting intervention effects. We included data from 786 families (452 intervention; 334 control) from all four trials on the Incredible Years parenting intervention in The Netherlands (three randomized; one matched control). Children ranged between 2 and 10 years (M = 5.79; SD = 1.66). Of the families, 31% had a lower educational level and 29% had an ethnic minority background. Using multilevel regression, we tested whether each of the putative moderators affected intervention effects. Incredible Years reduced children's conduct problems (d = - .34). There were no differential effects by families' educational or ethnic background, or by children's level of ADHD symptoms. Children with more severe conduct problems and those with more emotional problems benefited more. Post hoc sensitivity analyses showed that for the two trials with longer-term data, moderation effects disappeared at 4 or 12 months follow-up. Often assumed moderators have some, but limited abilities to explain who benefits from parenting interventions. This suggests the need for studying theoretically more precise moderators in prevention research, other than relatively static family characteristics alone.

Systematic Review and Meta-analysis of Parent Group Interventions for Primary School Children Aged 4-12 Years with Externalizing and/or Internalizing Problems

This systematic review and meta-analysis evaluates the efficacy of parent training group interventions to treat child externalizing and/or internalizing problems. A search identified 21 randomized controlled trials of parent group interventions aimed at ameliorating child externalizing and/or internalizing problems in children aged 4-12 years. Random effects meta-analyses yielded significant pooled treatment effect size (g) estimates for child externalizing (g = -0.38) and internalizing problems (g = -0.18). Child anxiety symptoms or internalizing problems evident in children with externalizing behavior problems did not change significantly following intervention. Study quality was a statistically significant moderator of treatment response for child externalizing problems, however hours of planned parent group treatment and treatment recipient were not. Findings support the use of parent group interventions as an effective treatment for reducing externalizing problems in children aged 4-12 years. Whilst statistically significant, programs had a limited impact on internalizing symptoms, indicating a need for further investigation.

Dutch Norms for the Eyberg Child Behavior Inventory: Comparisons with other Western Countries

The Eyberg Child Behavior Inventory (ECBI) is one of the most widely used and well-validated parent rating scales for children's disruptive behavior. This screening instrument is a short, targetted and easy to implement inventory with good psychometric properties and is normed for different countries, among which the United States, Spain, Sweden and Norway. The ECBI has been successfully used for research and clinical purposes, in several countries including The Netherlands. To date, Dutch studies have relied on Scandinavian or US norm scores. However, this may be problematic because of cross-cultural differences in the degree to which certain behaviors are seen as problematic by parents. The main goal of this paper therefore was to obtain norm scores for The Netherlands among 6462 Dutch children aged 4 to 8 years (Mage = 6.37 years; SD = 1.32; 50.6% boys). In line with previous research, we found small differences on the mean sum scores across children of different ages (intensity scale) and gender (intensity and problem scale). Therefore, Dutch norm scores were provided age- and gender specific. Our results showed that disruptive behavior of children in the most rural areas was reported as occurring less frequently and was seen as less problematic by parents compared to the disruptive behavior of children in less rural areas. Finally, we found that Dutch norm scores on the ECBI were significantly lower than US norm scores, and significantly higher on the intensity scale (but not the problem scale) than Norwegian and Swedish norm scores.

Does the Incredible Years reduce child externalizing problems through improved parenting? The role of child negative affectivity and serotonin transporter linked polymorphic region (5-HTTLPR) genotype

In a randomized controlled trial, the Observational Randomized Controlled Trial of Childhood Differential Susceptibility (ORCHIDS study), we tested whether observed parental affect and observed and reported parenting behavior are mechanisms of change underlying the effects of the behavioral parent training program the Incredible Years (IY). Furthermore, we tested whether some children are more susceptible to these change mechanisms because of their temperamental negative affectivity and/or serotonin transporter linked polymorphic region (5-HTTLPR) genotype. Participants were 387 Dutch children between 4 and 8 years of age (M age = 6.31, SD = 1.33; 55.3% boys) and their parents. Results showed that although IY was successful in improving parenting behavior and increasing parental positive affect, these effects did not explain the significant decreases in child externalizing problems. We therefore found no evidence for changes in parenting behavior or parental affect being the putative mechanisms of IY effectiveness. Furthermore, intervention effects on child externalizing behavior were not moderated by child negative affectivity or 5-HTTLPR genotype. However, child 5-HTTLPR genotype did moderate intervention effects on negative parenting behavior. This suggests that in research on behavioral parent training programs, "what works for which parents" might also be an important question.