The effectiveness of the Incredible Years pre-school parenting programme in the United Kingdom: a pragmatic randomised controlled trial

Clinical and cost-effectiveness of an adapted intervention for preschoolers with moderate to severe intellectual disabilities displaying behaviours that challenge: the EPICC-ID RCT

Background

Stepping Stones Triple P is an adapted intervention for parents of young children with developmental disabilities who display behaviours that challenge, aiming at teaching positive parenting techniques and promoting a positive parent-child relationship.

Objective

To evaluate the clinical and cost-effectiveness of level 4 Stepping Stones Triple P in reducing behaviours that challenge in children with moderate to severe intellectual disabilities.

Design, setting, participants

A parallel two-arm pragmatic multisite single-blind randomised controlled trial recruited a total of 261 dyads (parent and child). The children were aged 30-59 months and had moderate to severe intellectual disabilities. Participants were randomised, using a 3 : 2 allocation ratio, into the intervention arm (Stepping Stones Triple P; n = 155) or treatment as usual arm (n = 106). Participants were recruited from four study sites in Blackpool, North and South London and Newcastle.

Intervention

Level 4 Stepping Stones Triple P consists of six group sessions and three individual phone or face-to-face contacts over 9 weeks. These were changed to remote sessions after 16 March 2020 due to the coronavirus disease 2019 pandemic.

Main outcome measure

The primary outcome measure was the parent-reported Child Behaviour Checklist, which assesses the severity of behaviours that challenge.

Results

We found a small non-significant difference in the mean Child Behaviour Checklist scores (-4.23, 95% CI -9.98 to 1.52, p = 0.146) in the intervention arm compared to treatment as usual at 12 months. Per protocol and complier average causal effect sensitivity analyses, which took into consideration the number of sessions attended, showed the Child Behaviour Checklist mean score difference at 12 months was lower in the intervention arm by -10.77 (95% CI -19.12 to -2.42, p = 0.014) and -11.53 (95% CI -26.97 to 3.91, p = 0.143), respectively. The Child Behaviour Checklist mean score difference between participants who were recruited before and after the coronavirus disease 2019 pandemic was estimated as -7.12 (95% CI -13.44 to -0.81) and 7.61 (95% CI -5.43 to 20.64), respectively (p = 0.046), suggesting that any effect pre-pandemic may have reversed during the pandemic. There were no differences in all secondary measures. Stepping Stones Triple P is probably value for money to deliver (-£1057.88; 95% CI -£3218.6 to -£46.67), but decisions to roll this out as an alternative to existing parenting interventions or treatment as usual may be dependent on policymaker willingness to invest in early interventions to reduce behaviours that challenge. Parents reported the intervention boosted their confidence and skills, and the group format enabled them to learn from others and benefit from peer support. There were 20 serious adverse events reported during the study, but none were associated with the intervention.

Limitations

There were low attendance rates in the Stepping Stones Triple P arm, as well as the coronavirus disease 2019-related challenges with recruitment and delivery of the intervention.

Conclusions

Level 4 Stepping Stones Triple P did not reduce early onset behaviours that challenge in very young children with moderate to severe intellectual disabilities. However, there was an effect on child behaviours for those who received a sufficient dose of the intervention. There is a high probability of Stepping Stones Triple P being at least cost neutral and therefore worth considering as an early therapeutic option given the long-term consequences of behaviours that challenge on people and their social networks.

Future work

Further research should investigate the implementation of parenting groups for behaviours that challenge in this population, as well as the optimal mode of delivery to maximise engagement and subsequent outcomes.

Study registration

This study is registered as NCT03086876 (https://www.clinicaltrials.gov/ct2/show/NCT03086876?term=Hassiotis±Angela&draw=1&rank=1).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: HTA 15/162/02) and is published in full in Health Technology Assessment; Vol. 28, No. 6. See the NIHR Funding and Awards website for further award information.

Early parenting interventions to prevent internalising problems in children and adolescents: a global systematic review and network meta-analysis

QUESTION

We compared the effectiveness of different types of parenting interventions based on an a priori taxonomy, and the impact of waitlists versus treatment as usual (TAU), in reducing child internalising problems.

STUDY SELECTION AND ANALYSIS

We conducted a systematic review and network meta-analysis of published and unpublished randomised controlled trials (RCTs) until 1 October 2022 that investigated parenting interventions with children younger than 4 years.

EXCLUSION CRITERIA

studies with children born preterm, with intellectual disabilities, or families receiving support for current abuse, neglect, and substance misuse. We assessed the certainty of evidence using the Confidence in Network Meta-Analysis framework. We used random-effects network meta-analysis to estimate standardised mean differences (SMDs) with 95% credible intervals (CrIs).

FINDINGS

Of 20 520 citations identified, 59 RCTs (18 349 participants) were eligible for the network meta-analysis. Parenting interventions focusing on the dyadic relationship (SMD: -0.26, 95% CrI: -0.43 to -0.08) and those with mixed focus (-0.09, -0.17 to -0.02) were more effective in reducing internalising problems than TAU at the first time point available. All interventions were more effective than waitlist, which increased the risk of internalising problems compared with TAU (0.36, 0.19 to 0.52). All effects attenuated at later follow-ups. Most studies were rated as with 'high risk' or 'some concerns' using the Risk of Bias Assessment Tool V.2. There was no strong evidence of effect modification by theoretically informed components or modifiers.

CONCLUSIONS

We found preliminary evidence that relationship-focused and mixed parenting interventions were effective in reducing child internalising problems, and the waitlist comparator increased internalising problems with implications for waiting times between referral and support. Considering the high risk of bias of most studies included, the findings from this meta-analysis should be interpreted with caution. PROSPERO registration number CRD42020172251.

Does behavioural parent training reduce internalising symptoms (or not) among children with externalising problems? Systematic review and meta-analysis

Behaviour parent training (BPT) is known to effectively reduce child externalising problems. However, evidence for BPT to have secondary benefits for reducing internalising symptoms remains unclear. To address this, electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, and SCOPUS) were systematically searched for studies examining internalising outcomes from BPT among children aged 2-12 years with clinically elevated externalizing problems. Outcomes for internalising problems following BPT were analysed by meta-analysis. Of 9105 studies identified, 24 studies met the eligibility criteria. Results from meta-analysis demonstrated a significant small treatment effect size (g = - 0.41) for reducing internalising symptoms immediately after treatment. Studies showed moderate heterogeneity (I² = 44%). Moderation analyses indicated that the overall treatment effect was robust against variations in treatment and study design characteristics. However, a review of individual study methods indicate that these results are limited by significant heterogeneity and limitations in clinical assessment. Overall, the results suggest that BPT programmes for reducing externalising problems have the potential to improve internalising outcomes, but that there is limited information to determine the reliability of these effects, highlighting the need for further investigation.

A proportionate, universal parenting programme to enhance social-emotional well-being in infants and toddlers in England: the E-SEE Steps RCT

Background

Mental disorders have become a public health crisis. Early prevention is key. Parenting programmes are effective for children aged ≥ 3 years; however, there is a lack of evidence of their effectiveness for children aged ≤ 2 years.

Objectives

To establish if the model named Enhancing Social–Emotional Health and Well-being in the Early Years (E-SEE) Steps can (1) enhance child social emotional well-being and establish whether or not it is cost-effective at 20 months of age when compared with services as usual; and (2) be delivered as a proportionate universal model with fidelity.

Design

A pragmatic two-arm randomised controlled trial and economic appraisal, with an embedded process evaluation to examine the outcomes, implementation and cost-effectiveness of the intervention, and intervention uptake, compared with services as usual. The study had an external pilot phase (which was originally planned as an internal pilot).

Setting

The intervention was delivered in community settings by early years children’s services and/or public health staff in four sites.

Participants

A total of 341 parents of infants aged ≤ 8 weeks were randomised in a ratio of 5 : 1 (intervention, n = 285; control, n = 56). The target sample was 606 parents.

Intervention

Two Incredible Years® parenting programmes (i.e. infant and toddler) delivered in a proportionate universal model with three levels [one universal (book) and two targeted group-based parenting programmes].

Main outcome measures

Child social and emotional well-being (primary outcome) was assessed using the Ages and Stages Questionnaire: Social and Emotional, 2nd edition, at 2, 9 and 18 months after randomisation. Parent depression (secondary key outcome) was assessed using the Patient Health Questionnaire-9 items. Both questionnaires were eligibility screeners for targeted groups.

Results

The primary outcome analysis provided no evidence that the E-SEE Steps model was effective in enhancing child social and emotional well-being. The adjusted mean difference was 3.02 on the original Ages and Stages Questionnaire: Social and Emotional, 2nd edition, in favour of the control [95% confidence interval –0.03 to 6.08; p = 0.052; N = 321 (intervention, n = 268; control, n = 53)]. Analysis of the key secondary outcome (i.e. parent depression levels as assessed by the Patient Health Questionnaire-9 items) provided weak evidence on the Patient Health Questionnaire-9 items in favour of the intervention (adjusted mean difference –0.61, 95% confidence interval –1.34 to 0.12; p = 0.1). Other secondary outcomes did not differ between arms. The economic analysis showed that the E-SEE Steps model was associated with higher costs and was marginally more effective (0.031 quality-adjusted life-years gained from E-SEE Steps compared with SAU, 95% confidence interval –0.008 to 0.071) than services as usual, resulting in an incremental cost-effectiveness ratio of approximately £20,062 per quality-adjusted life-year compared with services as usual. Overall take-up of the targeted parenting programmes was low. Sites, although enthusiastic, identified barriers to delivering the intervention.

Limitations

The target sample size was not met and the study was not powered to explore the effectiveness of each level of intervention. Most parents in the sample were well educated and, therefore, the results are unlikely to be generalisable, particularly to those at greatest risk of poor social and emotional well-being.

Conclusions

The E-SEE Steps proportionate universal model did not enhance child social and emotional well-being, but generated non-significant improvements in parent health outcomes, resulting in considerable uncertainty around the cost-effectiveness of the intervention. The primary and key secondary outcome gave inconsistent signals. Although, with system changes, increased resources and adaptations to the intervention, the model could be implemented, evidence for positive outcomes from the E-SEE Steps model is poor.

Future work

The universal-level E-SEE Step data (i.e. the Incredible Years book) from the external pilot will be pooled with the main trial data for further exploration up to follow-up 1, which is the time point at which most change was seen.

Trial registration

This trial is registered as ISRCTN11079129.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 8. See the NIHR Journals Library website for further project information.

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.

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.

Reducing mental health disparities among racially and ethnically diverse populations: A review of couple and family intervention research methods (2010-2019)

Racially and ethnically diverse and globally underserved populations continue to experience mental health disparities. The goal of this review was to examine the extent to which diverse populations were included in couple and family intervention research over the past decade and whether these studies were conducted with attention to issues of diversity. We performed a review of 271 articles reviewed in the current special issue on the efficacy and effectiveness of couple and family interventions across 11 mental health topics. Overall, only 68 of the 271 (25%) articles included predominately racial/ethnic minority samples or globally underserved populations. Among articles (n = 60) describing US-based research with racial/ethnic minority samples, there was a pattern of inattention to methodological considerations relevant to diverse populations. Although some progress was noted, more research is necessary. Specifically, we call for research that advances social justice by using critically conscious methods to promote mental health equity.

What do parents think of using informational videos to support recruitment for parenting trials? A qualitative study

Background

Lower than expected recruitment and retention rates are common challenges in parenting trials—particularly for community-based trials targeting parents of young children that rely on face-to-face recruitment by frontline workers. Recruitment requires parental informed consent, yet information sheets have been criticized for being lengthy and complex, and particularly challenging for parents with low literacy. Recent innovations include ‘talking head’ information videos. This paper aims to explore parent perceptions of using a ‘talking head’ video to support informed consent, recruitment, and retention procedures in parenting trials.

Methods

We conducted semi-structured interviews with a sample of 24 mothers recruited after their final follow-ups in two different parenting trials in Denmark. Before consenting to participate in the trials, parents were invited to view a video of a member of the study team giving information about the study, and again before the interviews for the current study. The audio data was transcribed and thematic analysis was conducted.

Results

We identified three overarching themes: (1) general impression of the video, (2) thoughts on participation in research, and (3) recruitment and retention. Participants were generally positive in their appraisal of the two talking head informational videos. We found that participants felt that a mix of paper-based and video-based sources of information would enable them to make an informed choice about whether to participate in a research study. We also found that a professionally produced video featuring a key member of the study team produced a feeling of commitment to the study that could impact retention rates.

Conclusions

Informational videos are acceptable to parents; however, co-production or participant/patient involvement in the development of such videos is recommended. Informational videos may not increase recruitment but have the potential for improving retention. Key design recommendations are to ensure a ‘professional’ look to the video, to supplement videos with paper-based information, to keep the length to < 3 min, and for the ‘talking head’ part to feature a key member of the study team.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05826-0.

The Efficacy of Parent Training Interventions for Disruptive Behavior Disorders in Treating Untargeted Comorbid Internalizing Symptoms in Children and Adolescents: A Systematic Review

Disruptive behavior disorders (DBDs) are among the primary reasons for child and youth referrals to mental health services and are linked to poor adult outcomes including antisocial behavior disorder. Research indicates a high incidence of internalizing problems in those with DBDs and those who have DBDs with cooccurring internalizing problems may have more severe later outcomes. Interventions targeted at internalizing symptoms have been found to also reduce comorbid externalizing problems. The impact of treatments for DBDs on comorbid internalizing disorders is not known. Databases PsycINFO, EMBASE and MEDLINE were systematically searched based on the Cochrane guidelines for systematic reviews. Records were independently reviewed by two reviewers. 12 papers were deemed eligible. A quality assessment of the selected studies was conducted independently by both reviewers. The 12 studies included 1334 young people with a mean age of 5 years. The parent training interventions assessed were the Incredible Years (6/12 studies), Triple-P (5/12) and Tuning In To Kids (1/12). 11 of the 12 studies reported significant reductions in primary externalizing behavior problems and DBDs. 7 studies reported significant reductions in internalizing symptoms. Mechanisms of change, clinical implications and directions for future research are discussed.

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.

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.

The Earlier the Better? Individual Participant Data and Traditional Meta-analysis of Age Effects of Parenting Interventions

Strong arguments have been made for early intervention for child problems, stating that early is more effective than later, as the brain is more malleable, and costs are lower. However, there is scant evidence from trials to support this hypothesis, which we therefore tested in two well-powered, state-of-the-art meta-analyses with complementary strengths: (a) Individual participant data (IPD) meta-analysis of European trials of Incredible Years parenting intervention (k = 13, n = 1696; age = 2-11); (b) Larger, trial-level robust variance estimation meta-analysis of a wider range of parenting programs (k = 156, n = 13,378, M_age  = 2-10) for reducing disruptive behavior. Both analyses found no evidence that intervention earlier in childhood was more effective; programs targeted at a narrower age range were no more effective than general ones.

Parenting practices of Singaporean mothers of children with ADHD

Objectives:

We wanted to determine: (1) whether ADHD symptoms were more common in mothers of children with ADHD; (2) whether mothers of children with ADHD differed in their parenting strategies; and (3) whether there was a difference in care-giving arrangements for children with ADHD and without ADHD. This was done by comparing mothers of children with ADHD with mothers of children without ADHD in Singapore.

Methods:

Mothers of children with ADHD ( n=46) and mothers of children without ADHD ( n=45) completed the Conners’ Parent Rating Scale-Revised, the Conners’ Adult ADHD Rating Scale-Self Report and the Alabama Parenting Questionnaire.

Results:

Mothers of children with ADHD did not report higher levels of current ADHD symptoms compared with the control group. However, they did use less adaptive parenting strategies. There were also no differences in the reported behaviours of children cared for by a paid worker and those cared for by mothers.

Conclusions:

Data support the Singapore Clinical Guidelines recommendations for the promotion of parenting skills, and referral to parenting programmes for parents of children with ADHD. The promotion of parenting skills and referral to parenting programmes for mothers of children with ADHD might include the option of electronic forms of programme delivery. The model of using paid help in the home, which is commonplace in Singapore, does not seem to disadvantage children with ADHD.

Research Review: Harnessing the power of individual participant data in a meta-analysis of the benefits and harms of the Incredible Years parenting program

BACKGROUND

Parenting programs aim to reduce children's conduct problems through improvement of family dynamics. To date, research on the precise benefits and possible harms of parenting programs on family well-being has been unsystematic and likely to be subject to selective outcome reporting and publication bias. Better understanding of program benefits and harms requires full disclosure by researchers of all included measures, and large enough numbers of participants to be able to detect small effects and estimate them precisely.

METHODS

We obtained individual participant data for 14 of 15 randomized controlled trials on the Incredible Years parenting program in Europe (total N = 1,799). We used multilevel modeling to estimate program effects on 13 parent-reported outcomes, including parenting practices, children's mental health, and parental mental health.

RESULTS

Parental use of praise, corporal punishment, threats, and shouting improved, while parental use of tangible rewards, monitoring, or laxness did not. Children's conduct problems and attention deficit hyperactivity disorder (ADHD) symptoms improved, while emotional problems did not. Parental mental health (depressive symptoms, self-efficacy, and stress) did not improve. There was no evidence of harmful effects.

CONCLUSIONS

The Incredible Years parenting program improves the aspects of family well-being that it is primarily designed to improve: parenting and children's conduct problems. It also improves parent-reported ADHD symptoms in children. Wider benefits are limited: the program does not improve children's emotional problems or parental mental health. There are no signs of harm on any of the target outcomes.

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Background

Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years®(IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects.

Objectives

To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings.

Design

Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention.

Settings

UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal.

Participants

Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys).

Interventions

IY Basic parenting programme.

Main outcome measures

Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms.

Results

There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximumn = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention.

Limitations

Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention.

Conclusions

There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions.

Funding

The National Institute for Health Research Public Health Research programme.