A randomized controlled trial of technology-enhanced behavioral parent training: sustained parent skill use and child outcomes at follow-up

Emotion Regulation and Organizational Skills in Children With ADHD Symptoms Are Associated With Behavioral Parent Training Adherence

OBJECTIVE

Behavioral parent training (BPT) is a well-established treatment for ADHD; however, treatment response is variable. Consistency in parent skill use during BPT is known to influence child outcomes post-treatment, while less research has focused on specific child factors that may be impacting parent skill utilization during treatment. The current study examined associations between child organizational skills and emotion dysregulation (ED) with parent treatment adherence during BPT and post-treatment child impairment.

METHOD

Parents of 72 children (Mage = 8.31) with ADHD symptoms and impairment participated in BPT which was embedded in a 12-week, multicomponent, school-based intervention for children delivered by school mental health clinicians. Outcomes included parent treatment adherence and child improvements in global impairment post-treatment.

RESULTS

Greater pre-treatment child organizational problems were associated with less parent treatment adherence regardless of ADHD symptom severity. Worse pre-treatment child ED was associated with more impairment post-treatment regardless of ADHD symptom severity whereas the effects of child ED on parent treatment adherence were moderated by child ADHD symptom severity.

CONCLUSION

The current study suggests that pre-treatment child ED and organizational difficulties impact parent treatment adherence to behavioral interventions targeting ADHD symptoms, potentially in unique ways, and should be considered in future BPT treatment studies.

Estimating the Heterogeneous Causal Effects of Parent-Child Relationships among Chinese Children with Oppositional Defiant Symptoms: A Machine Learning Approach

Oppositional defiant symptoms are some of the most common developmental symptoms in children and adolescents with and without oppositional defiant disorder. Research has addressed the close association of the parent-child relationship (PCR) with oppositional defiant symptoms. However, it is necessary to further investigate the underlying mechanism for forming targeted intervention strategies. By using a machine learning-based causal forest (CF) model, we investigated the heterogeneous causal effects of the PCR on oppositional defiant symptoms in children in Chinese elementary schools. Based on the PCR improvement in two consecutive years, 423 children were divided into improved and control groups. The assessment of oppositional defiant symptoms (AODS) in the second year was set as the dependent variable. Additionally, several factors based on the multilevel family model and the baseline AODS in the first year were included as covariates. Consistent with expectations, the CF model showed a significant causal effect between the PCR and oppositional defiant symptoms in the samples. Moreover, the causality exhibited heterogeneity. The causal effect was greater in those children with higher baseline AODS, a worse family atmosphere, and lower emotion regulation abilities in themselves or their parents. Conversely, the parenting style played a positive role in causality. These findings enhance our understanding of how the PCR contributes to the development of oppositional defiant symptoms conditioned by factors from a multilevel family system. The heterogeneous causality in the observation data, established using the machine learning approach, could be helpful in forming personalized family-oriented intervention strategies for children with oppositional defiant symptoms.

Family-centered profiles of mindful parenting: Longitudinal associations with negative parenting and youth emotional and behavioral problems

There has been great interest in analyzing the potential of mindful parenting in promoting family well-being. Studies indicated that there is a lack of research on the predictive relationship between parenting practice and youth emotional and behavioral problems analyzed from a multi-informant perspective. This study evaluates the family-centered profiles of mothers and fathers' mindful parenting and negative parenting and youth problems associated with those profiles. A total of 441 youths (aged 9-14 years), along with their parents, answered self-report questionnaires in a three-wave longitudinal study conducted over 1 year. A latent profile analysis was performed to examine the mindful parenting profiles and to identify their associations with youth emotional and behavioral problems and negative parenting as outcomes. The results of latent profile analyses supported a three-profile solution: low mindful parenting family (35%), high maternal mindful parenting family (24%), and average mindful parenting family (41%). The low mindful parenting family profile showed the highest scores on negative parenting and youth emotional and behavioral problems. The high maternal mindful parenting family profile had the lowest scores on youth negative outcomes but demonstrated similar levels to those of the average mindful parenting family profile regarding negative parenting. Our findings highlight the importance of analyzing specific family profiles that help to develop personalized interventions with optimized treatments regarding family cohesion and environment.

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.

Calculating power for multilevel implementation trials in mental health: Meaningful effect sizes, intraclass correlation coefficients, and proportions of variance explained by covariates

Background

Despite the ubiquity of multilevel sampling, design, and analysis in mental health implementation trials, few resources are available that provide reference values of design parameters (e.g., effect size, intraclass correlation coefficient [ICC], and proportion of variance explained by covariates [covariate R 2]) needed to accurately determine sample size. The aim of this study was to provide empirical reference values for these parameters by aggregating data on implementation and clinical outcomes from multilevel implementation trials, including cluster randomized trials and individually randomized repeated measures trials, in mental health. The compendium of design parameters presented here represents plausible values that implementation scientists can use to guide sample size calculations for future trials.

Method

We searched NIH RePORTER for all federally funded, multilevel implementation trials addressing mental health populations and settings from 2010 to 2020. For all continuous and binary implementation and clinical outcomes included in eligible trials, we generated values of effect size, ICC, and covariate R2 at each level via secondary analysis of trial data or via extraction of estimates from analyses in published research reports. Effect sizes were calculated as Cohen d; ICCs were generated via one-way random effects ANOVAs; covariate R2 estimates were calculated using the reduction in variance approach.

Results

Seventeen trials were eligible, reporting on 53 implementation and clinical outcomes and 81 contrasts between implementation conditions. Tables of effect size, ICC, and covariate R2 are provided to guide implementation researchers in power analyses for designing multilevel implementation trials in mental health settings, including two- and three-level cluster randomized designs and unit-randomized repeated-measures designs.

Conclusions

Researchers can use the empirical reference values reported in this study to develop meaningful sample size determinations for multilevel implementation trials in mental health. Discussion focuses on the application of the reference values reported in this study.

Technology-Enhanced Behavioral Parent Training: The Relationship Between Technology Use and Efficiency of Service Delivery

Behavior disorders (BDs) are common and, without treatment, can have long-term impacts on child and family health. Behavioral Parent Training (BPT) is the standard of care intervention for early-onset BDs; however, structural socioeconomic barriers hinder treatment outcomes for low-income families. While digital technologies have been proposed as a mechanism to improve engagement in BPT, research exploring the relationship between technology use and outcomes is lacking. Thus, this study with 34 low-income families examined the impact of parents' use of adjunctive mobile app components on treatment efficiency in one technology-enhanced (TE-) BPT program, Helping the Noncompliant Child (HNC). While parent use of the TE-HNC app and its impact on the efficiency of service delivery varied across specific components, increased app use significantly reduced the number of weeks required for families to achieve skill mastery. Implications for the design and development of behavior intervention technologies in general, as well as for BPT in particular, are discussed.

Behavioral Parent Training via Telehealth for Autistic Children: Further Exploration of Feasibility During the COVID-19 Pandemic

Objectives

Many autistic children exhibit challenging and disruptive behaviors that can present challenges for both children and their families by interfering with acquisition of adaptive skills and affecting family and peer relationships. Behavioral parent training (BPT) is an evidence-based approach to reducing autistic children's disruptive behavior, but many families face a number of barriers to accessing BPT, such as availability of BPT in their community, and transportation and scheduling challenges. Therefore, we sought to explore the feasibility and promise of effectiveness of adapting an established BPT program to a telehealth format during the COVID-19 pandemic.

Methods

A feasibility trial of BPT via telehealth was conducted with fourteen parents of autistic children.

Results

Parents and clinicians were able to implement BPT via telehealth with a high degree of fidelity, and parents rated both BPT and the telehealth format favorably. The program also showed promise of effectiveness in reducing autistic children's disruptive behavior, improving their adaptive skills, as well as reducing parents' stress, and improving parents' sense of parenting competence.

Conclusions

The findings replicate and extend findings from previous studies, further demonstrating the promise of telehealth as a viable alternative format for delivering BPT. We also explore implications for future research, including the opportunity for more thorough evaluation of the effectiveness of BPT via telehealth.

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.

The Effects of Young Children's Callous-Unemotional Traits on Behaviorally Observed Outcomes in Standard and Technology-Enhanced Behavioral Parent Training

Behavioral Parent Training (BPT) remains the current standard of care for early onset behavior disorders (BD); however, problem behaviors characterized by relatively high callous unemotional (CU) traits are linked to poorer treatment outcomes, highlighting the need for novel interventions. This study examined the relation of baseline child CU traits to changes in observed parent and child (3 to 8 years old) behavior in 101 families with low-income randomized to either a standard (Helping the Noncompliant Child, HNC) or technology-enhanced BPT program (TE-HNC). Assessments occurred at baseline, post-intervention, and at a three-month follow-up. Treatment group moderated the relation between CU traits and observed parenting behaviors and child compliance. Specifically, higher levels of child CU traits at baseline predicted lower levels of positive parenting at post-intervention and follow-up, and lower levels of child compliance at follow-up but only in the standard program (HNC). This is the first intervention study to behaviorally assess the differential impact of CU traits in standard, relative to technology-enhanced, BPT and suggests the promise of a technology-enhanced treatment model.

A Smartphone App for Parental Management of Adolescent Conduct Problems: Randomized Clinical Trial of iKinnect

OBJECTIVE

This study evaluates iKinnect, a linked caregiver-teen mobile app system designed to address serious adolescent conduct problems through a focus on key targets of evidence-based treatments for juvenile offending, such as parent expectation setting, monitoring, consistency, and positive reinforcement. Additional gamification and autonomy-supporting features are designed to maximize youth engagement. Digital therapeutics such as mobile apps have great potential to expand access to effective interventions, particularly for youth who engage in serious conduct problems and substance abuse, since most never receive an evidence-based treatment and few apps exist for these concerns.

METHODS

This randomized clinical trial used a short-term (12 week) longitudinal design with four time points. Recruited was a U.S. national sample of teens (n = 72, age 13-17, 59.7% male, 68.1% White) receiving services for a serious conduct problem and their primary caregiver. The efficacy of iKinnect, used by parent and teen dyads, was measured against an active control condition, Life360, an app that provided mutual GPS-based location tracking to dyads.

RESULTS

Across 12 weeks of app use, youth who used iKinnect showed significantly greater reductions in alcohol use, marijuana use, school delinquency, status offenses, and general delinquency than did controls. Parents who used iKinnect Reported greater improvements in structure/rule clarity and discipline consistency relative to control parents. Teen and parent iKinnect app use and acceptability ratings were high.

CONCLUSIONS

Real-world use of iKinnect in future applications can, like other emerging digital health technologies, help to expand the reach of evidence-based interventions to children, youth, and families.Registered at clinicaltrials.gov (NCT03065517).