Remote population-based intervention for disruptive behavior at age four: study protocol for a randomized trial of Internet-assisted parent training (Strongest Families Finland-Canada)

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.

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.

Pandemic Perils and Promise: Implementation of a Virtual Parenting Intervention during COVID-19 among Children with Early Neurological Conditions

OBJECTIVE

In this study, we examined feasibility, acceptability, and preliminary efficacy of a telepsychological positive parenting intervention (I-InTERACT-North, Internet-basedInteracting Together Everyday: Recovery After Childhood Traumatic Brain Injury) during the COVID-19 pandemic among Canadian families of children at-risk for neurodevelopmental challenges given congenital or neonatal conditions. I-InTERACT-North was developed to improve behavioral and emotional outcomes in children with neurological conditions by utilizing and adapting parenting strategies from several established family-focused programmes.

METHODS

A pragmatic prospective pre-post single-site pilot study design was used to assess feasibility, acceptabilty, and preliminary efficacy of I-InTERACT North during the COVID-19 pandemic.

RESULTS

Thirty-five families of children ages three to nine years were referred between March 2020 and January 2021. Eighteen families enrolled, and 12 (67% adherence) completed the programme. Parents reported strong therapeutic alliance and programme acceptability with barriers due to competing time demands. Therapists reported high acceptability but perceived parental burnout. Parenting confidence (d = 0.70), and child behavior (d = 1.30) improved following the intervention.

CONCLUSIONS

Results demonstrate the programme's value to families during the pandemic, while underscoring unique participation barriers. Future research and clinicial implications are discussed.

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

Rationale and Description of Implementation of Regional Collaborative Service Model for Enhancing Psychosocial Wellbeing of Children and Families-Oulu Collective Impact Study

BACKGROUND

The psychosocial wellbeing of children and adolescents is an ongoing global concern. Despite positive outcomes of child- and family-focused programs, the fragmentation of services presents challenges. To enhance harmonization and diminish fragmentation of service policies, we implement a preventive collaborative service model for children and families. The rationale for our study is based on analyses of national and local data before implementing the service model in the pilot area.

METHODS

The need for a preventive service model for children and families was demonstrated using national and local data sources. First, a national school health survey was utilized to screen adolescents' perceptions of their depressive symptoms and support. Second, time trends in child and adolescent psychiatric and child protection service use were investigated. For these aims, epidemiological data of the study area (city of Oulu) were compared with data from the whole country (Finland). Third, local usage data of the preventive stand-alone Let's Talk About Children (LT) intervention before the service model implementation were evaluated. After these analyses, Let's Talk About Children Service Model (LT-SM) implementation in the pilot area is described in detail.

RESULTS

The background data showed that 17% of the adolescents in the study area had reported depressive symptoms, and almost half of them had not received professional help. Child and adolescent psychiatric outpatient visits had increased during the last decade, but the number of visits remains lower in the study area compared with the country as a whole. The number of adolescent psychiatric inpatient days had increased contrary to a decreasing national trend. The number of urgent child welfare placements was also higher compared with the whole country. The local LT intervention data revealed very low utilization rates. These results indicated a necessity to enhance preventive and collaborative support for children and their families. This article describes the implementation of the LT-SM.

DISCUSSION

We demonstrated excessive use of curative services in social and health care and insufficient usage of the stand-alone preventive intervention. The LT-SM is now piloted in one regional service area of the city of Oulu. Its effectiveness will be evaluated when enough data have been accumulated for statistical analyses.

Enhancement of Social Communication Behaviors in Young Children With Autism Affects Maternal Stress

Children with autism spectrum disorder (ASD) show difficulties in social communication behaviors, emotion regulation and daily living skills, and they frequently present with challenging behaviors. In parents of children with ASD, higher rates of stress and mental health problems have been reported than in parents of either typically developing children or children with other conditions. In this study, we tested whether maternal well-being changes with improved social communicative behaviors of children with ASD receiving early intervention. We examined developmental changes in 72 pre-schoolers and stress levels in their mothers (measured by the Parental Stress Inventory) before and after a 12-month community-based intervention program based on the Early Start Denver Model, a naturalistic developmental behavioral intervention targeting social communication. Multiple regression analyses showed that maternal child-related stress was predicted by changes in children's social communication behaviors (measured with the Pervasive Developmental Disorder Behavior Inventory). Gains in the early social communication behavior domain were the strongest predictor of post-intervention child-related maternal stress, surpassing adaptive behavior, language and non-verbal cognitive gains, and reduction in challenging behavior. These findings support the hypothesis that, in children with ASD, the acquisition of social communication behaviors contribute to improvements in maternal well-being.

Youth mental health in the time of COVID-19

Youth mental health is a rapidly developing field with a focus on prevention, early identification, treatment innovation and service development. In this perspective piece, we discuss the effects of COVID-19 on young people’s mental health. The psychosocial effects of COVID-19 disproportionately affect young people. Both immediate and longer-term factors through which young people are affected include social isolation, changes to the delivery of therapeutic services and almost complete loss of all structured occupations (school, work and training) within this population group. Longer-term mechanisms include the effects of the predicted recession on young people’s mental health. Opportunities within this crisis exist for service providers to scale up telehealth and digital services that may benefit service provision for young people’s mental health in the future.

Smartteen- a computer assisted cognitive behavior therapy for Indian adolescents with depression- a pilot study

The prevalence of unipolar depression among adolescents in India is high. Cognitive behavior therapies (CBTs) are considered the current gold standard treatment for depression in adolescents; however, their access is limited in India. Given the ubiquity of technology including smartphones and computers, technology can be leveraged to improve access of CBT treatment in India. Our team developed smartteen- a computer application designed to augment in-person CBT for treatment of depression in adolescents. This paper will present results of the pilot evaluation of smartteen (a cCBT) for its feasibility, acceptability and effectiveness in reducing depressive symptoms. Twenty-one adolescents with unipolar depression seeking treatment at a tertiary care hospital were randomly assigned to smartteen (n = 11) and TAU (n = 10). Both groups received twelve weeks of treatment and were assessed at baseline, mid-treatment (6 weeks) and post-treatment (12 weeks) using four clinical measures including BDI-II, CDRS-R, CGI-S and CGAS. smartteen was shown to be feasible and acceptable treatment to adolescents. At 6 weeks, both treatments were effective in reducing depression. At 12 weeks, smartteen was significantly more effective than TAU in reducing depression symptoms and improving functioning on CGAS. Treatment compliance was better in smartteen group. smartten was shown to reduce the time spent by therapist to deliver 12 sessions of CBT treatment for depression. Results indicate that smartteen may be subjected to more rigorous evaluations with larger samples and considered for wider implementation if found effective.

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.

Evidence-based prevention programs targeting youth mental and behavioral health in primary care: A systematic review

The objectives of this systematic review were to: 1) identify evidence-based youth (i.e., infancy, pre-school age, school age, and adolescence) mental and behavioral health disorder preventive interventions conducted in or offered by primary care settings, and 2) describe these interventions' characteristics, efficacy, and clinical involvement. Randomized controlled trials that targeted the prevention of mental or behavioral health outcomes for youth and had a connection to primary care were included. The PRISMA guidelines were utilized for two phases: 1) searching PubMed, EMBASE, PsycInfo, CINAHL, and Cochrane databases in January 2017; and 2) searching United States Preventive Services Task Force (USPSTF) Systematic Reviews in November 2017. The two phases revealed 504 and 58 potential articles, respectively. After removal of duplicates, screening of abstracts, and full-text reviews, 19 interventions (infancy: n = 2, pre-school age: n = 3, school age: n = 6, adolescence: n = 8) were included: 1) 10 interventions described in 17 articles from the databases, and 2) 9 interventions described in 11 articles from the USPSTF reviews. The included interventions capitalized on primary care settings as a natural entry point to engage youth and families into interventions without requiring a large amount of clinic involvement. Commonalities of efficacious interventions and recommendations for future research are discussed. The authors encourage primary care providers, mental and behavioral health providers, and/or public health researchers to continue developing and testing preventive interventions, or adapting existing interventions, to be implemented in primary care.

Identifying military family cultural competencies: experiences of military and Veteran families in Canadian health care

Introduction: Military family life is characterized by mobility, separation, and increased risk for injury or death of the military member, which impacts the health and well-being of all family members. Additional stress is experienced when accessing and navigating a new health care system. Unknown to most Canadians is the reality that military and Veteran families (MVFs) access the civilian health care system; this indicates a need for military family cultural competency among health care providers. This current research identifies aspects of military family cultural competency to inform health care provision to MVFs. Method: A qualitative study using one-on-one interviews was completed with MVFs. Critical Incident Technique (CIT) was used to develop interview questions. Framework analysis was used for data analysis. Results: In total 17 interviews were completed including:1 family (female military spouse, male military member and child); 1 male Veteran; and 15 female military spouses (1 Veteran; 1 active member). Military family cultural competency domains such as cultural knowledge (characteristics of military families; impacts of mobility, separation, and risk) and cultural skills (building relationships; use of effective and appropriate assessments and interventions) were identified. The ecological context was also described as impacting the health care experience. Discussion: The reported experiences of MVFs in this study have highlighted the gaps in the military family cultural knowledge and military family cultural skills Canadian health care providers have when providing care. Results of this study can be used to develop continuing education for health professionals and inform future research.

Two-Year Follow-Up of Internet and Telephone Assisted Parent Training for Disruptive Behavior at Age 4

OBJECTIVE

To determine whether an internet-based and telephone-assisted parent training intervention, which used whole population screening and which comprehensively targeted symptomatic 4-year-old children, was effective 24 months after the start of treatment. No long-term follow-up studies using a randomized controlled trial (RCT) existed on this subject.

METHOD

Of the 4,656 children 4 years old who were screened in Southwest Finland, 730 met the criteria for high-level disruptive behavioral problems, and 464 parents agreed to be randomized to the 11-week Strongest Families Smart Website (SFSW) intervention (n = 232) or an educational control (EC) (n = 232). After 24 months, 163 SFSW parents (70%) and 165 EC parents (71%) were still participating.

RESULTS

When we compared the results at baseline and 24 months, the primary outcome of the Child Behavior Checklist (CBCL) externalizing score showed significantly higher improvements in the SFSW group (effect size 0.22; p < 0.001). This group also showed greater improvements in the secondary outcomes: the CBCL total and internalizing scales, 5 of the 7 CBCL symptom domains, 3 of the 5 DSM subscores, and self-reported parenting skills. Fewer SFSW children (17.5%) than EC children (28.0%) had been referred to child mental health services between baseline and 24 months (odds ratio = 1.8; 95% confidence interval = 1.1-3.1).

CONCLUSION

The SFSW internet-based and telephone-assisted parental training program was effective 24 months after initiation, underlining the value of identifying children at risk in the community early and providing evidence-based parent training for a large number of families.

CLINICAL TRIAL REGISTRATION INFORMATION

STRONGEST FAMILIES FINLAND CANADA: Family-based Prevention and Treatment Program of Early Childhood Disruptive Behavior (Fin-Can). http://www.clinicaltrials.gov; NCT01750996.

Parental and child factors associated with participation in a randomised control trial of an Internet-assisted parent training programme

BACKGROUND

Parental training is an effective way to treat and prevent children's conduct problems, but knowledge of who participates in such initiatives is limited.

METHOD

This study examined child and family factors associated with participation in an Internet-assisted parent training programme. The parents of 4-year-old children with high levels of disruptive behaviour in a region of Finland were offered the opportunity to participate in a randomised controlled trial of the Strongest Families Smart Website intervention (SFSW). The participants and nonparticipants were compared using the Strengths and Difficulties Questionnaire (SDQ), duration of child problems and information about family demographics, which were routinely collected prior to randomisation to the SFSW and control group.

RESULTS

We found that 464 (64.5%) of the 709 parents of children fulfilling the screening criteria, participated. In the multivariable analysis, nonparticipation was most strongly associated with a child only having minor difficulties [odds ratio (OR): 2.1; 95% confidence interval (CI): 1.5-3.0] and a shorter duration of problems, for less than 12 months (OR: 1.7, 95% CI: 1.2-2.5), after controlling for other child factors. Nonparticipation was significantly associated with mothers spending a shorter time in the education system (OR: 1.6, 95% CI: 1.2-2.3) after controlling for other parental factors.

CONCLUSIONS

A larger percentage of parents of children with longer lasting and more severe problems seemed to be motivated to participate in this remote parent training programme. Future studies on how to encourage parents with shorter duration of education to participate in early intervention programmes are warranted.

Usability, learnability and performance evaluation of Intelligent Research and Intervention Software: A delivery platform for eHealth interventions

Evaluation of an eHealth platform, Intelligent Research and Intervention Software was undertaken via cross-sectional survey of staff users and application performance monitoring. The platform is used to deliver psychosocial interventions across a range of clinical contexts, project scopes, and delivery modalities (e.g. hybrid telehealth, fully online self-managed, randomized control trials, and clinical service delivery). Intelligent Research and Intervention Software supports persuasive technology elements (e.g. tailoring, reminders, and personalization) as well as staff management tools. Results from the System Usability Scale involving 30 Staff and Administrative users across multiple projects were positive with overall mean score of 70 ("Acceptable"). The mean score for "Usability" sub-scale was 82 and for "Learnability" sub-scale 61. There were no significant differences in perceptions of usability across user groups or levels of experience. Application performance management analytics (e.g. Application Performance Index scores) across two test sites indicate the software platform is robust and reliable when compared to industry standards. Intelligent Research and Intervention Software is successfully operating as a flexible platform for creating, delivering, and evaluating eHealth interventions.

Modeling Parenting Programs as an Interim Service for Families Waiting for Children's Mental Health Treatment

Using a discrete choice conjoint experiment, we explored the design of parenting programs as an interim strategy for families waiting for children's mental health treatment. Latent class analysis yielded 4 segments with different design preferences. Simulations predicted the Fast-Paced Personal Contact segment, 22.1% of the sample, would prefer weekly therapist-led parenting groups. The Moderate-Paced Personal Contact segment (24.7%) preferred twice-monthly therapist-led parenting groups with twice-monthly lessons. The Moderate-Paced E-Contact segment (36.3%), preferred weekly to twice-monthly contacts, e-mail networking, and a program combining therapist-led sessions with the support of a computerized telephone e-coach. The Slow-Paced E-Contact segment (16.9%) preferred an approach combining monthly therapist-led sessions, e-coaching, and e-mail networking with other parents. Simulations predicted 45.3% of parents would utilize an option combining 5 therapist coaching calls with 5 e-coaching calls, a model that could reduce costs and extend the availability of interim services. Although 41.0% preferred weekly pacing, 58% were predicted to choose an interim parenting service conducted at a twice-monthly to monthly pace. The results of this study suggest that developing interim services reflecting parental preferences requires a choice of formats that includes parenting groups, telephone-coached distance programs, and e-coaching options conducted at a flexible pace.