Digital Parent Training for Children with Disruptive Behaviors: Systematic Review and Meta-Analysis of Randomized Trials

Enrollment and completion rates of a nationwide guided digital parenting program for children with disruptive behavior before and during COVID-19

Our aim was to study enrollment and completion levels for the internet-based and telephone-assisted Finnish Strongest Families Smart Website (SFSW) parent training intervention, for parents of young children with disruptive behavior before and after the COVID-19 lockdown period. Population-based screening was carried out on 39,251 children during routine check- ups at 4 years of age. The parents of children scoring at least 5 on the Strengths and Difficulties Questionnaire were assessed against inclusion and exclusion criteria. Associations with enrollment or completion were analyzed using logistic regression models. The effects of COVID-19 restrictions on these were estimated using interrupted timeseries analysis. Of 39,251 families, 4894 screened positive and met the eligibility criteria. Of those, 3068 (62.6%) decided to enroll in the SFSW program and 2672 (87.1%) of those families completed it. The highest level of disruptive behavior (OR 1.33, 95% CI 1.12-1.57, p < 0.001) and overall severity of difficulties (OR 2.22, 95% CI 1.91-2.57, p < 0.001) were independently associated with enrollment. Higher parental education was associated with enrollment and completion. Higher paternal age was associated with enrollment, and parent depressive symptoms with non-completion. The SFSW enrollment did not significantly change following the COVID-19 restrictions, while the completion rate increased (COVID-19 completion OR 1.75, 95% CI 1.22-2.50, p = 0.002). Guided digital parenting interventions increase the sustainability of services, by addressing the child mental health treatment gap and ensuring service consistency during crisis situations.

A Digital Microintervention Supporting Evidence-Based Parenting Skills: Development Study Using the Agile Scrum Methodology

BACKGROUND

Conduct disorder increases risks of educational dropout, future mental illness, and incarceration if untreated. First-line treatment of conduct disorder involves evidence-based parenting skills programs. Time-outs, a frequent tool in these programs, can be effective at improving behavior, and recent apps have been developed to aid this process. However, these apps promote the use of time-outs in inconsistent or developmentally inappropriate ways, potentially worsening behavior problems. Digital microinterventions like these apps could guide parents through high-quality time-outs in the moment, but current time-out apps lack features promoting adherence to the evidence-based best practice. Agile scrum is a respected approach in the software development industry.

OBJECTIVE

We aimed to explore the feasibility of using the agile scrum approach to build a digital microintervention to help parents deliver an evidence-based time-out.

METHODS

The agile scrum methodology was used. Four sprints were conducted. Figma software was used for app design and wireframing. Insights from 42 expert stakeholders were used during 3 sprint reviews. We consulted experts who were identified from councils around the Midlands region of the United Kingdom and charities through personal contacts and a snowballing approach.

RESULTS

Over 4 development sprints from August 2022 to March 2023, the app was iteratively designed and refined based on consultation with a diverse group of 42 experts who shared their knowledge about the content of common parenting programs and the challenges parents commonly face. Modifications made throughout the process resulted in significant app enhancements, including tailored timer algorithms and enhanced readability, as well as an onboarding zone, mindfulness module, and pictorial information to increase inclusivity. By the end of the fourth sprint, the app was deemed ready for home use by stakeholders, demonstrating the effectiveness of our agile scrum development approach.

CONCLUSIONS

We developed an app to support parents to use the evidence-based time-out technique. We recommend the agile scrum approach to create mobile health apps. Our experience highlights the valuable role that frontline health and social care professionals, particularly those working with vulnerable families, can play as experts in scrum reviews. There is a need for research to both evaluate the impact of digital microinterventions on child behavioral change and also create digital microinterventions that cater to non-English speakers and individuals who participate in parenting programs in settings outside the United Kingdom.

The Effects of Online Behavioral Parenting Interventions on Child Outcomes, Parenting Ability and Parent Outcomes: A Systematic Review and Meta-analysis

The twenty-first century has seen the development and delivery of online programs of behavioral family intervention for disruptive child behavior. Typically, programs evaluate outcomes in terms of change in child functioning and change in parenting ability. Existing research has also articulated the importance of parent-child relational capacity and its role in facilitating change in child functioning, and the importance of parent emotion regulation in the interests of ensuring optimal child development. These factors were explored in a meta-analysis of k = 14 prospective longitudinal research studies of online parenting interventions for disruptive child behavior. Peer reviewed randomized controlled trials with inactive control groups that were published in English between 2000 and 2022 were included in the review if they were delivered online; offered parent self-directed treatment; included as participants families who were screened as having child behavioral difficulties on validated psychometric assessment measures; and assessed child treatment outcomes, parenting ability and parent treatment outcomes. The protocol for this study was pre-registered with PROSPERO (CRD42020215947). Statistical analyses employed random effects models and reported pooled effect sizes (Hedge's g) within and between groups. Results emphasize the importance of child outcomes and parenting ability in program assessment, however, suggest that parents' capacity to develop optimal parent-child relationships and regulate emotion may not be sufficiently reflected in program content. Identified continuous and categorical moderators of treatment outcome were also assessed. Results of the review are discussed in terms of their potential to influence the future development of online programs of behavioral family intervention and, therefore, child development.

Families in transition (FIT) study protocol: feasibility, acceptability and preliminary effects of a group-based parent training in parents of youth in psychiatric residential treatment

INTRODUCTION

Although adolescents make treatment gains in psychiatric residential treatment (RT), they experience significant difficulty adapting to the community and often do not sustain treatment gains long term. Their parents are often not provided with the necessary support or behaviour management skillset to bridge the gap between RT and home. Parent training, a gold standard behaviour management strategy, may be beneficial for parents of these youth and web-based parent training programmes may engage this difficult-to-reach population. This study focuses on a hybrid parent training programme that combines Parenting Wisely (PW), a web-based parent training with facilitated discussion groups (Parenting Wisely for Residential Treatment (PWRT)). This study aims to: (1) establish the feasibility and acceptability of PWRT, (2) evaluate whether PWRT engages target mechanisms (parental self-efficacy, parenting behaviours, social support, family function) and (3) determine the effects of PWRT on adolescent outcomes (internalising and externalising behaviours, placement restrictiveness).

METHODS AND ANALYSIS

In this randomised control trial, parents (n=60) will be randomly assigned to PWRT or treatment as usual. Each week for 6 weeks, parents in the PWRT condition will complete two PW modules (20 min each) and attend one discussion group via Zoom (90 min). Adolescents (n=60) will not receive intervention; however, we will evaluate the feasibility of adolescent data collection for future studies. Data from parents and adolescents will be collected at baseline, post intervention (6 weeks post baseline) and 6 months post baseline to allow for a robust understanding of the longer-term effects of PWRT on treatment gain maintenance.

ETHICS AND DISSEMINATION

The study has been approved by The Ohio State University Institutional Review Board (protocol number 2022B0315). The outcomes of the study will be shared through presentations at both local and national conferences, publications in peer-reviewed journals and disseminated to the families and organisations that helped to facilitate the project.

TRIAL REGISTRATION NUMBER

NCT05764369 (V.1, December 2022).

Acceptance and utilization of web-based self-help for caregivers of children with externalizing disorders

BACKGROUND

Web-based self-help interventions for parents of children with ADHD and other externalizing disorders have been proven to be effective. In order to recommend individualized and optimized interventions, a better understanding of the acceptance and utilization of this innovative treatment approach is needed. Previous research has frequently employed subjective reports of utilization, but the validity of these studies may be limited.

METHODS

Data from the German WASH study were used. Participants (n = 276) were randomly assigned to the intervention condition (a) web-based self-help or (b) web-based self-help with optional telephone-based support calls. Data collection took place at baseline (T1) and 12 weeks later (T2). Utilization data were tracked using a log file generated for each participant at T2. Prediction models were calculated using CART (Classification and Regression Trees), a method known mostly from the field of machine learning.

RESULTS

Acceptance, of the intervention as defined in this paper was very high on objective (89.4% have taken up the intervention) and subjective measures (91.4% reported having used the intervention and 95.3% reported they would recommend the intervention to a friend). The average number of logins corresponded to recommendations. Predictors of acceptance and predictors of utilization were similar and included, e.g., child's externalizing symptoms, parental psychopathology, and above all additional telephone-based support by counselors.

CONCLUSIONS

Through a detailed identification of acceptance and utilization, and the predictors thereof, we were able to gain a better understanding of the acceptance and utilization of web-assisted self-help for a parent management intervention in the treatment of children with ADHD and ODD. These findings can be used to recommend web-based interventions to particularly suitable families. It should be noted that some form of support is required for an intensive engagement with the content of the program.

TRIAL REGISTRATION

The protocol of the study (German Clinical Trials Register DRKS00013456 conducted on January 3rd, 2018) was approved by the Ethics Committee of the University Hospital, Cologne.

Technology-Enhanced BPT for Early-Onset Behavior Disorders: Improved Outcomes for Children With Co-Occurring Internalizing Symptoms

OBJECTIVE

Early-onset behavior disorders (BDs) are common and costly. The evidence-base for Behavioral Parent Training (BPT), the standard of care for early intervention for BDs in young children, is well-established; yet, common comorbidities such as internalizing symptoms are common and their impact, not well understood. The goal of the current study was to examine the potential for technology to improve BPT effects on observed parenting and child behavior outcomes for families of children recruited for clinically significant problem behavior who also presented with relatively higher internalizing symptoms.

METHOD

Families with low incomes (N = 101), who are overrepresented in statistics on early-onset BDs, were randomized to an evidence-based BPT program, Helping the Noncompliant Child (HNC), or Technology-Enhanced HNC (TE-HNC). Children were ages 3 to 8 years (55.4% were boys). Child race included White (64.0%), Black or African American (21.0%), more than one race (14.0%), and Hispanic/Latinx (13.9%).

RESULTS

Families in both groups evidenced improvement in internalizing symptoms at posttreatment; however, TE-HNC yielded the greatest improvement in positive parenting and child compliance at posttreatment and follow-up for children with the highest internalizing symptoms at baseline.

CONCLUSIONS

TE-HNC resulted in improved parenting and child behavior outcomes for children with elevated levels of co-occurring internalizing symptoms at baseline relative to standard HNC. We posit that these added benefits may be a function of TE-HNC, creating the opportunity for therapists to personalize the treatment model boosting parent skill use with more complex presentations, although a formal test of mediation will be important in future work.

Universal Digital Programs for Promoting Mental and Relational Health for Parents of Young Children: A Systematic Review and Meta-Analysis

Digital parenting programs aim to increase program access, improve psychosocial outcomes for parents and children, and support triage to targeted interventions where required. This meta-analysis assessed the efficacy of online parenting programs in improving parenting skills and capabilities, and by consequence, the mental health and well-being of parents and children, and the quality of the parent-child relationship. Studies were included if they were: (1) online, (2) self-delivered, (3) designed for universal general population prevention, (4) evaluated experimental or quasi-experimental designs, and (5) assessed parent and child emotional and/or relational health, from pregnancy to 5 years of age. A systematic search of electronic databases and grey literature identified 22 studies that met inclusion criteria, including 24 independent samples, with 5671 unique parents. Meta-analyses were conducted using random effects models and Cohen's d effects. Small-to-moderate improvements in parent depression, anxiety, self-efficacy, and social support were observed. No effects on parent stress, satisfaction, or parent-child relationship quality were observed. Meta-regression and sub-group analysis were conducted to identify sensitivity or moderation effects. Collectively, findings suggest any benefits of online parenting programs mostly occur at the time of the intervention, for parent mental health and well-being outcomes, and that enduring effects are unlikely. However, given the cost effectiveness and accessibility of online programs, further research into ways of sustaining effects on parenting outcomes is warranted. Furthermore, given the centrality of the parent-child bond to child development across the lifecourse, additional investment in new digitally facilitated approaches focusing on this bond are likewise warranted.PROSPERO registration CRD42021275647.

Parent training for disruptive behavior symptoms in attention deficit hyperactivity disorder: a randomized clinical trial

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) affects 5% of children and 2.5% of adults worldwide. Comorbidities are frequent, and Oppositional Defiant Disorder (ODD) reaches 50%. Family environment is crucial for the severity of behaviors and for prognosis. In middle-income countries, access to treatment is challenging, with more untreated children than those under treatment. Face-to-face behavioral parent training (PT) is a well-established intervention to improve child behavior and parenting.

Method

A clinical trial was designed to compare PT-online and face-to-face effects to a waiting list group. Outcomes were the ADHD and ODD symptoms, parental stress and styles, and quality of life. Families were allocated into three groups: standard treatment (ST), ST + PT online, and ST + Face-to-Face PT. We used repeated measures ANOVA for pre × post treatment analysis corrected for multiple comparisons.

Results and discussion

Parent training was effective in reducing symptoms of ADHD (p = 0.030) and ODD (p = 0.026) irrespective of modality (p = 1.000). The combination of ST and PT was also associated with better quality of life in the physical domain for patients (p = 0.009) and their parents (p = 0.050). In addition to preliminary data, online intervention seems effective for parenting and improving social acceptance of children. The potential to reach many by an online strategy with a self-directed platform may imply effectiveness with a low cost for public health to support parents' symptoms management.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

The acceptability and preliminary effectiveness of a brief, online parenting program: Expanding access to Evidence-Based parenting intervention content

Parenting interventions are a promising means for preventing and treating a variety of child behavior and conduct problems; yet, many families lack access to such services. Online parenting programs offer an opportunity to mitigate many barriers to intervention access by extending service delivery options. The purpose of the present study was to evaluate the acceptability and preliminary effectiveness of a brief, online parenting program. We developed a new online parenting program based on foundational content from the evidence-based GenerationPMTO intervention and used a mixed-methods, single-arm open trial (pre-post) design to perform a preliminary evaluation. The combined results from the quantitative and qualitative data provide initial support for the acceptability and preliminary effectiveness of the online program, based on participant self-report data from program completers. Participants indicated high levels of acceptability for the program topics and videos. They also reported statistically significant improvements from baseline to 4 weeks postintervention in parental efficacy, parenting practices, and child behavior problems. The qualitative data corroborated and expanded these findings. We go on to discuss important accessibility and sustainability considerations addressed by this online parenting program as well as to suggest implications for intervention research and mental health practice.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

The efficacy of online parenting interventions in addressing emotional problems in children and adolescents: A meta-analysis of randomized controlled trials

BACKGROUND

Parenting interventions offer opportunities for reducing emotional problems in children and adolescents, based on addressing parental risk and protective factors. Online parenting interventions were developed more recently to increase access to interventions for parents, and the aim of this systematic review and meta-analysis is to investigate their efficacy.

METHODS

We conducted a meta-analysis pooling studies that tested online parenting interventions having as outcome emotional problems in children/adolescents. We considered as secondary outcome parent mental health and moderation effects for the type of population, intervention characteristics, and risk of bias.

RESULTS

Thirty-one studies met the inclusion criteria and were included in the meta-analysis. For child/adolescent emotional problems, at post-intervention, 13 studies were pooled, yielding an ES of g = -0.26 (95% CI [-0.41, -0.11]; p < .001) favoring the online parental interventions over wait-list, while at follow-up five RCTs were pooled, yielding an ES of g = -0.14 (95% CI [-0.25, -0.02]; p = .015) favoring the parental online interventions over wait-list. Moderation analyses suggest that longer online parenting programs are more effective in improving child emotional problems.

CONCLUSIONS

Online parent programs have positive effects on reducing emotional symptoms in children and adolescents. Future research will need to develop and investigate the efficacy of the programs that can personalize their contents and delivery methods.

Using a Design Thinking Approach to Develop a Social Media-Based Parenting Program for Parents of Children With Attention-Deficit/Hyperactivity Disorder: Mixed Methods Study

Background: Parenting programs have proven effective in improving the behavior of children with attention-deficit/hyperactivity disorder (ADHD). However, barriers such as job and transportation constraints hinder parents from attending face-to-face therapy appointments. The COVID-19 pandemic has further exacerbated these challenges. Objective: This study aimed to develop and test the feasibility of a social media-based parenting program for parents of children with ADHD, considering both the pre-existing challenges faced by parents and the additional barriers imposed by the COVID-19 pandemic. Methods: This study used a 5-stage design thinking process, encompassing empathizing with parents, defining their needs, ideating innovative solutions, prototyping the program, and testing the program with parents. Qualitative interviews were conducted with 18 parents of children with ADHD to understand their unique needs and values. Brainstorming techniques were used to generate creative ideas, leading to the creation of a prototype that was tested with 32 parents. Participants' engagement with the program was measured, and posttraining feedback was collected to assess the program's effectiveness. Results: Parents of children with ADHD encounter specific challenges, including managing impulsive behavior and difficulties in emotion regulation. The social media-based parenting program was delivered through the LINE app (Line Corporation) and consisted of 7 modules addressing topics related to ADHD management and effective parenting strategies. The program exhibited a high completion rate, with 84% (27/32) of participants successfully finishing it. Program provider-participant interaction peaked during the first week and gradually decreased over time. Qualitative feedback indicated that the program was feasible, accessible, and well received by participants. The LINE app was found to be convenient and helpful, and participants preferred content delivery once or twice per week, expressing acceptance for various content formats. Conclusions: This study emphasizes the significance of adopting a human-centered design thinking approach to develop parenting programs that cater to the unique needs and values of parents. By leveraging social media platforms, such as LINE, a parenting program can overcome the challenges posed by the COVID-19 pandemic and other constraints faced by parents. LINE offers a viable and feasible option for supporting parents of children with ADHD, with the potential for customization and widespread dissemination beyond the pandemic context.

Optimising engagement in a digital parenting intervention to prevent violence against adolescents in Tanzania: protocol for a cluster randomised factorial trial

BACKGROUND

Violence against adolescents is a universal reality, with severe individual and societal costs. There is a critical need for scalable and effective violence prevention strategies such as parenting programmes, particularly in low- and middle-income countries where rates of maltreatment are highest. Digital interventions may be a scalable and cost-effective alternative to in-person delivery, yet maximising caregiver engagement is a substantial challenge. This trial employs a cluster randomised factorial experiment and a novel mixed-methods analytic approach to assess the effectiveness, cost-effectiveness, and feasibility of intervention components designed to optimise engagement in an open-source parenting app, ParentApp for Teens. The app is based on the evidence-based Parenting for Lifelong Health for Teens programme, developed collaboratively by academic institutions in the Global South and North, the WHO, and UNICEF.

METHODS/DESIGN

Sixteen neighbourhoods, i.e., clusters, will be randomised to one of eight experimental conditions which consist of any combination of three components (Support: self-guided/moderated WhatsApp groups; App Design: sequential workshops/non-sequential modules; Digital Literacy Training: on/off). The study will be conducted in low-income communities in Tanzania, targeting socioeconomically vulnerable caregivers of adolescents aged 10 to 17 years (16 clusters, 8 conditions, 640 caregivers, 80 per condition). The primary objective of this trial is to estimate the main effects of the three components on engagement. Secondary objectives are to explore the interactions between components, the effects of the components on caregiver behavioural outcomes, moderators and mediators of programme engagement and impact, and the cost-effectiveness of components. The study will also assess enablers and barriers to engagement qualitatively via interviews with a subset of low, medium, and high engaging participants. We will combine quantitative and qualitative data to develop an optimised ParentApp for Teens delivery package.

DISCUSSION

This is the first known cluster randomised factorial trial for the optimisation of engagement in a digital parenting intervention in a low- and middle-income country. Findings will be used to inform the evaluation of the optimised app in a subsequent randomised controlled trial.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, PACTR202210657553944. Registered 11 October 2022, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24051 .

Policies are Needed to Increase the Reach and Impact of Evidence-Based Parenting Supports: A Call for a Population-Based Approach to Supporting Parents, Children, and Families

Parents can be essential change-agents in their children's lives. To support parents in their parenting role, a range of programs have been developed and evaluated. In this paper, we provide an overview of the evidence for the effectiveness of parenting interventions for parents and children across a range of outcomes, including child and adolescent mental and physical health, child and adolescent competencies and academic outcomes, parental skills and competencies, parental wellbeing and mental health, and prevention of child maltreatment and family violence. Although there is extensive research showing the effectiveness of evidence-based parenting programs, these are not yet widely available at a population level and many parents are unable to access support. We outline how to achieve increased reach of evidence-based parenting supports, highlighting the policy imperative to adequately support the use of these supports as a way to address high priority mental health, physical health, and social problems.

The School of Hard Talks: A telehealth parent training group for caregivers of adolescents and young adults

AIM

A large body of evidence demonstrates the importance of the family environment in the developmental trajectory of mental illness in young people. Caregiver communication skills training represents a potential model for influencing the outcomes of adolescents and young adults struggling with emerging mental health and behavioural difficulties. The aim of the current study is to describe the development of a telehealth group training intervention for caregivers of adolescents and young adults, and to report the results of a pilot feasibility-effectiveness study that took place in 2020-2021.

METHODS

The "School of Hard Talks" intervention consisted of 8 h of training in communication skills consistent with motivational interviewing techniques. All pilot study participants were assigned to receive the intervention. Outcomes of interest were family conflict, caregiver stress, caregiver self-efficacy and expressed emotion (EE). Participants were assessed three times: prior to the intervention, after the intervention and 12 weeks later.

RESULTS

A total of 62 participants enrolled in the study, of whom 49 completed the intervention. Large, significant improvements were observed over time in all four domains of interest. Qualitative feedback from parents was very positive and added context to quantitative observations.

CONCLUSIONS

The School of Hard Talks was a feasible and effective intervention targeting both caregiver wellbeing as well as important mechanisms of risk for youth psychopathology, namely family conflict and EE. Further research involving a larger sample and a control condition are needed to confirm these findings.

AI-based chatbot micro-intervention for parents: Meaningful engagement, learning, and efficacy

Introduction

Mental health issues have been on the rise among children and adolescents, and digital parenting programs have shown promising outcomes. However, there is limited research on the potential efficacy of utilizing chatbots to promote parental skills. This study aimed to understand whether parents learn from a parenting chatbot micro intervention, to assess the overall efficacy of the intervention, and to explore the user characteristics of the participants, including parental busyness, assumptions about parenting, and qualitative engagement with the chatbot.

Methods

A sample of 170 parents with at least one child between 2-11 years old were recruited. A randomized control trial was conducted. Participants in the experimental group accessed a 15-min intervention that taught how to utilize positive attention and praise to promote positive behaviors in their children, while the control group remained on a waiting list.

Results

Results showed that participants engaged with a brief AI-based chatbot intervention and were able to learn effective praising skills. Although scores moved in the expected direction, there were no significant differences by condition in the praising knowledge reported by parents, perceived changes in disruptive behaviors, or parenting self-efficacy, from pre-intervention to 24-hour follow-up.

Discussion

The results provided insight to understand how parents engaged with the chatbot and suggests that, in general, brief, self-guided, digital interventions can promote learning in parents. It is possible that a higher dose of intervention may be needed to obtain a therapeutic change in parents. Further research implications on chatbots for parenting skills are discussed.

Technology Matters: Digital micro interventions to support parenting: Evaluating time out apps

Digital interventions to support parenting skills are popular but engagement can be low. Digital micro interventions such as apps targeting specific aspects of parenting are a novel development with the potential to overcome this challenge. Time out is an evidence-based component of many parenting skills training programmes and is an appropriate target for digital micro intervention. We describe the eight requirements of high-quality time out according to the literature and how these can be supported by an app. Searches of the App Store, Google Play, and Alexa Skills in the UK identified six apps designed to support time out. Current time out apps all promoted consistency, but they all risked low-quality time out through inappropriate initiation, duration, and termination. Professionals in child and adolescent mental health should explore the details of any digital micro interventions being used by parents for time out and provide appropriate counselling. We recommend that all future digital micro interventions in this area should incorporate evidence-based guidance.

My Early Relational Trust-Informed Learning (MERTIL) for Parents: A study protocol for a brief, universal, online, preventative parenting program to enhance relational health

BACKGROUND

Early relational health is a key determinant of childhood development, while relational trauma in the parent-infant dyad can instigate a cascading pattern of infant risk. Fortunately, early relational trauma is detectable and modifiable. In 2018, Australian Maternal and Child Health (MCH) nurses participated in MERTIL (My Early Relational Trauma-Informed Learning), a program to identify and prevent relational trauma. Program evaluations revealed nurses felt competent and confident to identify and respond to relational trauma; however, response capacity was inhibited by inadequate parent referral options. In response, MERTIL for Parents (My Early Relational Trust-Informed Learning) was developed, which is an online, evidence-based, self-paced parenting program that focuses on enhancing parental knowledge of relational trust and its significance for infant development. This low-cost, accessible prevention resource targets emerging relational concerns to reduce later service system engagement. The potential for universal preventative online programs that target parental and relational wellbeing remains under-explored. This paper reports on a protocol for implementing a MERTIL for Parents pilot study describing practitioners' and parents' perspectives on program feasibility and efficacy.

METHODS

This study is a mixed methods, parallel armed, uncontrolled, repeated measures design. We aim to recruit 48 Australian MCH practitioners from the states of Victoria and New South Wales. These professionals will in turn recruit 480 parents with a child aged 0-5 years. All parents will receive MERTIL for Parents, which entails a 40-minute video, tipsheets, posters, and support resources. Parent data will be obtained at three periods: pre-program, program exit, and program follow-up. Practitioner data will be collected at two periods: pre-parent recruitment and program follow-up. Data collection will occur through surveys and focus groups. Primary parent outcomes will be socioemotional assessments of program efficacy. Practitioners and parents will each report on program feasibility.

DISCUSSION

This protocol describes the feasibility and efficacy of a new online parenting program, MERTIL for Parents, with pilot field studies commencing in March 2023. We anticipate that this resource will be a valuable addition to various child and family services, for use in individual support and group work.

Web-Based Parent Training in Parents with Adolescents Admitted to Psychiatric Residential Treatment: A Mixed-Methods Study

Despite intensive treatment, adolescents discharged from residential treatment (RT) often do not maintain treatment gains in the community. Providing support and education to caregivers through parent training may ameliorate the loss of treatment gains. Successful parent training programs have been delivered to this population; however, these interventions were delivered in-person, posing significant barriers affecting reach, access, and engagement. A convergent mixed methods design was used to assess the acceptability, appropriateness, and feasibility of a web-based parent training in a sample of parents (N = 20) with adolescents admitted to RT. Parents completed two interviews and an end-of-program survey. Parents completed at least 80% of the assigned modules and felt that PW was easy to use and that the features facilitated learning. Parents reported practicing the skills in their daily lives and found it beneficial to have a partner to practice with. Consistent with previous studies, parents perceived the delivery method as a strength because the web-based delivery circumvented multiple known barriers to in-person interventions. A large subset of parents related to the scenarios, while a small subset of parents felt the modules were challenging to relate to because of the severity of their adolescent's mental health challenges. Overall, findings indicate that web-based parent training programs may be an acceptable, appropriate, and feasible adjuvant evidence-based support. However, tailoring the intervention content is necessary to create a more relatable intervention that captures the breadth and severity of mental health challenges adolescents in RT face.

An Internet-Based Parent Training With Telephone Coaching on Managing Disruptive Behavior in Children at Special Family Counseling Centers During the COVID-19 Pandemic: Feasibility Study

BACKGROUND

There is growing concern about the short- and long-term impacts that the COVID-19 pandemic will have on the mental health and psychosocial well-being of children and families. There are no existing studies about feasibility and outcomes using internet-based parent training programs with telephone coaching for disruptive behavioral problems in childhood during the COVID-19 pandemic in clinical settings.

OBJECTIVE

This study explored how the Strongest Families Smart Website (SFSW) parent training program, with telephone coaching, provided support during the COVID-19 pandemic at specialist family counseling centers in Helsinki, Finland, when restrictions made face-to-face counseling impossible. This study followed the success of a randomized controlled trial (RCT) and its implementation study of the SFSW parent training program by primary care child health clinics. The aim was to improve parenting skills, so that parents could tackle disruptive behavior by developing positive parent-child relationships. It started in May 2020, when the COVID-19 pandemic was at its height in Finland.

METHODS

In total, 8 family counseling centers in Helsinki identified 50 referrals aged 3-8 years with high levels of parent-reported disruptive behavioral problems. Child psychopathology and functioning and parental skills and well-being were measured at baseline, posttreatment, and 6 months later using a range of tools. The data were extracted from questionnaires completed by the parents.

RESULTS

We found that 44 (88%) of the 50 families completed the whole 11-session parent training program. Most of the children (n=48, 96%) had definitive or severe behavioral problems when they were initially screened by the centers, but with those assessed at the 6-month follow-up (n=45, 90%), this dropped to 58% (n=26). There were significant changes from baseline to 6-month follow-up in most of the child psychopathology measures, including the Child Behavior Checklist-Parent Report Form (CBCL) total score (mean change 16.3, SE 3.0, 95% CI 10.2-22.3; P<.001) and externalizing score (mean change 7.0, SE 1.0, 95% CI 4.9-9.0; P<.001). When parenting skills were measured with the Parenting Scale (PS), they showed significant changes from baseline to 6-month follow-up in total scores (mean change 0.5, SE 0.1, 95% CI 0.4-0.7; P<.001). Parents showed significant change in the stress subscore (mean change 3.9, SE 0.8, 95% CI 2.2-5.6; P<.001). Of the parents who filled in the satisfaction questionnaire (n=45, 90%), 42 (93%) reported high satisfaction in the skills and 44 (98%) in the professionalism of the family coaches.

CONCLUSIONS

The program proved to be an effective method for improving parenting skills and child psychopathology and functioning. The parents were satisfied with the program, and the dropout rate was exceptionally low. The study shows that the training program could be implemented in specialist clinical settings and during crisis conditions, such as the COVID-19 pandemic.

Online parent training platform for complementary treatment of disruptive behavior disorders in attention deficit hyperactivity disorder: A randomized controlled trial protocol

Background

Attention Deficit/Hyperactivity Disorder (ADHD) is associated with a diversity of impairments and Oppositional Defiant Disorder (ODD) is a very frequent comorbidity. Parent Training, as an evidence-based intervention, seems effective in reducing externalizing/disruptive behaviors, possibly leading to a better prognosis. This clinical trial aims to evaluate the effectiveness of an online parent training model as a complementary treatment for ADHD and ODD.

Methods

Patients and their families will be screened upon their entry into the Research Center of Impulsivity and Attention (NITIDA) at UFMG—Brazil. Ninety families whose children are male, between 6–12 years old, and have significant externalizing symptoms and whose primary caregiver have complete high school education will be invited to participate. Families will be randomized (1:1) into 03 groups: 1) standard care; 2) standard care + face-to-face parent training; 3) standard care + online parent training. Interventions are analogous, differing only in delivery format. In the face-to-face format, the intervention will be conducted by a specialized therapist and the online format will be carried out through a platform. There will be six sessions/modules, arranged on a weekly basis. Measures of externalizing symptoms, parental and children quality of life, parental stress and parenting style will be collected at baseline and after the intervention.

Discussion

This clinical trial intends to verify the effects of a new, online, model of an evidence-based intervention, which would allow a wider access in the Brazilian context.

Trial registration

Registered on Brazilian Registry of Clinical Trials (ReBEC). Number: RBR-6cvc85. July 24^th (2020) 05:35 pm.

Protocol of a cluster randomised controlled trial evaluating the effectiveness of an online parenting intervention for promoting oral health of 2-6 years old Australian children

INTRODUCTION

Dental decay is a major problem among Australian children. It can be prevented through good self-care and limiting sugar intake, but many parents/caregivers lack the skills and confidence to help their children adopt these practices. This trial will evaluate the efficacy of Healthy Habits Triple P - Oral health, a web-based online programme, in improving children's oral health-related behaviours (toothbrushing, snacking practices and dental visits) and related parenting practices, thereby preventing dental caries.

METHODS AND ANALYSIS

This is a cluster, parallel-group, single-blinded, randomised controlled trial of an online intervention for parents/caregivers of children aged 2-6 years. From the City of Gold Coast (Australia), 18 childcare centres will be randomly selected, with equal numbers randomised into intervention and control arms. Intervention arm parents/caregivers will receive access to a web-based parenting intervention while those in the control arm will be directed to oral health-related information published by Australian oral health agencies. After the completion of the study, the Healthy Habits Triple P - Oral health intervention will be offered to parents/caregivers in the control arm. The primary outcome of this trial is toothbrushing frequency, which will be assessed via Bluetooth supported smart toothbrushes and parent/caregiver report. Data on other outcomes: parenting practices and child behaviour during toothbrushing, consumption of sugar rich foods and parents' confidence in dealing with children's demands for sugar rich food, and dental visiting practices, will be collected through a self-administered questionnaire at baseline (before randomisation), and 6 weeks (primary endpoint), 6 months and 12 months after randomisation. Data on dental caries will be collected at baseline, 12 and 18 months post-randomisation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Human Research Ethics Committees of Griffith University (2020/700) and the University of Queensland (2020002839). Findings will be submitted for publication in leading international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12621000566831.

Protocol for randomized control trial of a digital-assisted parenting intervention for promoting Malaysian children’s mental health

Background

Mental illness among Malaysian children is gradually reaching a fundamentally alarming point as it persistently shows increasing trend. The existing literature on the etiologies of children’s mental illness, highlights the most common cause to be ineffective or impaired parenting. Thus, efforts to combat mental illness in children should focus on improving the quality of parenting. Documented interventional studies focusing on this issue, particularly in Malaysia, are scarce and commonly report poor treatment outcomes stemming from inconvenient face-to-face instructions. Consequently, proposing an accessible online and digital-assisted parenting program is expected to reach a larger number of parents, as it can overcome substantial barriers. Hence, this study aims to develop a universal digital-assisted preventive parenting intervention called DaPI, that aims to enhance mental health of children in Malaysia.

Methods

A total of 200 parents of children aged 10–14 years will be recruited and randomized into two groups either intervention or waitlist-control based on a 1:1 ratio for a duration of 8 weeks. Those in the intervention group will receive eight sessions of the DaPI program that focus mainly on parenting and children’s mental health. The primary outcome of this study will essentially focus on the changes in parent-reported parenting behavior and parental self-efficacy. The secondary outcome will be changes in children’s mental health (i.e., behavioral problems and emotional maladjustment). Assessments will be arranged pre- and post-intervention as well as at the 1-month follow-up. Analyses will be conducted using a paired t-test and multivariate analysis of covariance.

Discussion

The expected outcome will be the establishment of DaPI in promoting children’s mental health by targeting changes in parenting behavior and parental self-efficacy in Malaysia. Findings from this study will be beneficial for policymakers to invest in parenting programs that could provide support to parents in enhancing their child’s overall development.

Clinical trial registration

[www.irct.ir], identifier [IRCT20211129053207N1].

"Will it Work as Well on Zoom?" A Natural Experiment During the Covid-19 Pandemic of Delivering Parenting Groups Via Video Conferencing or in Person

While rates of child maltreatment increased during the Covid-19-pandemic, face-to-face interventions to support families got difficult to carry out due to restrictions. Meanwhile, many services do not have access to parenting programs designed for digital or remote delivery. A solution employed by some services was to use video conferencing (VC) to deliver their regular parenting programs. This study examined the effectiveness of the universal group-based parenting program ABC offered through VC instead of on-site meetings during the pandemic. Pre and post measurements were collected from 469 parents participating in either 1) ABC with VC meetings only, 2) on-site meetings only, or 3) blended - a combination of VC and on-site sessions. In addition, 74 group leaders completed a survey about their experiences of VC groups. Analyses showed general improvements in parent practices and child conduct over time, but no differences in effectiveness depending on the format of the parent group (VC, blended, or on-site). Qualitative analyses of group leaders' experiences revealed four key-themes pertaining to both challenges (e.g., concerns about parents' ability to benefit and learn parenting skills) and benefits (e.g., reaching parents who would not have been able to attend physical meetings) of VC groups. Overall, this study showed no significant differences in outcomes between the VC, blended, or on-site format of delivery. There are however limitations of this trial, and results should be considered preliminary. Effectiveness and potential negative consequences of replacing interventions intended to be delivered on-site with VC alternatives need to be further investigated in future trials.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

From the Cradle to the Web: The Growth of “Sharenting”—A Scientometric Perspective

“Sharenting” is an internet trend in which parents report detailed information or repeatedly post pictures, videos, and other content about their children on social media. Due to the duality of sharenting, which takes place online but has offline consequences, it is essential to understand the implications of sharenting for real-world parenting and child development. The present work analyzes references in the existing literature and links among published articles to better understand sharenting, evidence for it, and major topics associated with it and to uncover the gaps in the literature. Citation analysis of the current literature mainly focuses on risks and benefits related to sharenting practices, especially for the children, and on ethical and privacy concerns. Future studies should investigate the psychological mechanisms that drive sharenting-related behaviors in parents and multidisciplinary approaches to the phenomenon. With a broader perspective on these issues, practitioners and professionals in family studies will be able to delineate guidelines for informative interventions to increase awarenes about the causes and consequences of publicly sharing child content.

Effectiveness of an Internet-Based and Telephone-Assisted Training for Parents of 4-Year-Old Children With Disruptive Behavior: Implementation Research

Background

There is a lack of effectiveness studies when digital parent training programs are implemented in real-world practice. The efficacy of the internet-based and telephone-assisted Finnish Strongest Families Smart Website (SFSW) parent training intervention on the disruptive behavior of 4-year-old children was studied in a randomized controlled trial setting in Southwest Finland between 2011 and 2013. After that, the intervention was implemented nationwide in child health clinics from 2015 onwards.

Objective

The main aim of this study was to compare the treatment characteristics and effectiveness of the SFSW parent training intervention between the families who received the intervention when it was implemented as a normal practice in child health clinics and the families who received the same intervention during the randomized controlled trial.

Methods

The implementation group comprised 600 families who were recruited in the SFSW intervention between January 2015 and May 2017 in real-world implementation. The RCT intervention group comprised 232 families who were recruited between October 2011 and November 2013. The same demographic and child and parent measures were collected from both study groups and were compared using linear mixed-effect models for repeated measurements. The child psychopathology and functioning level were measured using the Child Behavior Checklist (CBCL) version 1.5-5 for preschool children, the Inventory of Callous-Unemotional Traits (ICU), and a modified version of the Barkley Home Situations Questionnaire. Parenting skills were measured using the 31-item Parenting Scale and the shorter 21-item Depression, Anxiety and Stress Scale (DASS-21). The estimated child and parent outcomes were adjusted for CBCL externalizing scores at baseline, maternal education, duration of the behavior problems, and paternal age. The baseline measurements of each outcome were used as covariates.

Results

The implementation group was more likely to complete the intervention than the RCT intervention group (514/600, 85.7% vs 176/232, 75.9%, respectively; P<.001). There were no significant differences between the implementation and RCT intervention groups with regard to child measures, including CBCL externalizing score (–0.2, 95% CI –1.3 to 1.6; P=.83), total score (–0.7, 95% CI –3.0 to 4.5; P=.70), internalizing score (–0.3, 95% CI –1.0 to 1.6; P=.64), and ICU total score (–0.4, 95% Cl –1.9 to 1.2; P=.64). No significant difference was detected in the Parenting Scale total score (0.0, 95% Cl –0.1 to 0.1; P=.50), while DASS-21 total score differed nearly significantly (2.5, 95% Cl 0.0-5.1; P=.05), indicating better improvement in the implementation group.

Conclusions

The internet-based and telephone-assisted SFSW parent training intervention was effectively implemented in real-world settings. These findings have implications for addressing the unmet needs of children with disruptive behavior problems. Our initiative could also provide a quick socially distanced solution for the considerable mental health impact of the COVID-19 pandemic.

Trial Registration

ClinicalTrials.gov NCT01750996; https://clinicaltrials.gov/ct2/show/NCT01750996

International Registered Report Identifier (IRRID)

RR2-10.1186/1471-2458-13-985

Effectiveness of a digital parenting program to improve parental well-being after the Christchurch earthquakes: a cluster-randomized trial (Preprint)

BACKGROUND

Up to 6 years after the 2011 Christchurch earthquakes, approximately one-third of parents in the Christchurch region reported difficulties managing the continuously high levels of distress their children were experiencing. In response, an app named Kākano was co-designed with parents to help them better support their children's mental health.

OBJECTIVE

The objective of this study was to evaluate the acceptability, feasibility, and effectiveness of Kākano, a mobile parenting app to increase parental confidence in supporting children struggling with their mental health.

METHODS

A cluster-randomized delayed access controlled trial was carried out in the Christchurch region between July 2019 and January 2020. Parents were recruited through schools and block randomized to receive immediate or delayed access to Kākano. Participants were given access to the Kākano app for 4 weeks and encouraged to use it weekly. Web-based pre- and postintervention measurements were undertaken.

RESULTS

A total of 231 participants enrolled in the Kākano trial, with 205 (88.7%) participants completing baseline measures and being randomized (101 in the intervention group and 104 in the delayed access control group). Of these, 41 (20%) provided full outcome data, of which 19 (18.2%) were for delayed access and 21 (20.8%) were for the immediate Kākano intervention. Among those retained in the trial, there was a significant difference in the mean change between groups favoring Kākano in the brief parenting assessment (F_1,39=7, P=.012) but not in the Short Warwick-Edinburgh Mental Well-being Scale (F_1,39=2.9, P=.099), parenting self-efficacy (F_1,39=0.1, P=.805), family cohesion (F_1,39=0.4, P=.538), or parenting sense of confidence (F_1,40=0.6, P=.457). Waitlisted participants who completed the app after the waitlist period showed similar trends for the outcome measures with significant changes in the brief assessment of parenting and the Short Warwick-Edinburgh Mental Well-being Scale. No relationship between the level of app usage and outcome was found. Although the app was designed with parents, the low rate of completion of the trial was disappointing.

CONCLUSIONS

Kākano is an app co-designed with parents to help manage their children's mental health. There was a high rate of attrition, as is often seen in digital health interventions. However, for those who did complete the intervention, there was some indication of improved parental well-being and self-assessed parenting. Preliminary indications from this trial show that Kākano has promising acceptability, feasibility, and effectiveness, but further investigation is warranted.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12619001040156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377824&isReview=true.

Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review

BACKGROUND

Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking.

OBJECTIVE

This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents.

METHODS

A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research).

RESULTS

A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded.

CONCLUSIONS

The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.

Comparing Traditional and Ebook-Augmented Parent-Child Interaction Therapy (PCIT): A Randomized Control Trial of Pocket PCIT

Disruptive behavior in young children is one of the most common referrals to behavioral health providers. While numerous effective parenting programs, such as parent-child interaction therapy (PCIT), exist for improving children's behaviors, challenges with treatment engagement and retention limit the intended positive impact on child and caregiver outcomes, particularly for racial and ethnic minority families. In an effort to address barriers contributing to poor engagement and retention in traditional PCIT service delivery and among ethnic and racial minority families, a multimedia PCIT ebook was developed and evaluated. In a sample of the general public that utilized the ebook, users were found to be more engaged in viewing embedded videos within the ebook that were related to expert skill explanations and skill demonstrations than caregiver testimonies. A randomized controlled trial was also conducted to evaluate the extent that the ebook + PCIT improved treatment engagement, retention, parenting skills, skill acquisition efficiency, and child behavior above and beyond traditional PCIT. Participating families were randomly assigned to either the traditional PCIT (n = 71) or ebook + PCIT (n = 107) group using an online random number generator. Forty-nine caregivers (traditional PCIT n = 24, ebook + PCIT n = 25) were excluded from analyses because they were lost to follow-up during the intervention. Families in both the traditional PCIT and ebook + PCIT groups demonstrated generally equivalent positive outcomes in treatment engagement (i.e., attendance, treatment length, completion rate) and caregiver skill acquisition efficiency at midtreatment, posttreatment, and 3-month follow-up. The addition of the ebook to PCIT also reduced child disruptive behavior at midtreatment, above and beyond traditional PCIT, but not at posttreatment or follow-up. Clinical implications and future directions are discussed.

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

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

Does a Behavioral Parent Training Program for Parents of ADHD Children Improve Outcomes? A Pilot Project

Attention Deficit Hyperactivity Disorder (ADHD) is the most common chronic neurobehavioral disorder of childhood. Research suggests increased parent-child conflict exists in families with an ADHD child. The evidence indicates links between child behavior problems and parenting practices. Behavioral Parent Training (BPT) is an evidence-based intervention recommended for the treatment of ADHD. BPT is recommended as first-line treatment in ADHD children under age six and as a combination treatment approach for children older than the age six. BPT programs have demonstrated significant improvement in frequency of the problem behaviors of inattention, hyperactivity, and impulsivity associated with ADHD. Pre- and Post-BPT Parenting Scales and Vanderbilt ADHD Diagnostic Rating Scales for Parents and Teachers were used to evaluate the efficacy of the BPT program. Percent changes for each participant pre- and post-BPT were calculated. The Parenting Scale overall score and overreactivity factor score showed significant improvement post-BPT (p = .05). Participation in a BPT program can affect parenting practices and improve outcomes for ADHD children. BPT programs are effective in reducing negative parenting practices and improving outcomes for this population.

A Caregiver Digital Intervention to Support Shared Decision Making in Child and Adolescent Mental Health Services: Development Process and Stakeholder Involvement Analysis

Background

Parents and caregivers are generally recognized by literature and the law as key to child and adolescent mental health decisions. Digital interventions are increasingly being used to support care and treatment in child and adolescent mental health services (CAMHS). However, evidence of the design and development process is generally not made available.

Objective

In light of calls for more transparency, this paper aims to describe the development of an evidence-based, theoretically informed digital decision support intervention for parents and caregivers of young people accessing CAMHS.

Methods

The intervention was developed in line with the UK Medical Research Council framework for developing complex interventions. The process incorporated the steps for developing patient decision aids, as follows: assessing need, assessing feasibility; defining objectives; identifying the framework of decision support; and selecting the methods, designs, and dissemination approach. We synthesized theory, research, international guidelines, and input from relevant stakeholders using an iterative design approach.

Results

The development steps resulted in Power Up for Parents, a decision support intervention, with five key features (ie, decisions, goals, journey, support, and resources). The intervention aims to encourage discussion, allow parents to ask questions during sessions or seek further information between sessions, and allow service providers to tailor the shared decision-making process to accommodate the needs of the parent and child.

Conclusions

We confirmed that it is possible to use input from end users—integrated with theory and evidence—to create digital interventions to be used in CAMHS. Key lessons with implications for practice, policy, and implementation science, along with preliminary findings, are presented.

International Registered Report Identifier (IRRID)

RR2-10.2196/14571

Health Personnel's Perceived Usefulness of Internet-Based Interventions for Parents of Children Younger Than 5 Years: Cross-Sectional Web-Based Survey Study

BACKGROUND

Approximately 10%-15% of children struggle with different socioemotional and psychological difficulties in infancy and early childhood. Thus, health service providers should have access to mental health interventions that can reach more parents than traditional face-to-face interventions. However, despite increasing evidence on the efficacy of internet-based mental health interventions, the pace in transferring such interventions to health care has been slow. One of the major suggested barriers to this may be the health personnel's attitudes to perceived usefulness of internet-based interventions.

OBJECTIVE

The purpose of this study was to examine health professionals' perceived usefulness of internet-based mental health interventions and to identify the key areas that they consider new internet-based services to be useful.

METHODS

Between May and September 2018, 2884 leaders and practitioners of infant and child health services were recruited to a cross-sectional web-based survey through the following channels: (1) existing email addresses from the Regional Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, course database, (2) an official mailing list to infant and child health services, (3) social media, or (4) other recruitment channels. Respondents filled in background information and were asked to rate the usefulness of internet-based interventions for 12 different infant and child mental health problem areas based on the broad categories from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5). Perceived usefulness was assessed with 1 global item: "How often do you think internet-based self-help programs can be useful for following infant and child mental health problems in your line of work?" The answers were scored on a 4-point scale ranging from 0 (never) to 3 (often).

RESULTS

The participants reported that they sometimes or often perceived internet-based interventions as useful for different infant and child mental health problems (scale of 0-3, all means>1.61). Usefulness of internet-based interventions was rated acceptable for sleep problems (mean 2.22), anxiety (mean 2.09), and social withdrawal and shyness (mean 2.07), whereas internet-based interventions were rated as less useful for psychiatric problems such as obsessive behaviors (mean 1.89), developmental disorders (mean 1.91), or trauma (mean 1.61). Further, there were a few but small differences in perceived usefulness between service leaders and practitioners (all effect sizes<0.32, all P<.02) and small-to-moderate differences among daycare centers, well-baby clinics, municipal child welfare services, and child and adolescent mental health clinics (all effect sizes<0.69, all P<.006).

CONCLUSIONS

Internet-based interventions for different infant and child mental health problems within services such as daycare centers, well-baby clinics, municipal child welfare services, and child and adolescent mental health clinics are sometimes or often perceived as useful. These encouraging findings can support the continued exploration of internet-based mental health interventions as a way to improve parental support.

Online parent programs for children's behavioral problems: a meta-analytic review

A recent increase in the development of online parent programs calls for the need to understand how effective these strategies are for improving children's mental health. We meta-analyzed the effects of online parent programs on children's behavioral problems. Moreover, we explored the combinations of program components to yield stronger program effects. Medline, PsycINFO, Web of Science, and the Cochrane Library were searched. We included peer-reviewed randomized studies evaluating the effect of an online parent program. Effect sizes (Hedges' g) were calculated from post intervention means and standard deviations. We used Qualitative Comparative Analysis (QCA) to identify pathways to effectiveness and individual content and delivery components that seem sufficient or necessary for yielding high effectiveness. Of 2941 articles, 12 articles with a total of 2025 participants met the inclusion criteria. Online parent programs have significant effects on children's behavioral problems (g =   - 0.32; 95% CI, - 0.47 to - 0.17), emotional problems (g =  - 0.22; 95% CI, - 0.31 to - 0.13), and parental mental health problems (g =  - 0.30; 95% CI, - 0.42 to - 0.17). In the QCA, sending parents reminders to work on the program was the only one sufficient component. In conclusion, online support programs reduce children's behavioral and emotional problems and improve parental mental health. Sending parents reminders to work on the program seems to contribute to high effectiveness. Review Registration This study was registered with PROSPERO, number CRD42017080051.

Is there a trial bias impacting user engagement with unguided e-mental health interventions? A systematic comparison of published reports and real-world usage of the same programs

Trial settings that include proactive recruitment, human contact, and assessment procedures may substantially impact the way users engage with unguided e-mental health programs and the generalizability of reported findings. This study examined the impact of trial setting on user behavior by directly comparing reported user engagement in trial-based research and objective measures of real-world usage of the same unguided mental health programs. The authors conducted a systematic search for papers reporting user engagement with off-the-shelf unguided e-mental health programs. Real-world usage was obtained from a panel that presents aggregated nonpersonal information on user engagement with digital programs across the world. A total of 13 papers yielding 14 comparable usage metrics met all inclusion criteria. In three papers reporting the use of programs by lay users without any proactive trial procedures, the ratios calculated by dividing the usage reported in the paper by the usage documented within the objective dataset were 0.84, 1.05, and 1.27-suggesting a sufficient criterion validity for our examination. In studies that proactively recruited users and included pre- to post-assessment procedures (11 comparisons), the median program usage rate reported was 4.06 times higher (IQR = 4.49) than the real-world usage of the same program. Severity of clinical symptoms, in-person versus remote assessment procedures, study design, and program cost had no impact on these differences. The results suggest that trial settings have a large impact on user engagement with unguided interventions and, therefore, on the generalizability of the findings to the real world.

A Mobile Health Intervention for Fetal Alcohol Spectrum Disorders (Families Moving Forward Connect): Development and Qualitative Evaluation of Design and Functionalities

Background

Fetal alcohol spectrum disorders (FASD) affect approximately 2% to 5% of the US population. However, most families are unable to access FASD-informed interventions. Barriers to care include the lack of a knowledgeable and skilled workforce and family-level barriers such as limited financial resources, inability to access childcare, and stigma. As a result, families often try peer-to-peer and self-help support strategies. However, they often take these strategies from disparate sources, which have quite variable intervention quality and empirical support.

Objective

This study aimed to initiate systematic development and evaluation of a mobile health intervention (app) for caregivers raising children with FASD. Focus groups were conducted to elicit participant perspectives on app design and functionalities to inform further app development.

Methods

The app, called FMF Connect, was derived from the scientifically validated Families Moving Forward (FMF) Program, a clinician-delivered behavioral consultation intervention. FMF Connect was intended for caregiver self-delivery and included five main components: (1) Learning Modules, (2) Family Forum, (3) Library, (4) Notebook, and (5) Dashboard. Focus group methods were used to solicit perspectives from diverse families during the early stages of app development. Questions were asked about interface design, relevance of components and content, and perceived barriers and facilitators of use. A total of 25 caregivers participated in 7 focus groups across 5 US cities. Data were analyzed thematically.

Results

Focus group participants were generally enthusiastic about the app interface design and components. Four global positive impression themes emerged, including (1) ease of access, (2) how the app guides and organizes information, (3) connection to other users and information, and (4) ability to share some content with others. Themes arose not only in discussions relating to positive app features but also when participants were asked about motivators for app use. Participants related how these positive global themes could address some system-level barriers, such as limited access to services, feeling isolated, and increased advocacy needs related to the societal lack of FASD knowledge. Participants identified many positive features about individual app components and functionalities. They also communicated potential barriers to use and raised important concerns and considerations relating to several app components. These included recognizability of the app based on the logo, and the balance of following the planned intervention sequence versus obtaining immediate answers. Also mentioned were privacy and dynamics within the Family Forum.

Conclusions

FMF Connect is a promising novel intervention with potential to reach many families in need and reduce significant barriers to care, resulting in a broader public health impact. Study findings will guide further app development both in terms of content and technological advances to optimize intervention effects. FMF Connect app development provides useful directions for other apps aimed at changing parenting practices.

Evaluating the efficacy of the Family Check-Up Online: A school-based, eHealth model for the prevention of problem behavior during the middle school years

This study evaluated the efficacy of a family-centered preventive intervention, the Family Check-Up (FCU), delivered as an online, eHealth model to middle school families. To increase accessibility of family-centered prevention in schools, we adapted the evidence-based FCU to an online format, with the goal of providing a model of service delivery that is feasible, given limited staffing and resources in many schools. Building on prior research, we randomly assigned participants to waitlist control (n = 105), FCU Online as a web-based intervention (n = 109), and FCU Online with coaching support (n = 108). We tested the effects of the intervention on multiple outcomes, including parental self-efficacy, child self-regulation, and child behavior, in this registered clinical trial (NCT03060291). Families engaged in the intervention at a high rate (72% completed the FCU assessment) and completed 3-month posttest assessments with good retention (94% retained). Random assignment to the FCU Online with coaching support was associated with reduced emotional problems for children (p = .003, d = -0.32) and improved parental confidence and self-efficacy (p = .018, d = 0.25) when compared with waitlist controls. Risk moderated effects: at-risk youth showed stronger effects than did those with minimal risk. The results have implications for online delivery of family-centered interventions in schools.

Fathering Through Change (FTC) intervention for single fathers: Preventing coercive parenting and child problem behaviors

Dishion and Patterson's work on the unique role of fathers in the coercive family process showed that fathers' coercion explained twice the variance of mothers' in predicting children's antisocial behavior and how treatment and prevention of coercion and promotion of prosocial parenting can mitigate children's problem behaviors. Using these ideas, we employed a sample of 426 divorced or separated fathers randomly assigned to Fathering Through Change (FTC), an interactive online behavioral parent training program or to a waitlist control. Participating fathers had been separated or divorced within the past 24 months with children ages 4 to 12 years. We tested an intent to treat (ITT) mediation hypothesis positing that intervention-induced changes in child problem behaviors would be mediated by changes in fathers' coercive parenting. We also tested complier average causal effects (CACE) models to estimate intervention effects, accounting for compliers and noncompliers in the treatment group and would-be compliers in the controls. Mediation was supported. ITT analyses showed the FTC obtained a small direct effect on father-reported pre-post changes in child adjustment problems (d = .20), a medium effect on pre-post changes in fathers' coercive parenting (d = .61), and a moderate indirect effect to changes in child adjustment (d = .30). Larger effects were observed in CACE analyses.

ParentWorks: Evaluation of an Online, Father-Inclusive, Universal Parenting Intervention to Reduce Child Conduct Problems

Evidence-based parenting interventions are effective in reducing conduct problems, yet these interventions have limited reach, and few involve the participation of fathers. This paper describes the outcomes of an open trial of ParentWorks, a universal, online, father-inclusive parenting intervention aiming to decrease childhood behavioural problems and promote positive parenting in mothers and fathers. A total of 388 families (456 individual parents; 36.6% fathers) were included in the study. Mixed model analyses showed significant decreases in child emotional/behavioural problems, dysfunctional parenting, interparental conflict, and parental mental health problems. The baseline severity of child behavioural problems significantly moderated the effects on child outcomes so that children with higher levels of problems benefitted more from the program. Participation of both caregivers in two-parent families, as well as parent sex, did not significantly affect the program outcomes. Results provide initial empirical support for the universal, self-directed, online parenting intervention, in addressing both child behavioural problems and parenting outcomes. Trial registration: ACTRN12616001223426, registered 05/09/2016.

Evaluation of 'The Father Effect' Media Campaign to Increase Awareness of, and Participation in, an Online Father-Inclusive Parenting Program

There is substantial evidence that parenting programs are effective in improving parenting and child mental health outcomes. While there is increasing focus on delivering parenting interventions online to increase their reach and dissemination, fathers are underrepresented in all formats of parenting programs. However, research suggests that father participation is important for intervention effectiveness. This study evaluated the effectiveness of a media campaign for increasing awareness of, and participation in, an online father-inclusive parenting program called 'ParentWorks'. An 8-week campaign was conducted in Australia via social media channels, digital display advertising, digital television, and radio. To assess the impact of the campaign, data were obtained from caregivers registering for ParentWorks during the campaign period (n = 848) and an 8-week comparison period that occurred 3 months later (n = 254). Additionally, a nationally representative sample of 2021 caregivers of children aged 2-16 years completed an online survey. Survey questions asked about exposure to the campaign, registration for participation in ParentWorks, and knowledge of the importance of father participation in parenting programs. Three times as many caregivers registered during the 8-week media campaign compared to the comparison period, and a significantly greater proportion of male caregivers registered in the campaign versus the comparison period. The online survey found that 11% of caregivers reported exposure to the campaign, and significantly more fathers than mothers reported exposure. Results showed that those who were exposed to the campaign were significantly more likely to endorse the importance of father participation in parenting programs, than those not exposed to the campaign. The findings indicate that media campaigns appear to be an effective method of increasing awareness of online parenting programs and enhancing rates of father involvement.

Self-directed or therapist-led parent training for children with attention deficit hyperactivity disorder? A randomized controlled non-inferiority pilot trial

BACKGROUND AND OBJECTIVES

Therapist-led behavioral parent training is a well-established treatment for behavior problems in children with attention-deficit/hyperactivity disorder (ADHD). However, parental attrition is high; self-directed forms of parent training may be a promising alternative. To date, no studies have compared these two forms of parent training in referred children with ADHD. The objectives of this pilot study were to examine the non-inferiority of a blended parent training (i.e. online program + supportive therapist contact) in comparison to its therapist-led equivalent (i.e. face-to-face parent training) regarding effects on behavioral problems, and to compare attrition rates, parental satisfaction, and therapist-time between both treatments.

METHODS

21 school-aged children with ADHD and behavioral problems, who had been referred to an outpatient mental health clinic, were randomized to blended (n = 11) or face-to-face (n = 10) parent training. Behavior problems were measured with the Child Behavior Checklist. Treatment completers and dropouts were included in the analyses.

RESULTS AND CONCLUSIONS

Blended parent training was not found to be non-inferior to face-to-face parent training in the reduction of behavior problems. Parents in the blended condition dropped out of treatment significantly earlier than parents in the face-to-face condition and were less satisfied. Therapists in the blended condition spent significantly less time on parent training than therapists in the face-to-face condition.

Applying Self-Regulation Principles in the Delivery of Parenting Interventions

An individual's capacity to self-regulate their cognitions, emotions and actions is an important life skill and emergent developmental competency for both children and parents. Individuals with better self-regulation achieve more positive life course outcomes and are less likely to develop significant mental health, social, and relationship problems. Parenting support programs that promote positive, nurturing parent-child relationships provide a unique multigenerational context to promote the self-regulatory capacity of both parents and children. Such programs provide a meaningful context and many opportunities for parents to enhance their self-regulation capacities, including skills such as goal setting, self-monitoring, self-evaluation, self-efficacy, personal agency, and thought and emotion regulation that, in turn, enable independent problem solving and responsive parenting. Parenting programs based on social learning theory, cognitive behavioral principles, and developmental theory typically include structured session activities and homework tasks that can be optimized to promote parental self-regulation. These include enhancing executive functions such as anticipating, planning ahead, following a plan, and problem solving, so that parents acquire greater cognitive flexibility, better impulse control, and are better able to generalize and apply learned parenting principles and skills beyond their immediate concerns to a broader range of child problems and challenging parenting and family situations. We illustrate how positive parenting principles and strategies can promote enhanced self-regulation, and discuss implications for research and practice.

Web-Based Parent Training Intervention With Telephone Coaching for Disruptive Behavior in 4-Year-Old Children in Real-World Practice: Implementation Study

Background

Parent training is the most effective approach to the psychosocial treatment of disruptive behavioral problems in childhood. However, no studies exist on how well Web-based training programs work when they make the transition from the research setting to implementation in primary health care.

Objective

The study aimed to examine how the randomized controlled trial (RCT) and implementation study groups of the Strongest Families Smart Website (SFSW) intervention differed in child psychopathology, family demographics and treatment-related factors, such as therapeutic alliance and parents’ satisfaction rates. The intervention was conducted in the pediatric primary health care in Finland.

Methods

The study focused on 232 parents who had taken part in the SFSW intervention, which formed part of a 2-arm RCT study, and 882 families that would participate in the subsequent SFSW implementation study group. Both groups comprised parents whose children displayed high levels of parent-reported disruptive behavioral problems when they were screened in child health clinics at 4 years of age. Parents in both groups were provided with the SFSW intervention, which consisted of a Web-based training program with 11 weekly themes and associated telephone sessions.

Results

Demographic factors or duration of behavioral problems did not differ statistically or clinically between the RCT and implementation groups. Overall, 42.0% (362/862) of children in the implementation group and 35.4% (80/226) in the RCT intervention group had suffered from behavioral difficulties more than 1 year before the screening phase (χ₁²=3.2; P=.07). The mean duration of telephone coaching calls was very similar in the implementation and RCT intervention groups, that is, 38 and 37 min per call, respectively (t_279.5=0.26; P=.79). The total time spent on the website of the program was 451 min in the implementation group and 431 min in the RCT intervention group (t_318.8=1.38; P=.17). In the RCT intervention group, 52 of the 232 participants (22.4%) discontinued the program before the tenth week, whereas in the implementation group, 109 of the 882 participants (12.4%; odds ratio 2.05, 95% CI 1.4-3.0; P<.001) discontinued. Parents in both the implementation (77.1% to 98.5%, 498/742 to 731/742, respectively) and the RCT (64.8% to 98.2%, N=105/162- to 159/162, respectively) groups reported qualitatively similar and high level of posttreatment satisfaction rates in improved parenting skills, expectations, and stress relief. Parents in both groups reported a high level of satisfaction in skills and professionalism of the telephone coaches.

Conclusions

The implementation of population-based screening of Web-based parent training intervention with telephone coaching resulted in good feasibility, fidelity, accessibility, and similar satisfaction level post treatment when compared with intervention in RCT research setting. The discontinuation of treatment in the implementation group was exceptionally low.