Behavioral family intervention for children with developmental disabilities and behavioral problems

Predictors of homework engagement in internet-delivered Parent-Child Interaction Therapy for children with developmental delay: what about acculturation and enculturation?

Introduction

Families from racial/ethnic minoritized backgrounds and families of children with developmental delay (DD) often face more obstacles to engaging in psychosocial interventions compared to White families and families of typically developing children. Yet, research on engagement in behavioral parenting interventions has predominantly focused on typically developing children and White families from majority cultural groups. The present study offers the first examination of acculturation and enculturation as predictors of homework engagement among caregivers of children with DD from underrepresented racial/ethnic backgrounds participating in a telehealth behavioral parenting intervention.

Methods

Data were collected from 65 caregiver-child dyads participating in the Advancing Child Competencies by Extending Supported Services (ACCESS) Study evaluating Internet-delivered Parent-Child Interaction Therapy (iPCIT) for children with DD. Homework engagement was measured as the proportion of days caregivers practiced "special time" with their child. Acculturation and enculturation were assessed using the Abbreviated Multidimensional Acculturation Scale (AMAS). Linear regression analyses evaluated associations between these two cultural factors and subsequent homework engagement, controlling for caregiver nativity, language of preference, income-to-needs ratio (INR), and caregiver work status.

Results

While higher levels of acculturation (B = .110, p = .054) did not significantly predict homework engagement, enculturation (B = .140, p = .007) significantly predicted greater homework engagement throughout treatment with small and small-to-medium effect sizes (Cohen's f² = 0.029 and 0.104, respectively).

Discussion

These findings underscore the nuanced role of acculturation and enculturation in predicting homework engagement in telehealth behavioral interventions for children with DD. Although acculturation did not facilitate homework engagement, caregivers who retained a stronger connection to their cultural heritage demonstrated higher homework engagement within the context of iPCIT. The study highlights the need for incorporating cultural considerations into treatment planning and flexibility in adapting treatment protocols to optimize family engagement and improve outcomes in this population.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT03260816).

Stepped-Care Web-Based Parent Support Following Congenital Heart Disease: Protocol for a Randomized Controlled Trial

BACKGROUND

Early neurodevelopmental risks, compounded with traumatic medical experiences, contribute to emotional and behavioral challenges in as many as 1 in 2 children with congenital heart disease (CHD). Parents report a strong need for supports; yet, there remains a lack of accessible, evidence-based behavioral interventions available for children with CHD and their families. I-InTERACT-North is a web-based stepped-care mental health program designed to support family well-being and reduce behavioral concerns through positive parenting for children with early medical complexity. In previous pilot studies, the program was effective in increasing positive parenting skills and decreasing child behavior problems, with high parent-reported acceptability. This paper presents the protocol for the first randomized study of stepped-care parent support for families of children with CHD.

OBJECTIVE

This study will involve a single-site, 2-arm, single-blind randomized controlled trial to evaluate (1) the feasibility and acceptability of a web-based stepped-care parent support program (I-InTERACT-North) and (2) the effectiveness of the program in enhancing positive parenting skills and reducing behavioral concerns among families of children with CHD.

METHODS

Families will be randomized (1:1) to either receive treatment or continue with care as usual for 12 months. Randomization will be stratified by child's sex assigned at birth and baseline parent-reported child behavior intensity. Primary outcomes include positive parenting skills and child behavior at baseline, 3 months, 6 months, and 12 months. Secondary outcomes include parental mental health, quality of life, service usage, and feasibility including program reach and adherence. A sample size of 244 families will provide >95% power to detect an effect size of d=0.64. Based on attrition data from pilot studies, a target of 382 families will be enrolled. Parent reports of acceptability, adoption, and suggested adaptability of the program will be examined using cross-case thematic analyses. Primary efficacy analysis will be conducted using an intent-to-treat approach. Generalized estimating equations will be used to examine changes in positive parenting. Child behavior, quality of life, and parent mental health will be tested with repeated-measures analyses. Additional sensitivity and replication analyses will also be carried out.

RESULTS

Recruitment began in February 2024, and recruitment and follow-up will continue until January 2029. We anticipate results in late 2029.

CONCLUSIONS

This study aims to test the effectiveness of I-InTERACT-North web-based stepped-care parent support in improving positive parenting skills and reducing child behavior problems in families of children with CHD compared with a care as usual control group. Results will inform future clinical implementation and expansion of this program among families of children with early medical conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06075251; https://clinicaltrials.gov/study/NCT06075251.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64216.

Process evaluation of a parenting intervention for pre-schoolers with intellectual disabilities who display behaviours that challenge in the UK

BACKGROUND

Stepping Stones Triple P (SSTP) is a complex parent-mediated intervention aimed to reduce behaviours that challenge in children with moderate to severe intellectual disabilities, aged 30-59 months.

METHODS

To formulate a comprehensive understanding of SSTP implementation in the UK, we conducted a process evaluation collecting stakeholder views and considering intervention fidelity, dose, reach, delivery adaptations, and acceptability.

RESULTS

Fidelity and quality of delivery ratings were high. Parents perceived SSTP as valuable, reporting increased parental confidence and understanding of the child's behaviours. However, only 30% of families received an adequate dose of the intervention. Parents who only received treatment as usual described feeling abandoned by current services. Service managers emphasised the importance of availability of resources and therapist training for successful intervention delivery.

CONCLUSIONS

SSTP supports effective management of early-onset behaviours that challenge. Further work is needed to ensure equitable access to the intervention across health and social care services.

TRIAL REGISTRATION

NCT03086876 - https://www.

CLINICALTRIALS

gov/ct2/show/NCT03086876?term=Hassiotis+Angela&draw=1&rank=1.

Caregiver skills training for caregivers of individuals with neurodevelopmental disorders: A systematic review and meta-analysis

AIM

To systematically review the effectiveness of caregiver and parent skills training programs, including caregiver-mediated interventions, for caregivers of individuals with neurodevelopmental disorders.

METHOD

We conducted a systematic review with a random-effects meta-analysis. We searched 11 electronic databases through July 2021 and used a snowball methodology to locate relevant articles of randomized controlled trials. Effect size estimates were pooled using Hedges' g from data extracted from study reports and through author requests using random-effects meta-analyses for three child outcome categories (child development, adaptive behavior, and problem behavior) and three caregiver outcome categories (parenting skills and knowledge, psychological well-being, and interpersonal family relations).

RESULTS

We located 44 910 records, from which 75 randomized controlled trials involving 4746 individuals with neurodevelopmental disorders and their caregivers were included. Random-effects meta-analyses showed improvements in child development (g = 0.30; 99% confidence interval [CI] = 0.07-0.53) and reduction in reported problem behaviors (g = 0.41; 99% CI = 0.24-0.59), but not a statistically significant improvement in adaptive behavior (g = 0.28; 99% CI = -0.42 to 0.98). Caregivers showed improvements in parenting skills and knowledge (g = 0.72; 99% CI = 0.53-0.90), psychological well-being (g = 0.52; 99% CI = 0.34-0.71), and interpersonal family relations (g = 0.76; 99% CI = 0.32-1.20).

INTERPRETATION

Caregiver skills training programs benefit both caregivers and children with neurodevelopmental disorders. Skills training programs improve child development and behavior, improve parenting skills, reduce caregiver mental health issues, and improve family functioning. Programs using culturally appropriate training material to improve the development, functioning, and participation of children within families and communities should be considered when caring for children with neurodevelopmental disorders.

WHAT THIS PAPER ADDS

Caregiver skills training programs are effective interventions for both caregivers and children. Children with neurodevelopmental disorders benefit from improvements in development and reduction of problematic behaviors. Caregivers benefit from enhanced skills and psychological well-being. Improvements in interpersonal family relationships have also been documented.

Parent-Therapist Partnership Survey: Parent Feedback and Psychometric Properties

Parents of children with disabilities are an important part of their child's special education team. However, parents often have limited involvement in school-based therapies that are provided as part of a child's Individualized Education Program. The field lacks tools to assess the domain and extent of parent needs for optimal engagement in their child's special education therapies. Study one assessed the Parent-Therapist Partnership Survey's (PTPS) (formerly known as the Needs of Parents Questionnaire -School-Based Therapy Version) measure's clarity, fit, and comprehensiveness. Study two assessed the factor structure and internal consistency. Two factors emerged - Need to Be an Informed, Engaged Member of Their Child's Team, and Need for Support and Guidance. Internal consistency was 0.93 for the overall scale. The PTPS can serve as a powerful measure to better identify opportunities to engage parents in school therapeutic goals while improving parent-provider collaboration in school-based therapies.

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

Background

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

Objective

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

Design, setting, participants

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

Intervention

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

Main outcome measure

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

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

Funding

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

Telehealth Treatment of Behavior Problems in Young Children With Developmental Delay: A Randomized Clinical Trial

Importance

Early behavior problems in children with developmental delay (DD) are prevalent and impairing, but service barriers persist. Controlled studies examining telehealth approaches are limited, particularly for children with DD.

Objective

To evaluate the efficacy of a telehealth parenting intervention for behavior problems in young children with DD.

Design, Setting, and Participants

A randomized clinical trial was conducted from March 17, 2016, to December 15, 2020, in which children with DD and externalizing behavior problems were recruited from early intervention and randomly assigned to a telehealth parenting intervention or control group and evaluated through a 12-month follow-up. Most children were from ethnic or racial minoritized backgrounds. Over one-half of children were in extreme poverty or low income-need ratio categories.

Interventions

Internet-delivered parent-child interaction therapy (iPCIT), which leverages videoconferencing to provide live coaching of home-based caregiver-child interactions. Families received 20 weeks of iPCIT (provided in English or in Spanish) or referrals as usual (RAU).

Main Outcomes and Measures

Observational and caregiver-report measures of child and caregiver behaviors and caregiving stress were examined at preintervention, midtreatment, and postintervention and at 6- and 12-month follow-ups.

Results

The sample included a total of 150 children (mean [SD] age, 36.2 [1.0] months; 111 male children [74%]) and their caregivers with 75 each randomly assigned to iPCIT or RAU groups. Children receiving iPCIT relative to RAU displayed significantly lower levels of externalizing problems (postintervention Cohen d = 0.48; 6-month Cohen d = 0.49; 12-month Cohen d = 0.50) and significantly higher levels of compliance to caregiver direction after treatment. Of those children with data at postintervention, greater clinically significant change was observed at postintervention for children in the iPCIT group (50 [74%]) than for those in the RAU group (30 [42%]), which was maintained at the 6-month but not the 12-month follow-up. iPCIT did not outperform RAU in reducing caregiving stress, but caregivers receiving iPCIT, relative to RAU, showed steeper increases in proportion of observed positive parenting skills (postintervention odds ratio [OR], 1.10; 95% CI, 0.53-2.21; 6-month OR, 1.31; 95% CI, 0.61-2.55; 12-month OR, 1.64; 95% CI, 0.70-3.07) and sharper decreases in proportion of observed controlling/critical behaviors (postintervention OR, 1.40; 95% CI, 0.61-1.52; 6-month OR, 1.72; 95% CI, 0.58-1.46; 12-month OR, 2.23; 95% CI, 0.53-1.37). After treatment, iPCIT caregivers also self-reported steeper decreases in harsh and inconsistent discipline than did than RAU caregivers (postintervention Cohen d = 0.24; 6-month Cohen d = 0.26; 12-month Cohen d = 0.27).

Conclusions and Relevance

Results of this randomized clinical trial provide evidence that a telehealth-delivered parenting intervention with real-time therapist coaching led to significant and maintained improvements for young children with DD and their caregivers. Findings underscore the promise of telehealth formats for expanding scope and reach of care for underserved families.

Trial Registration

ClinicalTrials.gov Identifier: NCT03260816.

Content analysis of parent training programs for children with neurodisabilities and mental health or behavioral problems: a scoping review

PURPOSE

Several systematic reviews have examined parent training programs for families of children with autism spectrum disorder (ASD). The present review expands on this literature by describing the components, delivery methods, and level of parent involvement in parent training programs that target families of children with any neurodisability and comorbid disruptive behavior or other mental health problem.

MATERIALS AND METHODS

Following a scoping review protocol, the search strategy included randomized controlled trials of parent training programs conducted with families of children with neurodisabilities and comorbid disruptive behavior or mental health problems. Study characteristics, program content, delivery methods, and theoretical frameworks were extracted from eligible studies.

RESULTS

A total of 22 articles were included from the 453 full-text articles initially screened. Thirteen different programs fell into two general categories based on whether they targeted child disruptive behavior or anxiety. Analysis of the content yielded five themes: child skill enhancement, parenting as enacted, parenting as experienced, disability-related parenting, and parent-child relationships. The theoretical underpinnings were identified, when possible, from each study.

CONCLUSIONS

Parent training programs for parents of children with neurodisabilities targeting child anxiety involved parents in a complementary role in treatment while those targeting disruptive behavior involved parents in a primary role in creating behavior change. We suggest that the extent of parent involvement in interventions be guided by theory rather than diagnosis of the child.Implications for rehabilitationParents of children living with neurodisabilities play a key role in delivering interventions to address comorbid mental health or behavioral problems.Parent training programs for families of children with neurodisabilities vary in relation to their aims, involvement of parents in delivering interventions, disability-specific content, and delivery methods.When referring families, rehabilitation professionals should be aware of aspects of child, parent, and family relational well-being targeted by parent training programs and, when feasible, give families a choice of the style of program to meet their needs.

Acceptance and Commitment Training Focused on Psychological Flexibility for Family Members of Children with Intellectual Disabilities

The objective of the study was to analyse the effect of a psychological flexibility intervention programme based on Acceptance and Commitment Therapy (ACT) on 36 family members of children with intellectual disabilities. The 6-PAQ (parental psychological flexibility), PSS-14 (perceived stress), GHQ-12 (psychological health), and WBSI (suppression of unwanted thoughts) were used as measurement instruments before the programme (pre), after (post), and at follow-up (after two months). Possible change in family interactions due to the family intervention was also assessed through self-monitoring. A decrease in psychological inflexibility, a reduction in stress, an improvement in psychological well-being, and a reduction in the tendency to suppress thoughts and emotions were observed after the programme. Furthermore, the effects seem to extend to family interactions, with an increase in positive interactions and a decrease in negative ones. The study leads us to think about the importance of psychological flexibility in children with chronic conditions as a process that mediates the impact of stress and family well-being.

The Efficacy of Parent Training Interventions with Parents of Children with Developmental Disabilities

Parenting children with developmental disabilities (DD) can be generally characterized by a considerable psychological burden. The effects on parental and familial psychological well-being and, consequently, on children's developmental outcomes should not be underestimated, especially in early childhood. The current review aims to advance our understanding of the key factors (e.g., formats, sample characteristics, research design) that characterize parent training interventions, and that could be related to their outcomes, to guide researchers and clinical practitioners to develop and provide efficient programs. Studies were identified via an Internet search from three electronic databases, following PRIMSA guidelines. Studies published until November 2021 were taken into account. The initial search yielded a total of 2475 studies. Among them, 101 studies were fully reviewed. Finally, ten of the studies, which met all the inclusion criteria, formed the basis for this review. Participants' characteristics, main features of the interventions (i.e., study design, structure, and contents), outcome variables and treatment efficacy were deeply examined and discussed. Key factors of parent training interventions with parents of children affected by DD are enlightened, to guide researchers and clinicians in the design and implementation of tailored specific programs, aimed to sustain parenting and foster children's developmental outcomes, from early stages of life.

Perceived parent needs in engaging with therapeutic supports for children with disabilities in school settings: An exploratory study

BACKGROUND

Parent engagement in therapeutic services for children with disabilities could optimize service delivery while addressing service disparities. However, service providers must first understand parents' needs to effectively involve parents.

AIMS

This study examines what needs parents identify as important when engaging with school-based therapies and how well these needs are being met.

METHODS AND PROCEDURES

Parents of children with Individualized Education Plans rated statements related to their needs for trust, information, support and guidance, and personal needs when engaging with their child's therapies. Parents also provided demographic information on them and their child[ren] with a disability.

OUTCOMES AND RESULTS

Parents endorsed an average of 83 % of needs as important but 51 % of needs as unmet. On average, 65 % of needs related to feeling trusted by service providers were met. In contrast, needs related to receivings upport and guidance (M = 58 %), information (M = 55 %), and addressing parent's own needs (M = 53 %) were frequently unmet. Parents indicated that needs related to feeling trusted by service providers were most frequently met. In contrast, needs related to receiving information were most frequently unmet. Race/ethnicity and number of children with a disability influenced the number of needs endorsed as important and unmet.

CONCLUSION

This feasibility study suggests that parents find a variety of needs regarding their interactions with school-based providers as important to them. However, given the high proportion of needs indicated being unmet, significant gaps likely exist in effectively engaging parents, especially for Parents of Color and parents with multiple children with disabilities.

IMPLICATIONS

This study provides a list of tangible needs school-based providers can use to improve parent engagement with school-based therapies. School-based providers and administrators can use the needs identified as important and unmet in this study to create actionable steps that aim to improve parent engagement in school-based services.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Health-Related Quality of Life and Family Functioning of Primary Caregivers of Children with Cerebral Palsy in Malaysia

Caregiving for children with cerebral palsy (CP) has proved to negatively impact on the physical and psychological well-being of their primary caregivers. The aim of the current study was to examine the overall impact of caregiving for children with CP on the primary caregivers' health-related quality of life (HRQOL) and family functioning, and to identify potential factors associated with primary caregivers' HRQOL and family functioning. The cross-sectional study involved a total of 159 primary caregivers of children with CP with a mean age of 42.8 ± 8.4 years. Demographic data and information on the physical and leisure activities of the primary caregivers were collected, and their quality of life (QOL) was measured based on the self-reported Pediatric Quality of Life Inventory Family Impact Module (PedsQL FIM). Primary caregivers in the current study have shown good HRQOL and family functioning, with scores of 82.4 and 85.3 out of 100, respectively. Through multiple linear regression analyses, the mother's level of education, family monthly income, sleeping problems in children with CP, and the existence of children with other types of disability have been identified as factors contributing to HRQOL and family functioning. The findings help set out the course for stakeholders to establish action to enhance the QOL of primary caregivers.

German Law Reform Does Not Reduce the Prevalence of Coercive Measures in Residential Institutions for Children, Adolescents, and Young Adults With Intellectual and Developmental Disabilities

Background: Approximately 10% of children, adolescents and young adults with an intellectual and developmental disability (IDD) in Bavaria live in residential institutions. 2015 saw media reports raising suspicions about excessive use of coercive measures (cM) in those institutions. Until a law reform at the end of 2017 made permission from family courts mandatory for cM, their use was governed by parental consent. The REDUGIA project conducted a representative survey comparing cM and their relation to challenging behaviour (cB) and employee stress in Bavaria pre and post reform. Methods: We sent questionnaires to 65 residential institutions for children, adolescents and young adults with IDD in 2017 (pre reform, T1) and 2019 (post reform, T2). To assess changes, we analysed data from all available questionnaire pairs (T1 and T2, N = 43). We calculated paired t-test and correlative analyses concerning the relationship between cB, cM, and employee stress. Results: The number of residents overall (T1: N = 1,661; T2: N = 1,673) and per institution (T1: m = 38.6 ± 32.0; T2: m = 38.9 ± 34.5, p = 0.920) remained stable. We did not see any changes in the Index cB (p = 0.508) or the proportion of residents per institution displaying various types of challenging behaviour (all ps>0.220). There was no change in the Index cM (p = 0.089) or any indicator of employee stress, all ps > 0.323. At follow-up, the Index cB correlated positively with the Index cM (r = 0.519 p < 0.001). Regarding employee stress, the Index cB correlated positively with the frequency of sick leave (r = 0.322, p = 0.037) and physical attacks on employees (r = 0.552, p < 0.001). The Index cM also correlated positively with the frequency of sick leave (r = 0.340, p = 0.028) and physical attacks on employees (r = 0.492, p = 0.001). Discussion: Coercive measures are not a general phenomenon, but are focused on specialised institutions. The law reform did not lead to changes in the number of children, adolescents and young adults with IDD affected by coercive measures in residential institutions in Bavaria. There were still large discrepancies between institutions in the prevalence of challenging behaviour and coercive measures. Coercive measures were associated with challenging behaviour and employee stress. Taken together, findings from REDUGIA emphasise the need to prevent challenging behaviour and thus coercive measures.

Effectiveness of a multidisciplinary parent training program for children with developmental disabilities: A single-blind randomized waitlist controlled trial

This study aimed to evaluate the effectiveness of a multidisciplinary parent training program, Promoting Holistic Development of Young Kids (Poly Kids), using a single-blind randomized waitlist controlled design. The participants included 218 parents of children with developmental disabilities (DD) (intervention group = 107 and waitlist control group = 111). The primary outcomes were child learning, expressive language, fine and gross motor skills (based on individual assessment by respective blinded professionals), and parental reports of child behavior problems. The parents in the intervention group reported significantly lower child behavior problems (d = .34), higher child task motivation (d = .63), and lower parenting stress post-intervention (d = .25), while the children in the intervention group produced significantly more words post-intervention (d = .82). McNemar test results were significant for movement out of the clinical range in child behavior problems and cognitive skills in the intervention group, but not the control group. The results provided initial evidence on the effectiveness of this train-the-trainer program in supporting families with preschool children with DD in terms of child behavior problems, expressive language, cognitive skills, task motivation, and parenting stress.

What Can We Do to Promote Mental Health Among Individuals With Developmental Coordination Disorder?

Purpose of the Review

It is well-documented that individuals with DCD experience mental health problems, in both psychosocial and psychiatric domains. In this review, we propose a series of diverse options to improve mental health among individuals with DCD.

Recent Findings

Despite recognition of mental health problems in DCD, relatively little work has been done to develop effective interventions. There is an urgent need for action in this matter. We present and discuss options based on a societal perspective (awareness and understanding), parental perspective (access to services and resources), and child perspective (participation).

Summary

In order to improve mental health, interventions must take into account multiple levels in a complex framework that includes community, family, and the individual. While more research on intervention effectiveness is necessary, researchers, practitioners, and community advocates can use existing initiatives as a starting point to address the urgent need for improving mental health in DCD.

Addressing the neurodevelopmental needs of children and adolescents with congenital heart disease: A review of the existing intervention literature

Congenital heart disease (CHD) is among the most prevalent birth defects in the United States. Given that children with CHD are at risk for differences with development, learning, and psychosocial functioning, effective intervention becomes a central tenant of recommendations following neuropsychological consultation and evaluation. The primary focus of this review is to summarize available interventions for children and adolescents with CHD. The existing CHD literature has concentrated on early developmental services, psychopharmacological treatment, and need for academic supports. The literature is limited with regard to intervention studies that target cognitive deficits and psychosocial difficulties. To address this discrepancy, efficacious interventions that have been used to mitigate these concerns within other medical groups are also discussed in an effort to provide options for alternative recommendations and services. The current paper is intended to facilitate comprehensive care for cardiac patients by providing clinicians with a review of the available intervention literature, as well as potential interventions that may serve as supplemental strategies in the interim.

Clinical and cost effectiveness of a parent mediated intervention to reduce challenging behaviour in pre-schoolers with moderate to severe intellectual disability (EPICC-ID) study protocol: a multi-centre, parallel-group randomised controlled trial

BACKGROUND

Children with intellectual disabilities are likely to present with challenging behaviour. Parent mediated interventions have shown utility in influencing child behaviour, although there is a paucity of UK research into challenging behaviour interventions in this population. NICE guidelines favour Stepping Stones Triple P (SSTP) as a challenging behaviour intervention and this trial aims to evaluate its clinical and cost effectiveness in preschool children with moderate to severe intellectual disabilities.

METHODS

This trial launched in 2017 at four sites across England, with the aim of recruiting 258 participants (aged 30-59 months). The Intervention Group receive nine weeks of SSTP parenting therapy (six group sessions and three individualised face to face or telephone sessions) in addition to Treatment as Usual, whilst the Treatment as Usual only group receive other available services in each location. Both study groups undergo the study measurements at baseline and at four and twelve months. Outcome measures include parent reports and structured observations of behaviour. Service use and health related quality of life data will also be collected to carry out a cost effectiveness and utility evaluation.

DISCUSSION

Findings from this study will inform policy regarding interventions for challenging behaviour in young children with moderate to severe intellectual disabilities.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, NCT03086876. Registered 22nd March 2017, https://clinicaltrials.gov/ct2/show/NCT03086876.

A systematic review and meta-analysis of the effectiveness of interventions to improve psychological wellbeing in the parents of children with cerebral palsy

BACKGROUND

Caregivers of children with cerebral palsy (CP) face unique demands and challenges, with potential negative impact on psychological wellbeing and consequences for both caregiver and child. Timely support could improve parental wellbeing.

AIM

To evaluate the effectiveness of interventions aimed at improving the psychological wellbeing of caregivers of children with CP.

METHODS AND PROCEDURES

Systematic review and meta-analysis of randomised controlled trials of interventions to improve the psychological well-being of caregivers of children with cerebral palsy. Databases (including MEDLINE, EMBASE, PsycINFO, Cochrane) were searched for relevant English language publications between January 1990 and December 2017. Risk of bias was assessed including randomization, allocation concealment, incomplete outcome data and selective outcome reporting.

OUTCOME AND RESULTS

We included 13 studies (1293 participants, 1/3 with CP). Six studies investigated a positive parenting intervention; the other seven studies covered a range of other interventions. Meta-analysis of 7 studies (662 participants) showed that interventions significantly improved parental wellbeing (standardised mean difference -0.61, 95% CI -0.92 to -0.30, z = 3.84, p = 0.0001).

CONCLUSIONS AND IMPLICATIONS

Limitations include small sample sizes and heterogeneity in study design; however, our results indicate that interventions can improve the wellbeing of parents of children with CP and should be made available.

A randomised controlled trial of the Group Stepping Stones Triple P training programme for parents of children with developmental disabilities

The central aim of this study was to examine the effectiveness of Group Stepping Stones Triple P (GSSTP) in an Irish context for families of children with both developmental disabilities and internalising and externalising behavioural problems. Parents of 84 children (mean age = 5.73; SD = 2.06) with developmental disabilities and co-occurring behaviour problems attending Irish public health services were randomly assigned to a 9-week GSSTP group or a waiting list control (WLC) group. All parents completed self-report measures before (Time 1) and after (Time 2) the programme and parents in the GSSTP group were assessed at 3- to 5-month follow-up (Time 3). At Time 2, clinical improvement and reliable change rates on the primary dependent variables (summary scales of the Developmental Behaviour Checklist and Strengths and Difficulties Questionnaire) were significantly higher in the GSSTP group than in the WLC group. At Time 2, mean scores of the GSSTP group showed significant, small to medium improvements relative to the WLC group on parent-reported child behaviour problems, parenting skills and confidence, and parental adjustment. Most of these improvements were maintained at 3- to 5-month follow-up. These results indicate that GSSTP is a promising intervention for improving child behaviour and parenting outcomes in a mixed-disability group in an Irish context.

Psychological interventions in reducing stress, depression and anxiety among parents of children and adolescents with developmental disabilities: A systematic review and meta-analysis

AIMS

To evaluate the effectiveness of psychological interventions in reducing stress, depression and anxiety among parents of children and adolescents with developmental disabilities.

DESIGN

A systematic review and a meta-analysis.

DATA SOURCES

Seven electronic databases (CINAHL, CENTRAL, EMBASE, ProQuest Dissertation and Theses, PsycINFO, PubMed and Scopus) were searched from each database's point of inception to December 2018.

REVIEW METHODS

Quality appraisal was conducted using the Cochrane Risk of Bias Tool. Data were analysed using Review Manager 5.3. The overall quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

A total of 18 studies were included in this review. Eleven studies were involved in a meta-analysis and the remaining seven studies were summarized narratively. The meta-analysis found that psychological interventions significantly reduced parental stress at postintervention but not at 3-6 months' postintervention. Inconclusive evidence was found for the effectiveness of psychological interventions in reducing parental depression and anxiety.

CONCLUSION

Psychological interventions appeared to reduce parental stress temporarily. Healthcare professionals can offer varied psychological interventions for parents to choose from. Policymakers can ease accessibility and affordability for parents to attend interventions.

IMPACT

Psychological interventions were found to have short-term effects in reducing parental stress. Inconclusive evidence was found for the effectiveness of psychological interventions in reducing parental depression and anxiety. Healthcare professionals should ensure that knowledge is transmitted to parents when delivering their interventions. Policymakers worldwide should ensure that parents of children and adolescents with developmental disabilities can attend interventions by making them accessible and affordable.

Effectiveness of the Stepping Stones Triple P group parenting program in reducing comorbid behavioral problems in children with autism

Children with autism spectrum disorders often exhibit comorbid behavioral problems. These problems have an impact on the severity of the core symptoms, the progression of the disorder as well as on the families’ quality of life. We evaluated the effectiveness of the Stepping Stones Triple P group parent training program as a supplementary intervention in the treatment of children with autism spectrum disorder. Therefore, we employed a single group repeated measures design and assessed child variables via parents’ and teachers’ judgments at four successive time points. The participants were parents of 24 children with autism spectrum disorder aged between 3.6 and 12 years. We found a significant reduction of comorbid behavioral problems in the children, primarily in the parents’ judgment at follow-up. Furthermore, a reduction of the autism spectrum disorder core symptoms emerged. The teachers’ judgment particularly revealed an improvement in children’s social relationships. Effect sizes were large ( ƞ2 ranging from 0.14 to 0.23). The findings demonstrate the effectiveness of the Stepping Stones Triple P as a supplementary intervention for reducing comorbid behavioral problems in the treatment of children with autism spectrum disorder. Higher parental self-efficacy and parental attributions, including parents’ ability to influence child problem behaviors, are discussed as important factors for the effectiveness of Stepping Stones Triple P.

Predictive validity of developmental milestones for detecting limited intellectual functioning

Developmental milestones are commonly used in child health care, although from many milestones the predictive validity has not been adequately assessed. We aimed to determine the predictive validity of 75 developmental milestones for detecting limited intellectual functioning that can be obtained before the age of 4 years. We performed a case-control study with 148 children aged 5–10 years with limited intellectual functioning (IQ 50–69), who were in special education (cases) and a random sample of 300 children aged 5–10 years who were in regular elementary education (controls). Developmental milestones scores were retrieved from Child Healthcare files. We calculated sensitivity, specificity, positive likelihood ratios (LR+) and diagnostic odds ratios (DOR) for limited intellectual functioning. The LR+ determines whether a test result changes the probability that a condition exists. Given the prevalence of intellectual disability (1–3%), we considered that an LR+ > 10 would be clinically useful, as it increases the a priori probability of limited intellectual functioning from 2% to a posteriori probability of at least 17%. Out of 75 assessed milestones, 50 were included in the analysis. We found nine milestones to have a significant adjusted (for socio-economic status and prematurity) DOR > 1 and a significant LR+ > 10 (assessment age in months between brackets): ‘says "dada-baba‴ (9), ‘balances head well while sitting’ (9), ‘sits on buttocks while legs stretched’ (9), ‘babbles while playing’ (12), ‘sits in stable position without support’ (12), ‘walks well alone’ (24), ‘says "sentences" of 3 or more words’ (36), ‘places 3 forms in form-box’ (36) and ‘copies circle’ (48). Sensitivities of these 9 milestones varied from 8–54%, specificities of these 9 milestones varied from 95–100%. Combining these milestones at 9, 12, and 36 months respectively resulted in sensitivities of 27–60% and specificities of 94–99%. These nine developmental milestones have substantial predictive validity for limited intellectual functioning.

Systematic Review and Meta-analysis of Stepping Stones Triple P for Parents of Children with Disabilities

The aim of this systematic review and meta-analysis was to examine the effectiveness of Stepping Stones Triple P (SSTP) parent training programs on child behavior problems and parenting outcomes in families of children with developmental disabilities. Sixteen suitable studies including data from over 900 families were identified in a search for English language published and unpublished controlled outcome studies. SSTP has five levels on a graded continuum of increasing intensity targeting families with differing degrees of treatment need from low intensity media-based parenting information campaigns at level 1, through brief interventions at levels 2 and 3, to more intensive parent training and family therapy interventions at levels 4 and 5. Analyses were conducted on the combination of all levels of SSTP and separately for each level. For combined levels, significant overall effect sizes were found for parent-reported child problems (d = 0.46), researcher observed child behavior (d = 0.51), parenting style (d = 0.70), parenting satisfaction/self-efficacy (d = 0.44), parental adjustment (d = 0.27), and coparental relationship (d = 0.26), but not researcher-observed parent behavior. Strong support was found for level 4 SSTP as an effective intervention for improving child and parent outcomes in families of children with disabilities who have clinically significant problems. Less intensive SSTP interventions for cases with circumscribed difficulties yielded fewer significant treatment effects, and there were relatively few studies of such interventions.

Development of a psycho-social intervention for reducing psychological distress among parents of children with intellectual disabilities in Malawi

BACKGROUND

The burden of intellectual disabilities in low and middle income countries (LMIC) is high and is associated with parental psychological distress. There are few services for children and parents in most developing countries and few interventions have been created that target the psychological issues among parents of such children. This study aimed to develop a contextualized intervention to provide psychological support for parents of children with intellectual disabilities in an African setting.

METHODS

Six steps were adopted from the Medical Research Council framework for designing complex interventions. This include: literature review of similar interventions and models, qualitative studies to gain insights of lived experiences of parents of such children, a consensus process with an expert panel of professionals working with children with disabilities and piloting and pre-testing the draft intervention for its acceptability and practicability in this settings.

RESULTS

21 intervention modules were found from a systematic search of the literature which were listed for possible use in our intervention along with four themes from our qualitative studies. An expert panel formed consensus on the eight most pertinent and relevant modules for our setting. This formed the intervention; "Titukulane." This intervention was piloted and found to have high acceptability and practicability when contextualized in the field.

CONCLUSION

The use of a systematic framework for designing a complex intervention for supporting the mental health of parents of children with disabilities enables good acceptability and practicability for future use in low resource settings.

Parent-mediated interventions for promoting communication and language development in young children with Down syndrome

BACKGROUND

Communication and language development are areas of particular weakness for young children with Down syndrome. Caregivers' interaction with children influences language development, so many early interventions involve training parents how best to respond to their children and provide appropriate language stimulation. Thus, these interventions are mediated through parents, who in turn are trained and coached in the implementation of interventions by clinicians. As the interventions involve a considerable commitment from clinicians and families, we undertook this review to synthesise the evidence of their effectiveness.

OBJECTIVES

To assess the effects of parent-mediated interventions for improving communication and language development in young children with Down syndrome. Other outcomes are parental behaviour and responsivity, parental stress and satisfaction, and children's non-verbal means of communicating, socialisation and behaviour.

SEARCH METHODS

In January 2018 we searched CENTRAL, MEDLINE, Embase and 14 other databases. We also searched three trials registers, checked the reference lists of relevant reports identified by the electronic searches, searched the websites of professional organizations, and contacted their staff and other researchers working in the field to identify other relevant published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared parent-mediated interventions designed to improve communication and language versus teaching/treatment as usual (TAU) or no treatment or delayed (wait-listed) treatment, in children with Down syndrome aged between birth and six years. We included studies delivering the parent-mediated intervention in conjunction with a clinician-mediated intervention, as long as the intervention group was the only group to receive the former and both groups received the latter.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures for data collection and analysis.

MAIN RESULTS

We included three studies involving 45 children aged between 29 months and six years with Down syndrome. Two studies compared parent-mediated interventions versus TAU; the third compared a parent-mediated plus clinician-mediated intervention versus a clinician-mediated intervention alone. Treatment duration varied from 12 weeks to six months. One study provided nine group sessions and four individualised home-based sessions over a 13-week period. Another study provided weekly, individual clinic-based or home-based sessions lasting 1.5 to 2 hours, over a six-month period. The third study provided one 2- to 3-hour group session followed by bi-weekly, individual clinic-based sessions plus once-weekly home-based sessions for 12 weeks. Because of the different study designs and outcome measures used, we were unable to conduct a meta-analysis.We judged all three studies to be at high risk of bias in relation to blinding of participants (not possible due to the nature of the intervention) and blinding of outcome assessors, and at an unclear risk of bias for allocation concealment. We judged one study to be at unclear risk of selection bias, as authors did not report the methods used to generate the random sequence; at high risk of reporting bias, as they did not report on one assessed outcome; and at high risk of detection bias, as the control group had a cointervention and only parents in the intervention group were made aware of the target words for their children. The sample sizes of each included study were very small, meaning that they are unlikely to be representative of the target population.The findings from the three included studies were inconsistent. Two studies found no differences in expressive or receptive language abilities between the groups, whether measured by direct assessment or parent reports. However, they did find that children in the intervention group could use more targeted vocabulary items or utterances with language targets in certain contexts postintervention, compared to those in the control group; this was not maintained 12 months later. The third study found gains for the intervention group on total-language measures immediately postintervention.One study did not find any differences in parental stress scores between the groups at any time point up to 12 months postintervention. All three studies noted differences in most measures of how the parents talked to and interacted with their children postintervention, and in one study most strategies were maintained in the intervention group at 12 months postintervention. No study reported evidence of language attrition following the intervention in either group, while one study found positive outcomes on children's socialisation skills in the intervention group. One study looked at adherence to the treatment through attendance data, finding that mothers in the intervention group attended seven out of nine group sessions and were present for four home visits. No study measured parental use of the strategies outside of the intervention sessions.A grant from the Hospital for Sick Children Foundation (Toronto, Ontario, Canada) funded one study. Another received partial funding from the National Institute of Child Health and Human Development and the Department of Education in the USA. The remaining study did not specify any funding sources.In light of the serious limitations in methodology, and the small number of studies included, we considered the overall quality of the evidence, as assessed by GRADE, to be very low. This means that we have very little confidence in the results, and further research is very likely to have an important impact on our confidence in the estimate of treatment effect.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine the effects of parent-mediated interventions for improving the language and communication of children with Down syndrome. We found only three small studies of very low quality. This review highlights the need for well-designed studies, including RCTs, to evaluate the effectiveness of parent-mediated interventions. Trials should use valid, reliable and similar measures of language development, and they should include measures of secondary outcomes more distal to the intervention, such as family well-being. Treatment fidelity, in particular parental dosage of the intervention outside of prescribed sessions, also needs to be documented.

Treatment Response among Preschoolers with EBP: The Role of Social Functioning

OBJECTIVE

The purpose of the study was to identify profiles of social functioning for preschoolers with externalizing behavior problems (EBP) and examine how profiles are predictive of response to a behavioral treatment program.

METHOD

139 preschoolers with EBP participated in an 8-week Summer Treatment Program for Pre-Kindergartners (STP-PreK). Latent profiles of social functioning were created from parent and teacher rated atypicality and social skills scales, along with child performance on an emotion knowledge and hostile attribution task. Baseline and treatment outcomes included behavioral, academic, and executive functioning measures.

RESULTS

Latent profile analyses resulted in two profiles (e.g., average and low) marked by differences in social skills, emotion knowledge and rates of atypical behaviors. Children in the low social functioning group had higher teacher rated hyperactivity and attention problems at baseline (d = .44 & 1.07), as well as lower IQ (d = .39). Children in the low social functioning group also had poorer treatment response as they had lower executive functioning scores (β = -.17, p < .05) at the completion of treatment. IQ moderated the association between social functioning profiles and behavioral treatment outcomes, such that lower social functioning was only associated with higher rates of attention problems for children with average IQ.

CONCLUSIONS

Findings highlight the differential impact of social functioning in predicting treatment outcomes.

Mediator or moderator? The role of mindfulness in the association between child behavior problems and parental stress

BACKGROUND

Raising a child with intellectual disability (ID) may be stressful for parents. Previous studies have suggested the mediating role of mindfulness in the association between child behavior problems and parental stress.

AIMS

The present study examined whether this mediating role is a result of parents' self-report bias. It also explored whether mindfulness has a moderating role instead when child behavior problems are reported by teachers.

METHODS

In a questionnaire survey, 271 Chinese parents of children with ID in 6 Hong Kong special schools reported their levels of stress and mindfulness, as well as their children's behavior problems. The latter was also reported by teachers.

RESULTS

When child behavior problems were reported by parents, parental mindfulness was a mediator between child behavior problems and parental stress. In contrast, when child behavior problems were reported by teachers, parental mindfulness was a moderator between child behavior problems and parental stress.

CONCLUSION

The mediation role of mindfulness maybe an artifact of measurement. The findings provide an encouraging message that parenting a child with ID and behavior problems does not necessarily mean more stress among all parents. Parents with a high level of mindfulness may experience less stress than those with a low level of mindfulness.

WHAT THIS PAPER ADDS

Parents of children with intellectual disability (ID) tend to report high psychological stress. Previous self-report studies have identified mindfulness as a mediator in the association between child behavior problems and parental stress. The present study differs from previous studies by including third-party's reports. It has contributed to the existing body of knowledge in two respects. First, it examined whether the mediation effect resulted from parent self-report bias. Second, it tested an alternative hypothesis of the moderation effect by using teachers' reports to measure child behavior problems. The results showed that when child behavior problems were measured by parents' reports, parental mindfulness was a mediator between child behavior problems and parental stress. The more the parents reported that their children had behavior problems, the less they reported being mindful, which in turn the more stressful they were. However, when child behavior problems were measured by teachers' reports, parental mindfulness was a moderator instead, moderating the association between child behavior problems and parental stress. The association was ameliorated when parents reported high levels of mindfulness. These findings reveal another possible role of mindfulness and shed light on the support for parents of children with ID.

A randomized controlled trial of a telehealth parenting intervention: A mixed-disability trial

BACKGROUND

The quality of parenting a child receives has a major impact on development, wellbeing and future life opportunities.

AIMS

This study examined the efficacy of Triple P Online - Disability (TPOL-D) a telehealth intervention for parents of children with a disability.

METHODS

Ninety-eight parents and carers of children aged 2-12 years diagnosed with a range of developmental, intellectual and physical disabilities were randomly assigned to either the intervention (51) or treatment-as-usual (47) control group.

RESULTS

At post-intervention parents receiving the TPOL-D intervention demonstrated significant improvements in parenting practices and parenting self-efficacy, however a significant change in parent-reported child behavioral and emotional problems was not detected. At 3-month follow up intervention gains were maintained and/or enhanced. A significant decrease in parent-reported child behavioral and emotional problems was also detected at this time.

CONCLUSIONS

The results indicate that TPOL-D is a promising telehealth intervention for a mixed-disability group.

Effectiveness of an Intervention for Children with Externalizing Behavior and Mild to Borderline Intellectual Disabilities: A Randomized Trial

This study evaluated the effectiveness of Standing Strong Together (SST), a combined group based parent and child intervention for externalizing behavior in 9-16 year-old children with mild to borderline intellectual disabilities (MBID). Children with externalizing behavior and MBID (IQ from 55 to 85) (N = 169) were cluster randomly assigned to SST combined with care as usual or to care as usual only. SST led to a significant benefit on teacher reported but not on parent reported externalizing behavior. SST had significant effects on parent rated positive parenting and the parent-child relationship. The present study shows that a multicomponent group based intervention for children with MBID is feasible and has the potential to reduce children's externalizing behavior and improve both parenting behavior and the parent-child relationship.

Parenting children with intellectual disabilities in Malawi: the impact that reaches beyond coping?

BACKGROUND

Rates of disability are high in resource poor settings with 85% of children with disabilities living in these settings. Long-term caregiving for disabled children is associated with fatigue, financial difficulties, parenting distress and other psychological issues. While such parents of children have repeatedly highlighted their feelings of discrimination, stigma and exclusion, leading to mental health issues, there is little research from the developing world addressing these issues.

RESEARCH OBJECTIVES

This study aims to explore psychological experiences of parents caring for children with intellectual disabilities; understand their mechanisms of coping and their psychosocial needs in Malawi.

METHODOLOGY

This study used a qualitative phenomenological design. We purposively sampled parents who had children diagnosed with intellectual disability from two clinics in two cities in Malawi. Between January 2015 and March 2015, we conducted 10 focus group discussions and four in-depth interviews. All ethical study procedures were carefully followed. All interviews were tape-recorded, transcribed and translated from vernacular to English. Thematic approach of data analysis was adopted to understand the data.

FINDINGS

Caring for intellectually disabled children comes with a number of challenges. Parents have limited access to services for their children let alone for their own psychological issues; they experience stigma and discrimination, have mental health issues resulting from the caring role, have suicidal ideas and in some cases have even been coerced by neighbours to kill their disabled child. To manage these issues, most parents cope through their spirituality.

DISCUSSION AND RECOMMENDATION

Apart from suicide and filicide, the findings of this study are similar to those performed in other countries. It is recommended that parents' psychological issues be managed concurrently when providing services for their children. There is also a need to develop psychosocial training interventions to address the needs of the parents of these children.

Educational intervention for parents of adolescents with chronic illness: a pre-post test pilot study

OBJECTIVE

This pilot experimental study tested the feasibility and intended effect of an educational intervention for parents to help them assist their adolescent child with chronic illness (CI) in becoming autonomous.

METHODS

A two-phase pre-post pilot intervention study targeting parents of adolescents with CI was conducted. Parents were allocated to group 1 and 2 and received the four-module intervention consecutively. Intended effect was measured through online questionnaires for parents and adolescents before, at 2 months after, and at 4-6 months after the intervention. Feasibility was assessed through an evaluation questionnaire for parents.

RESULTS

The most useful considered modules concerned the future of the adolescent and parents and social life. The most valued aspect was to exchange with other parents going through similar problems and receiving a new outlook on their relationship with their child. For parents, improvement trends appeared for shared management, parent protection, and self-efficacy, and worsening trends appeared for coping skills, parental perception of child vulnerability, and parental stress. For adolescents, improvement trends appeared for self-efficacy and parental bonding and worsening trends appeared for shared management and coping skills.

CONCLUSION

Parents could benefit from peer-to-peer support and education as they support the needed autonomy development of their child. Future studies should test an online platform for parents to find peer support at all times and places.

The effect of parent education program for preschool children with developmental disabilities: A randomized controlled trial

AIM

This study aimed to evaluate the efficacy of a parent education program, the Happy Parenting program, for Chinese preschool children with developmental disabilities.

METHODS

This study adopted randomized controlled trial design without blinding. Participants were randomized into intervention group (n=62) who were offered the Happy Parenting program delivered by educational psychologists and trainee educational psychologists, and a control group (n=57) who were offered a parent talk after the intervention group had completed treatment. Parent participants were requested to complete questionnaires on their children's behavior, their parenting stress, and discipline strategies.

RESULTS

Analysis was by intention-to-treat. The results indicated significant decrease in child problem behaviors, parenting stress and dysfunctional discipline strategies in the intervention group at post-intervention.

CONCLUSION

This study provided promising evidence on the effectiveness of a parent education program, the Happy Parenting program, for Chinese preschool children with developmental disabilities.

Parenting Intervention Combined With Acceptance and Commitment Therapy: A Trial With Families of Children With Cerebral Palsy

OBJECTIVE

To examine the effects of Stepping Stones Triple P (SSTP) and Acceptance and Commitment Therapy (ACT) on child functioning, quality of life, and parental adjustment.

METHOD

67 parents (97.0% mothers) of children (64.2% male; mean age 5.3 ± 3.0 years) with cerebral palsy participated in a randomized controlled trial with three groups: wait-list control, SSTP, and SSTP + ACT. This article details the secondary outcomes.

RESULTS

In comparison with wait-list, the SSTP + ACT group showed increased functional performance and quality of life as well as decreased parental psychological symptoms. No differences were found for parental confidence. No differences were found between SSTP and wait-list or between SSTP and SSTP + ACT.

CONCLUSIONS

ACT-integrated parenting intervention may be an effective way to target child functioning, quality of life, and parental adjustment.

Parent Training for Children With or at Risk for Developmental Delay: The Role of Parental Homework Completion

This study investigated the extent to which parental homework completion during behavioral parent training (BPT) for children with or at risk for developmental delay contributed to parenting and child outcomes. Parents of 48 children (Mage=44.17 months, SD=14.29; 73% male; 72% White) with developmental delay (IQ<75) or at risk for developmental delay (due to premature birth) with co-occurring clinically elevated externalizing behavior problems received Parent-Child Interaction Therapy (PCIT) as part of two previously completed randomized controlled trials. Parental homework completion was measured using parental report of home practice of treatment skills collected weekly by therapists. Parents also reported on child externalizing behavior problems and levels of parenting stress, while parenting skills were observed during a 5-min child directed play and child compliance was observed during a 5-min cleanup situation. Results indicated that higher rates of parental homework completion predicted parenting outcomes (i.e., increased positive parenting skills and decreased levels of parenting stress) and child outcomes (i.e., lower levels of externalizing behavior problems). Additionally, although limited by temporal precedence, there was an indirect effect of reductions in parenting stress on the negative association between parental homework completion and child externalizing behavior problems. These findings highlight the importance of parents practicing skills learned during BPT for optimizing treatment outcome. Parenting stress was also identified as a potential mechanism by which high levels of parental homework completion contributed to reductions in child externalizing behavior problems.

The effectiveness of psychosocial interventions for children with a psychiatric disorder and mild intellectual disability to borderline intellectual functioning: A systematic literature review and meta-analysis

Children with intellectual disability frequently have difficulties in adapting to their environment. The extent of the experienced problems does not only depend on cognitive functioning but is influenced by other factors, such as the presence of a psychiatric disorder or other brain disorders, or adverse environmental factors. Several epidemiological studies show that children with intellectual disabilities are at an increased risk to develop psychiatric disorders. This is also true for youth with a mild intellectual disability and even those with borderline intellectual functioning (mild to borderline intellectual disability (MBID)). Psychiatric disorders are often overlooked because behavioral problems are rather attributed to the intellectual disability. Consequently, effective psychiatric interventions, which are needed to improve the level of functioning, are not applied. This review aimed to systematically evaluate the currently available, qualitatively sound research concerning the effectiveness of psychosocial interventions, specifically directed at psychiatric disorders in children with MBID. Assessed for eligibility were 1409 unique reports, and the review ultimately included only 12 reports. Review of the results and meta-analyses showed that the majority of studies suffer from multiple limitations and that methodological variations between studies are extensive. This possibly reflects the high variance of factors that may be involved in MBID. It will be important in future research to address multi-causality.

Transforming Parent-Child Interaction in Family Routines: Longitudinal Analysis with Families of Children with Developmental Disabilities

The efficacy and consequential validity of an ecological approach to behavioral intervention with families of children with developmental disabilities was examined. The approach aimed to transform coercive into constructive parent-child interaction in family routines. Ten families participated, including 10 mothers and fathers and 10 children 3-8 years old with developmental disabilities. Thirty-six family routines were selected (2 to 4 per family). Dependent measures included child problem behavior, routine steps completed, and coercive and constructive parent-child interaction. For each family, a single case, multiple baseline design was employed with three phases: baseline, intervention, and follow-up. Visual analysis evaluated the functional relation between intervention and improvements in child behavior and routine participation. Nonparametric tests across families evaluated the statistical significance of these improvements. Sequential analyses within families and univariate analyses across families examined changes from baseline to intervention in the percentage and odds ratio of coercive and constructive parent-child interaction. Multiple baseline results documented functional or basic effects for 8 of 10 families. Nonparametric tests showed these changes to be significant. Follow-up showed durability at 11 to 24 months postintervention. Sequential analyses documented the transformation of coercive into constructive processes for 9 of 10 families. Univariate analyses across families showed significant improvements in 2- and 4-step coercive and constructive processes but not in odds ratio. Results offer evidence of the efficacy of the approach and consequential validity of the ecological unit of analysis, parent-child interaction in family routines. Future studies should improve efficiency, and outcomes for families experiencing family systems challenges.

Parenting Interventions for Children with Tic Disorders: Professionals' Perspectives

Tic disorders can have an emotional and social impact on children and families, which can in turn have a reciprocal impact on tics. Research into parenting interventions within this population is limited. Twenty-five professionals' views on the acceptability, effectiveness, feasibility and utility of parenting interventions were explored using Q-methodology. Three highly correlated factors emerged, indicating three viewpoints with discrete elements that were underpinned by similar general perspectives. All factors endorsed a psychological approach, the importance of parenting practices, and theoretical and clinical justifications for parenting interventions. Discrete elements of the viewpoints debated the advocated focus, barriers and audience of interventions. Multidisciplinary professionals endorsed parenting interventions as a therapeutic tool within tic disorders. Results provide suggestions to further develop and implement interventions.

Prevalence of Children's Mental Health Problems and the Effectiveness of Population-Level Family Interventions

The prevalence of mental health problems among children and adolescents is of growing importance. Intervening in children’s mental health early in life has been shown to be more effective than trying to resolve these problems when children are older. With respect to prevention activities in community settings, the prevalence of problems should be estimated, and the required level of services should be delivered. The prevalence of children’s mental health disorders has been reported for many countries. Preventive intervention has emphasized optimizing the environment. Because parents are the primary influence on their children’s development, considerable attention has been placed on the development of parent training to strengthen parenting skills. However, a public-health approach is necessary to confirm that the benefits of parent-training interventions lead to an impact at the societal level. This literature review clarifies that the prevalence of mental health problems is measured at the national level in many countries and that population-level parenting interventions can lower the prevalence of mental health problems among children in the community.

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities

BACKGROUND

Outwardly-directed aggressive behaviour is a significant part of problem behaviours presented by people with intellectual disabilities. Prevalence rates of up to 50% have been reported in the literature, depending on the population sampled. Such behaviours often run a long-term course and are a major cause of social exclusion. This is an update of a previously published systematic review (see Hassiotis 2004; Hassiotis 2008).

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly-directed aggressive behaviour in people with intellectual disabilities when compared to standard intervention or wait-list controls.

SEARCH METHODS

In April 2014 we searched CENTRAL, Ovid MEDLINE, Embase, and eight other databases. We also searched two trials registers, checked reference lists, and handsearched relevant journals to identify any additional trials.

SELECTION CRITERIA

We included studies if more than four participants (children or adults) were allocated by random or quasi-random methods to either intervention, standard treatment, or wait-list control groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies and extracted and assessed the quality of the data.

MAIN RESULTS

We deemed six studies (309 participants), based on adult populations with intellectual disabilities, suitable for inclusion in the current version of this review. These studies examined a range of cognitive-behavioural therapy (CBT) approaches: anger management (three studies (n = 235); one individual therapy and two group-based); relaxation (one study; n = 12), mindfulness based on meditation (one study; n = 34), problem solving and assertiveness training (one study; n = 28). We were unable to include any studies using behavioural interventions. There were no studies of children.Only one study reported moderate quality of evidence for outcomes of interest as assessed by the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We judged the evidence for the remaining studies to be of very low to low quality. Most studies were at risk of bias in two or more domains: one study did not randomly allocate participants and in two studies the process of randomisation was unclear; in one study there was no allocation concealment and in three studies this was unclear; blinding of assessors did not occur in three studies; incomplete outcome data were presented in one study and unclear in two studies; there was selective reporting in one study; and other biases were present in one study and unclear in four studies.Three of the six studies showed some benefit of the intervention on improving anger ratings. We did not conduct a meta-analysis, as we considered the studies too heterogeneous to combine (e.g. due to differences in the types of participants, sample size interventions, and outcome measures).Follow-up data for anger ratings for both the treatment and control groups were available for two studies. Only one of these studies (n = 161) had adequate long-term data (10 months), which found some benefit of treatment at follow-up (continued improvement in anger coping skills as rated by key workers; moderate-quality evidence).Two studies (n = 192) reported some evidence that the intervention reduces the number of incidents of aggression and one study (n = 28) reported evidence that the intervention improved mental health symptoms.One study investigated the effects of the intervention on quality of life and cost of health and social care utilisation. This study provided moderate-quality evidence, which suggests that compared to no treatment, behavioural or cognitive-behavioural interventions do not improve quality of life at 16 weeks (n = 129) or at 10 months follow-up (n = 140), or reduce the cost of health service utilisation (n = 133).Only one study (n = 28) assessed adaptive functioning. It reported evidence that assertiveness and problem-solving training improved adaptive behaviour.No studies reported data on adverse events.

AUTHORS' CONCLUSIONS

The existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited. There is a paucity of methodologically sound clinical trials and a lack of long-term follow-up data. Given the impact of such behaviours on the individual and his or her support workers, effective interventions are essential. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.

Skill acquisition and utilization during evidence-based psychosocial treatments for childhood disruptive behavior problems: a review and meta-analysis

We review 85 empirical articles published since 2000 that measured the acquisition and/or utilization of parent management skills and/or child cognitive-behavioral skills in the context of an evidence-based treatment (EBT) for childhood behavior problems. Results showed that: (1) there are no standardized measures of skill acquisition or skill utilization that are used across treatments, (2) little is known about predictors, correlates, or outcomes associated with skill acquisition and utilization, and (3) few studies systematically examined techniques to enhance the acquisition and utilization of specific skills. Meta-analytic results from a subset of 68 articles (59 studies) showed an overall treatment-control ES = .31, p < .01 for skill acquisition and ES = .20, p = ns for skill utilization. We recommend that future research focus on the following three areas: (1) development of standardized measures of skill acquisition and utilization from a "common elements" perspective that can used across EBTs; (2) assessment of the predictors, correlates, and outcomes associated with skill acquisition and utilization; and (3) development of innovative interventions to enhance the acquisition and utilization of cognitive-behavioral and parent management skills.

Effects of parent management training programs on disruptive behavior for children with a developmental disability: a meta-analysis

This meta-analysis determined the effects of parent management training (PMT) on disruptive behaviors in children with a developmental disability. Parent management training programs, based on behavioral theories of psychology, are commonly used in addressing disruptive behavior in children. Eleven studies met inclusion criteria with a total of 540 participants, with 275 in experimental groups and 265 in control groups. The effect of PMT on the disruptive behavior in children with a developmental disability was significant (g=0.39). The moderator effects of type of PMT, delivery type and setting, and administrator level of education were also significant. The moderator effects of child age, and session number and duration were not significant in this meta-analysis.

Stepping Stones Triple P: the importance of putting the findings into context

The Stepping Stones Triple P (SSTP) parenting program is an evidence-based program for parents of children with a disability. A trial of SSTP was recently published in BMC Medicine, which reported results of a randomized controlled trial comparing SSTP to care-as-usual. Although the paper described what should be an important replication trial of SSTP, there are significant shortcomings to the scientific approach of the reporting that need to be addressed. The paper initially cites only a few published SSTP studies and describes evidence for the efficacy of the program as "very scarce". A meta-analysis of studies evaluating SSTP published prior to submission of this paper was not cited. The results are inconsistent with previous evidence for SSTP, yet the authors provide scant interpretation for this inconsistency. Similarly, the unusually high dropout rate of 49% was not adequately explained. The claims that previous research has only been conducted by the developers, has not included children with intellectual disability, and has not used care-as-usual comparison groups, are inaccurate. This commentary explores these issues further in order to place the findings from the recent trial into context.