Research Review: The most effective parenting program content for disruptive child behavior - a network meta-analysis

Linking child adjustment difficulties with mother's maladaptive parental behavior: The mediating roles of parental cognitions and parenting stress

Child abuse is prevalent worldwide, with most of the burden in developing countries. To reduce and prevent child abuse occurrence, many efforts are directed toward reducing maladaptive parental behaviors (MPBs), a predictor of parents' risk of engaging in child abusive behaviors. MPBs have been associated with child (e.g., behavioral difficulties) and parent characteristics (e.g., parenting stress and parental cognitions), although little research tested for mediational pathways. This study aimed to test the pathways through which child and parent characteristics are linked to MPB. Consistent with the social information processing model of parenting, we hypothesized that child behavioral difficulties would exert an indirect influence on MPB through parenting stress and that parenting stress will exert a direct and indirect effect on MPB through parental cognitions (i.e., expectations, attitudes, and attributions). This study used data from 243 mothers of children aged between 2 and 9 years in Romania. Two-stage structural equation modeling was employed to test the hypothesized model. Results support the role of child behavior, parenting stress, and parental cognitions in predicting MPB (R2 = 0.69). Significant indirect effects were found from child behavior to MPB via parenting stress and parental cognitions. Direct effects from parenting stress and parental cognitions to MPB were significant. Findings show that parenting stress and parental cognitions are important mechanisms through which child behavioral difficulties influence maladaptive parental behavior, underscoring the need to focus on these mechanisms when assessing or intervening with families at risk for child abuse.

Study protocol for a randomized controlled trial of supportive parents - coping kids (SPARCK)-a transdiagnostic and personalized parent training intervention to prevent childhood mental health problems

BACKGROUND

To meet the scientific and political call for effective prevention of child and youth mental health problems and associated long-term consequences, we have co-created, tested, and optimized a transdiagnostic preventive parent-training intervention, Supportive parents - coping kids (SPARCK), together with and for the municipal preventive frontline services. The target group of SPARCK is parents of children between 4 and 12 years who display symptoms of anxiety, depression, and/or behavioral problems, that is, indicated prevention. The intervention consists of components from various empirically supported interventions representing different theorical models on parent-child interactions and child behavior and psychopathology (i.e., behavioral management interventions, attachment theory, emotion socialization theory, cognitive-behavioral therapy, and family accommodation intervention). The content and target strategies of SPARCK are tailored to the needs of the families and children, and the manual suggests how the target strategies may be personalized and combined throughout the maximum 12 sessions of the intervention. The aim of this project is to investigate the effectiveness of SPARCK on child symptoms, parenting practices, and parent and child stress hormone levels, in addition to later use of specialized services compared with usual care (UC; eg. active comparison group).

METHODS

We describe a randomized controlled effectiveness trial in the frontline services of child welfare, health, school health and school psychological counselling services in 24 Norwegian municipalities. It is a two-armed parallel group randomized controlled effectiveness and superiority trial with 252 families randomly allocated to SPARCK or UC. Assessment of key variables will be conducted at pre-, post-, and six-month follow-up.

DISCUSSION

The current study will contribute with knowledge on potential effects of a preventive transdiagnostic parent-training intervention when compared with UC. Our primary objective is to innovate frontline services with a usable, flexible, and effective intervention for prevention of childhood mental health problems to promote equity in access to care for families and children across a heterogeneous service landscape characterized by variations in available resources, personnel, and end user symptomatology.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NTCT05800522.

Practitioner Review: A core competencies perspective on the evidence-based treatment of child conduct problems

BACKGROUND

The effective treatment of child conduct problems is understood to rely on a range of therapist competencies, yet these have rarely been an explicit focus of research. In this practitioner review, we examine core competencies for the delivery of evidence-based parenting interventions for conduct problems in early-to-middle childhood. These are examined in light of research into the common elements shared by these interventions, literature regarding common challenges in these interventions, and conceptualisations of such competencies in other fields of mental health.

METHODS

We report on the development of a novel consensus-based model of core competencies for evidence-based practice in this field, based on consultation with an international expert panel. This includes competencies as they apply to complex presentations of conduct problems.

RESULTS

Despite considerable variation among widely disseminated programmes in terms of content, format and skills-training practices, there is strong consensus among practitioners regarding core competencies. These relate to three broad domains: (a) generic therapeutic competencies; (b) parenting intervention competencies; (c) specific parenting skills/techniques.

CONCLUSIONS

Practitioners working with conduct problems, particularly complex presentations thereof, require competencies for engaging not only mothers, but fathers and diverse/non-traditional caregivers and other stakeholders, in evidence-based parenting interventions. Moreover, the successful delivery of these interventions necessitates competencies that extend beyond behaviour management and encompass broader aspects of the family system and the wider ecology of the child.

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

QUESTION

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

STUDY SELECTION AND ANALYSIS

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

EXCLUSION CRITERIA

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

FINDINGS

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

CONCLUSIONS

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

Swedish parents' satisfaction and experience of facilitators and barriers with Family Check-up: A mixed methods study

Family Check-up (FCU) was introduced in Sweden more than a decade ago. Little is known about what parents experience as FCU's key mechanisms leading to changes in parenting. The aim of this study was to investigate Swedish parents' satisfaction with FCU, and their experiences of facilitators and barriers for making changes in their parenting. A mixed methods approach was employed using a parent satisfaction questionnaire (n = 77) and focus groups (n = 15). General satisfaction with FCU was adequate, with an average rating of 4 on a five-point scale (range 3.1-4.6). The analysis of quantitative and qualitative data resulted in eight themes representing facilitators and four themes representing barriers, organized into three categories: (1) access and engagement; (2) therapeutic process; and (3) program components. Ease of access to FCU facilitated initial engagement. Individual tailoring and access to FCU during different phases of change facilitated sustained engagement and change. Therapeutic process facilitators were a meaningful, supportive relationship with the provider, psychological benefits for parents and benefits for the whole family. Program components that facilitated change in parenting were new learning of parenting strategies and use of helpful techniques such as videotaping and home practice. Negative experiences with service systems prior to starting FCU, parent psychological barriers, and parent-provider mismatch were described as potential barriers. Some parents desired other program formats that were not offered, and some felt that new learning was insufficient to improve child behavior. Understanding the parent perspective can contribute to successful future work with implementing FCU.

Components of Behavioral Parent Training for Children With Attention-Deficit/Hyperactivity Disorder: A Series of Replicated Single-Case Experiments

Behavioral parent training (BPT) is an evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD). Stimulus control techniques (antecedent-based techniques, e.g., clear rules, instructions) and contingency management techniques (consequent-based techniques, e.g., praise, ignore) are the most common ones that are being taught to parents in BPT. However, research into the additive effects of these techniques is scarce. In this replicated single-case experimental ABC phase design, including six children on stable medication for ADHD (8-11 years) and their parents, the added efficacy of consequent-based techniques on top of antecedent-based techniques was evaluated. After a baseline period (phase A), we randomized the commencement time of two sessions parent training in antecedent-based techniques and two sessions parent training in consequent-based techniques for each child. Children's behaviors were assessed by daily parent ratings of selected problem behaviors and an overall behavior rating. Although visual inspection showed that behavior improved for most children in both phases, randomization tests did not demonstrate the added efficacy of the consequent-based techniques on top of the antecedent-based techniques. Limitations of the study and recommendations for future single-case experiments in this population are discussed.

Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses

BACKGROUND

Children with callous-unemotional (CU) traits are at high lifetime risk of antisocial behavior. It is unknown if treatments for disruptive behavior disorders are as effective for children with CU traits (DBD+CU) as those without (DBD-only), nor if treatments directly reduce CU traits. Separate multilevel meta-analyses were conducted to compare treatment effects on DBD symptoms for DBD+CU versus DBD-only children and evaluate direct treatment-related reductions in CU traits, as well as to examine moderating factors for both questions.

METHODS

We systematically searched PsycINFO, PubMed, Cochran Library (Trials), EMBASE, MEDLINE, APA PsycNet, Scopus, and Web of Science. Eligible studies were randomized controlled trials, controlled trials, and uncontrolled studies evaluating child-focused, parenting-focused, pharmacological, family-focused, or multimodal treatments.

RESULTS

Sixty studies with 9,405 participants were included (Mage  = 10.04, SDage  = 3.89 years, 25.09% female, 44.10% racial/ethnic minority). First, treatment was associated with similar reductions in DBD symptoms for DBD+CU (SMD = 1.08, 95% CI = 0.45, 1.72) and DBD-only (SMD = 1.01, 95% CI = 0.38, 1.64). However, DBD+CU started (SMD = 1.18, 95% CI = 0.57, 1.80) and ended (SMD = 0.73, p < .001; 95% CI = 0.43, 1.04) treatment with more DBD symptoms. Second, although there was no overall direct effect of treatment on CU traits (SMD = .09, 95% CI = -0.02, 0.20), there were moderating factors. Significant treatment-related reductions in CU traits were found for studies testing parenting-focused components (SMD = 0.21, 95% CI = 0.06, 0.35), using parent-reported measures (SMD = 0.16, 95% CI = 0.04, 0.28), rated as higher quality (SMD = 0.26, 95% CI = 0.13, 0.39), conducted outside the United States (SMD = 0.19, 95% CI = 0.05, 0.32), and with less than half the sample from a racial/ethnic minority group (SMD = 0.15, 95% CI = 0.002, 0.30).

CONCLUSIONS

DBD+CU children improve with treatment, but their greater DBD symptom severity requires specialized treatment modules that could be implemented alongside parenting programs. Conclusions are tempered by heterogeneity across studies and scant evidence from randomized controlled trials.

Co-Regulation as a Support for Older Youth in the Context of Foster Care: a Scoping Review of the Literature

Co-regulation is a relatively new theoretical framework for interventions that connects developmental science to adolescent needs and provides strategies that can be applied across contexts. It also has value in shifting the focus of interventions to the role of relationships and interactions with caring adults, as well as supportive environments. This framework may be particularly salient for older youth with foster care experience whose relationships with adults and availability of developmental supports are disrupted. To understand how co-regulation aligns with current understanding of needs and supports for this population, we conducted a scoping review that involved systematically searching four databases, coding and charting relevant information, and actively engaging expert consultants and other stakeholders. Across 46 primarily descriptive articles, co-regulation was discussed most often in relation to relationships, as expected (89% of articles). Despite theoretical and empirical evidence of the benefits of supportive environments and intentional day-to-day interactions in promoting developmental skills and competencies, these two domains of co-regulation were referenced much less (39% and 28%, respectively). Results highlight opportunities for co-regulation supports that can be provided to older youth with foster care experience by caring adults and near-aged peers in a wide range of roles. Notable limitations in the literature were identified in applying co-regulation within the context of employment and career readiness, healthy relationships, and teen parenting. Also under-researched is the role of adult self-regulation skills and co-regulation approaches for youth from diverse backgrounds, including those who identify as LGBTQ or have disabilities. Considerations for practice and future research are provided.

Personalised interventions for subgroups of children with conduct problems

BACKGROUND

Conduct problems are a range of disruptive behaviours in childhood that are associated with long-term adverse outcomes in adolescence and adulthood, including antisocial behaviour, substance misuse, and poor academic achievement. Children with conduct problems can vary according to age of onset, comorbidities, and environmental factors, and it has been suggested that certain groups of children may have different treatment outcomes. Therefore, it is important to assess the extent to which personalised interventions for different groups of children with conduct problems may affect outcomes. To our knowledge, this is the first review to systematically identify and appraise the effectiveness of personalised interventions, adapted, or developed, for prespecified subgroups of children with conduct problems.

OBJECTIVES

To assess whether personalised interventions, adapted or developed for subgroups of children with conduct problems are effective in improving outcomes.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was 1 February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), in any setting, in children (aged two to 12 years) with conduct problems and within a prespecified subgroup, comparing a personalised intervention with a non-personalised intervention, waitlist control, or treatment as usual. Personalised interventions included adaptations to standard practice, such as parent-training programmes; other recommended interventions for children with conduct problems; or interventions developed specifically to target subgroups of children with conduct problems. We excluded non-personalised and non-psychological interventions (e.g. pharmacological or dietary intervention). Prespecified subgroups of children with conduct problems, however defined, were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. child conduct problems or disruptive behaviour and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. personalised treatment outcomes relevant to each subgroup, 4. parenting skills and knowledge, 5. family functioning, engagement and decreased dropout, and 6. educational outcomes. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We identified 13 RCTs (858 participants). Seven studies were conducted in the USA, five in Australia, and one in Germany. Eleven studies reported their source of funding, with five studies receiving grants from the National Institute of Mental Health. In total, 15 different funders supported the studies included in the review. We separated subgroups of children with conduct problems into three broad categories: children with co-occurring conditions (e.g. emotional difficulties), parent characteristics (e.g. conflict between parents), or familial/environmental circumstances (e.g. rural families). All studies delivered a personalised intervention that was adapted or developed for a prespecified subgroup of children with conduct problems. We rated all trials at unclear or high risk of bias in most domains. Below, we report the results of improvement in child conduct problems and disruptive behaviour, personalised treatment outcomes, and parenting skills and knowledge for our main comparison: personalised versus non-personalised interventions. Improvement in child conduct problems and disruptive behaviour Compared with a non-personalised intervention, a personalised intervention may result in a slight improvement in child conduct problems or disruptive behaviour measured using the Eyberg Child Behavior Inventory (ECBI) Problem subscale in the short term (mean difference (MD) -3.04, 95% confidence interval (CI) -6.06 to -0.02; 6 studies, 278 participants; P = 0.05), but may have little to no effect on improving child conduct problems or disruptive behaviour measured by the ECBI Intensity subscale (MD -6.25, 95% CI -16.66 to 4.15; 6 studies, 278 participants; P = 0.24), or the Externalising subscale of the Child Behaviour Checklist (CBCL) (MD -2.19, 95% CI -6.97 to 2.59; 3 studies, 189 participants, P = 0.37) in the short term. We graded the certainty of evidence as very low for all three outcomes, meaning any estimate of effect is very uncertain.  Personalised treatment outcomes, relevant to each subgroup Although six studies reported personalised treatment outcomes, relevant to each subgroup, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive. Parenting skills and knowledge Although seven studies reported parenting skills and knowledge, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive.  Adverse events None of the trials reported monitoring adverse events. Summary of results In summary, there is limited evidence that personalised intervention improves child conduct problems, personalised treatment outcomes, relevant to each subgroup, or parenting skills and knowledge compared with a non-personalised intervention.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of personalised interventions for subgroups of children with conduct problems. The certainty of evidence for all outcomes was very low, meaning that we have very little confidence in the estimated effects and the true effects may be different to our findings, which will limit the relevance of our findings to clinical decisions. To overcome the limitations of the evidence, large-scale RCTs are needed to determine whether personalised interventions, adapted or developed, for subgroups of children with conduct problems are effective in improving outcomes. Consensus on the most appropriate measures to use in these studies is needed in order to facilitate cross-study comparisons. Persistent conduct problems predict a range of adverse long-term outcomes, so future research should investigate the medium- and long-term effects of personalised treatments. Studies are needed in low- and middle-income countries as well as studies recruiting children aged between nine and 12 years, as they were under-represented in the studies.

Research review: Effects of parenting programs for children's conduct problems on children's emotional problems - a network meta-analysis

BACKGROUND

Specific programs are often implemented for specific child mental health problems, while many children suffer from comorbid problems. Ideally, programs reduce a wider range of mental health problems. The present study tested whether parenting programs for children's conduct problems, and which individual and clusters of program elements, have additional effects on children's emotional problems.

METHODS

We updated the search of a previous systematic review in 11 databases (e.g., PsycINFO and MEDLINE) and included studies published until July 2020 with keywords relating to 'parenting', 'program', and 'child behavioral problems'. Also, we searched for recent trials in four trial registries and contacted protocol authors. Studies were eligible for inclusion if they used a randomized controlled trial to evaluate the effects of a parenting program for children aged 2-10 years which was based on social learning theory and included a measure of children's emotional problems postintervention.

RESULTS

We identified 69 eligible trials (159 effect sizes; 6,240 families). Robust variance estimation showed that parenting programs had small significant parent-reported additional effects on emotional problems immediately postintervention (Cohen's d = -0.14; 95% CI, -0.21, -0.07), but these effects faded over time. Teachers and children did not report significant effects. Additional effects on emotional problems were larger in samples with clinical baseline levels of such problems. No individual program elements predicted larger additional effects. Of the clusters of elements, combining behavior management and relationship enhancement elements was most likely to yield the strongest additional effects.

CONCLUSIONS

The additional effects on emotional problems of parenting programs designed to reduce conduct problems are limited, but some clusters of elements predict larger effects. Our findings may contribute to realistic expectations of the benefits of parenting programs for children's conduct problems and inform the development of programs with wider benefits across mental health problems.

Parent Training for ADHD: No Generalization of Effects From Clinical to Neuropsychological Outcomes in a Randomized Controlled Trial

OBJECTIVE

We examined whether neuropsychological function in ADHD can be improved by the New Forest Parenting Programme (NFPP), that combines standard parenting strategies with self-regulatory skills training, or predict ADHD and quality of life (QoL) treatment effects.

METHOD

Participants were 93 medication-naive preschool children with ADHD (3-7 years) randomized to either NFPP (n = 49) or treatment as usual (TAU; n = 44) in a recent randomized trial. Laboratory measures of executive function, reaction time variability, and delay of gratification were collected along with parent ratings of ADHD and QoL at baseline and post treatment. Ratings were collected again at 3-month follow-up.

RESULTS

NFPP did not improve neuropsychological function (compared to TAU), and baseline neuropsychological function did not predict treatment-related ADHD or QoL effects.

CONCLUSION

Although NFPP includes a neuropsychological training element and has been shown to improve several clinical outcomes, it did not improve the neuropsychological functions it targets.

Multiple needs and multiple treatments. What's a clinician to do? Update on the psychosocial treatment of disruptive behaviours in childhood

PURPOSE OF REVIEW

There are a wide range of psychosocial treatment options, delivered in different modalities, for children with disruptive behaviour. However, clinicians face many challenges in ensuring the empirically supported treatments (ESTs) they select will be effective for their patient. This has prompted studies to generate knowledge on how to improve treatment outcomes for children with disruptive behaviour. This review identifies the major challenges in treatment selection as well as emerging research seeking to improve outcomes.

RECENT FINDINGS

This review emphasizes the salience of the research-practice gap associated with establishing ESTs using narrow definitions of clinical problems. Recent research is reviewed considering the complex determinants of disruptive behaviours, including parent and family factors that influence outcomes. The review subsequently outlines recent advances in research and clinical practice guidelines aiming to surmount these challenges. Key advances discussed include examining the most impactful components of ESTs, personalizing interventions by targeting core dysfunction underlying behaviour, and addressing parent factors including mental health and cultural relevance to improve outcomes.

SUMMARY

Thorough assessment of patients' needs, combined with knowledge of treatment response predictors, are recommended to determine the most suitable treatment plan. Recent advances have focused on developing and designing interventions that meet needs in a way that is flexible and tailored.

Debate: 'A rose by any other name' would smell as sweet - myths peddled about the ills of diagnosing conduct disorders

Using a diagnosis of ODD/CD enables the clinician to apply a huge amount of helpful information about what has caused the concerns and then to offer effective treatment. More often than not, they do not use a diagnostic label with the family; the point is for the clinician to share the expertise. Myths about the nature of psychiatric diagnosis and the harms of a label of ODD/CD are debunked in this article. It is society who stigmatises these individuals because of their antisocial behaviour, and withholding skilfully applied benefits of the accumulated knowledge of the condition is cruel and especially harmful to disadvantaged groups in society where ODD/CD is far more prevalent.

Commentary: Are complex parenting interventions less than the sum of their parts? A reflection on Leijten et al. (2022)

Parenting interventions provide the backbone of professional support for children with behavioural problems and their families (Maughan et al., 2005). The overwhelming evidence for their value, at least in the short term, has prompted the field to move away from simply testing their efficacy to focus on issues of implementation. More and more studies are therefore addressing the interrelated goals of optimising outcomes, increasing scalability and affordability, improving access and removing barriers for hard-to-reach and treat families (e.g., Barnett et al., 2019; Day et al., 2012; Kazdin, 2015). Because parenting interventions are often complex and integrate multiple discrete therapeutic elements, achieving cost-effective interventions that can be implemented efficiently at scale will depend on identifying which elements work best and which are redundant and can be cut. This can help streamline interventions to make them less burdensome by cutting the time, effort and resources needed for families to take part and making the interventions themselves easier to train and deliver. It can also help focus energies on areas where improvements of existing interventions are most needed and/or likely to yield the most value. Leijten and colleagues (2022) addressed these issues in their excellent review.

Effects of Acceptance and Commitment Training Plus Behavior Parent Training on Parental Implementation of Autism Treatment

The objective of this study was to examine the effects of acceptance and commitment training (ACT) plus behavior parent training (BPT), when delivered via telehealth, on parental implementation of behavioral strategies, experiential avoidance (EA), and stress. The study also examined the subsequent effects on the parents’ autistic children’s behaviors. A multiple baseline design was implemented across four parent-child dyads who participated in the online training. The findings showed that ACT+BPT resulted in parental implementation reaching and maintaining high levels. The training also decreased EA and stress in three parents. Moreover, the parents’ ratings of their children’s challenging behaviors decreased. However, such a trend was not as clearly depicted by direct measures of the children’s behaviors. A social validity interview revealed parents found ACT beneficial in assisting them to learn and use the BPT strategies. Implications and suggestions for future research are discussed.