Is parenting the mediator of change in behavioral parent training for externalizing problems of youth?

The Reciprocal Relations between Parental Psychological Control and Social Anxiety and the Mediating Role of Self-Concept Clarity Among Chinese Early Adolescents

Although parental psychological control has been well-documented as a significant predictor of social anxiety among adolescents, few studies examine how changes in parental psychological control and adolescent social anxiety are reciprocally related at the within-person level, especially in Chinese culture. This longitudinal study examined reciprocal relations between parental psychological control and social anxiety, and the potential mediating role of self-concept clarity, by disentangling between- and within-person effects. A total of 4731 students (44.9% girls; Mage = 10.91 years, SD = 0.72) participated in a four-wave longitudinal study with 6-month intervals. Results from random intercept cross-lagged panel modeling indicated that parental psychological control directly predicted social anxiety, and vice versa. Parental psychological control indirectly predicted social anxiety via self-concept clarity, and social anxiety also indirectly predicted parental psychological control via self-concept clarity. These findings reveal a vicious cycle of mutual influence between parental psychological control and adolescent social anxiety in Chinese youth, and highlight the crucial role of self-concept clarity in the interplay between parenting and adolescent social functioning.

Process Mechanisms in Behavioral Versus Nondirective Guided Self-help for Parents of Children with Externalizing Behavior

The study examined potential mediating effects of therapist behaviors in the per-protocol sample (n = 108) of a randomized controlled trial comparing a behavioral and a nondirective guided self-help intervention for parents of children with externalizing disorders (4-11 years). Additionally, from an exploratory perspective, we analyzed a sequential model with parental adherence as second mediator following therapist behavior. Outcomes were child symptom severity of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder rated by blinded clinicians, and parent-rated child functional impairment. We found a significant indirect effect on the reduction of ADHD and functional impairment through emotion- and relationship-focused therapist behavior in the nondirective intervention. Additionally, we found limited support for an extended sequential mediation effect through therapist behavior and parental adherence in the models for these outcomes. The study proposes potential mediating mechanisms unique to the nondirective intervention and complements previous findings on mediator processes in favor of the behavioral group. Trial registration ClinicalTrials.gov NCT01350986.

Study Preregistration: Individual Participant Data Meta-Analysis: Individual Differences in Mediators of Parenting Program Effects on Disruptive Behavior

Parenting programs are the most widely used strategy to prevent and reduce children's disruptive behavior,1 and yet we know very little about what exact changes in parenting behavior underlie program effects on disruptive child behavior. In fact, most studies have been unable to identify any mediators of parenting program effects.2 This is likely because, at least in part, individual trials tend to be underpowered to detect mediation effects,3 and are unable to take the known heterogeneity in program effects4 into account.

Do dyadic interventions impact biomarkers of child health? A state-of-the-science narrative review

BACKGROUND

Early life adversity is related to numerous poor health outcomes in childhood; however, dyadic interventions that promote sensitive and responsive caregiving may protect children from the negative consequences of such exposures. To date, quasi-experimental and randomized controlled trials (RCTs) have examined the impact of dyadic interventions on a range of individual biomarkers in children, which may elucidate the relation between early stress exposure and transdiagnostic risk factors for prospective poor health. However, the content of interventions, analytic strategies, and findings vary widely across studies, obscuring key themes in the science and hindering policy and research efforts.

METHODS

We use a narrative approach to review findings from methodologically rigorous (predominantly RCT) studies of dyadic interventions' impacts on different biomarkers in children, including indicators of the hypothalamic-pituitary-adrenal (HPA) axis, parasympathetic (PNS) and sympathetic nervous systems (SNS), brain development, inflammation, and intracellular DNA processes. We contribute to this important area of inquiry through integrating findings across biological systems and identifying contextual and mechanistic factors to depict the current state of the field.

RESULTS

Evidence suggests dyadic interventions improved PNS functioning and advanced brain maturation. Some studies indicated interventions reduced hair cortisol concentrations, systemic inflammation, and resulted in differences in DNA methylation patterns. Findings did not support main effect-level change in salivary measures of HPA axis activity, SNS activity, or telomere length. Importantly, reviewed studies indicated significant heterogeneity in effects across biological systems, underscoring the importance of contextual factors (e.g., adversity subtype and severity) as potential moderators of effects. Further, findings suggested enhanced parenting behaviors may be a mechanism through which dyadic interventions operate on biomarkers.

CONCLUSIONS

We close with future policy and research directions, emphasizing the promise of biologically-informed dyadic interventions for understanding and ameliorating the effects of early adversity on transdiagnostic biomarkers of health.

Investigating the Trajectory and Associated Risk Factors of Clinical Outcomes for Early Childhood Disruptive Behavior Disorders Using Real World Data

Disruptive behavior disorders (DBDs) are common mental health problems among early childhood American youth that, if poorly managed, pose costly psychological and societal burdens. There is limited real world evidence on how parent management training (PMT) - the evidence-based treatment model of choice - implemented in common practice settings within the United States influences the behavioral progress of early childhood DBDs, and the risk factors associated with poor outcomes. This study used data from a measurement feedback system implemented within a U.S.-based private practice to study how behavioral outcomes change as a function of PMT treatment engagement and associated risk factors for 4-7 year-old children diagnosed with DBDs. Over 50% of patients reached optimal outcomes after 10 appointments. Attending 24-29 appointments provided maximum treatment effect - namely, 75% of patients reaching optimal outcomes by end of treatment. Outcomes attenuate after reaching the maximum effect. Patients also had higher odds of reaching optimal outcomes if they had consistent attendance throughout the treatment course. Notable risk factors associated with lower odds of reaching optimal outcomes included Medicaid insurance-type, greater clinical complexity, and having siblings concurrently in treatment. Increased implementation of systems that monitor and provide feedback on treatment outcomes in U.S.-based practice settings and similar investigations using its data can further enhance 'real world' management of early childhood DBDs among American youth.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Method

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

Results and discussion

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

A Literature Review of Digital Behavioral Parent Training Programs for Parents of Adolescents

Parents of adolescents are faced with a variety of challenges related to their children's behavior and development. Behavioral parent training (BPT) programs may be effective strategies to mitigate adverse childhood experiences (ACEs) and other common behavioral problems in the adolescent period. Adolescence is the period following the onset of puberty and describes the transition from childhood to adulthood. Digital BPTs, including those delivered via the internet, downloaded digital content, text message, tablet, and video call, may present a unique opportunity to reach a broad audience of parents of adolescents by removing barriers to program accessibility (e.g., cost and transportation). We conducted a literature review to synthesize the existing evidence on digital BPTs for parents of adolescents. We described the digital BPTs, study designs, and evaluation and feasibility outcomes. A structured literature search identified studies meeting the following criteria for inclusion: (a) published between January 2000 and October 2022, (b) peer-reviewed, (c) available in English language, (d) study included a description of a digital BPT methodological approach, (e) study had to identify at least one parent or child behavioral outcome (e.g., parent-reported communication with their child) or feasibility outcome associated with the digital BPT, and (f) study included parents of adolescents aged 10-18 years. We extracted data on the characteristics of the study and demographic characteristics of participants, digital BPT, and evaluation and feasibility outcomes. Twenty-eight studies met inclusion criteria. Twenty-two unique digital BPTs were evaluated across the published studies. Thirteen digital BPTs (59.1%) were developed from or grounded by an identified theory. Six digital BPTs were freely accessible by the public, while the remaining 16 were available through study participation or purchase. One digital BPT was specifically tailored to parents of adolescents of a racial/ethnic minority group. Of the 16 studies that reported either parent or adolescent race/ethnicity, 10 consisted of more than 50% White parent or adolescent participants. Twenty-four (88.9%) studies provided evaluation data for the digital BPT. Fourteen studies (63.6%) employed a randomized control trial study design, and the remaining study designs included quasi-experimental (n = 2), mixed methods (n = 1), open trial (n = 3), case study (n = 1), pretest-posttest design (n = 1), and feasibility and acceptability trial (n = 2). All studies reported improvements in at least one parent-reported or adolescent-reported behavioral outcome or feasibility outcomes, with effect sizes (Cohen's d) ranging from small (e.g., 0.20-0.49) to very large (e.g., > 1.20). The findings of this review illustrate that technology may be a valuable way to deliver BPTs to parents of adolescents. However, few digital BPTs were developed for parents of adolescents from racial/ethnic minority groups, and many digital BPTs were not available without cost or participation in a research study. Considerations for future research are discussed.

Parenting Practices May Buffer the Impact of Adversity on Epigenetic Age Acceleration Among Young Children With Developmental Delays

This study examined whether children exposed to adversity would exhibit lower epigenetic age acceleration in the context of improved parenting. Children with developmental delays and externalizing behavior problems (N = 62; Mage = 36.26 months; 70.97% boys, 29.03% girls; 71% Latinx, 22.6% Black) were drawn from a larger randomized controlled trial (RCT), which randomized them to receive Internet-delivered parent-child interaction therapy (iPCIT; n = 30) or community referrals as usual (RAU; n = 32). Epigenetic age acceleration was estimated with the pediatric buccal epigenetic clock, using saliva. Adversity was assessed using parent, family, and neighborhood-level cumulative-risk indicators. Adversity interacted with Time 2 (T2) observations of positive and negative-parenting practices to predict epigenetic age acceleration 1.5 years later, regardless of treatment assignment. Children exposed to more adversity displayed lower epigenetic age acceleration when parents evidenced increased positive (b = -0.15, p = .001) and decreased negative (b = -0.12, p = .01) parenting practices.

Service Utilization for Parent Management of Early Childhood Behavior Problems in a Private Outpatient Behavioral Clinic: The Impact of Out-of-Pocket Cost, Travel Distance, and Initial Treatment Progress

Poorly-managed early childhood disruptive behavior disorders (DBDs) have costly psychological and societal burdens. While parent management training (PMT) is recommended to effectively manage DBDs, appointment adherence is poor. Past studies on influential factors of PMT appointment adherence focused on parental factors. Less well studied are social drivers relative to early treatment gains. This study investigated how financial and time cost relative to early gains influence PMT appointment adherence for early childhood DBDs in a clinic of a large behavioral health pediatric hospital from 2016 to 2018. Using information obtained from the clinic's data repository, claims records, public census and geospatial data, we assessed how owed unpaid charges, travel distance from home to clinic, and initial behavioral progress influences total and consistent attendance of appointments for commercially- and publicly-insured (Medicaid and Tricare) patients, controlling for demographic, service, and clinical differences. We further assessed how social deprivation interacted with unpaid charges to influence appointment adherence for commercially-insured patients. Commercially-insured patients had poorer appointment adherence with longer travel distances, or having unpaid charges and greater social deprivation; they also attended fewer total appointments with faster behavioral progress. Comparatively, publicly-insured patients were not affected by travel distance and had higher consistent attendance with faster behavioral progress. Longer travel distance and difficulty paying service costs while living in greater social deprivation are barriers to care for commercially-insured patients. Targeted intervention may be needed for this specific subgroup to attend and stay engaged in treatment.

Parent-Child Inpatient Treatment in Child and Adolescent Mental Healthcare: Predictors of Child Outcomes

Family inpatient units in child and adolescent mental health (CAMH) services engage all admitted family members in the treatment of children's symptoms. Studies demonstrated improvements in child and family functioning following family inpatient treatment, but evidence regarding predictors of treatment outcome is lacking. We analyzed data of families (n = 66) who received a four-week inpatient treatment for families with severe parent-child interaction problems. Hierarchical linear regression analyses revealed that parents who recalled harsher parenting practices of their own fathers reported greater improvements in their children's externalizing and internalizing problems. Greater improvements in externalizing problems were further predicted by lower parental educational level, less adverse impacts of stressful life events, and less internalizing child problems prior to admission. We therefore conclude that family inpatient treatment was particularly effective for children in families with lower parental education and a history of harsh parenting.

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a disruptive behaviour disorder involving an ongoing pattern of angry/irritable mood, argumentative/defiant behaviour and vindictiveness. Onset is typically before 8 years of age, although ODD can be diagnosed in both children and adults. This disorder is associated with substantial social and economic burden, and childhood ODD is one of the most common precursors of other mental health problems that can arise across the lifespan. The population prevalence of ODD is ~3 to 5%. A higher prevalence in males than females has been reported, particularly before adolescence. No single risk factor accounts for ODD. The development of this disorder seems to arise from the interaction of genetic and environmental factors, and mechanisms embedded in social relationships are understood to contribute to its maintenance. The treatment of ODD is often successful, and relatively brief parenting interventions produce large sized treatment effects in early childhood. Accordingly, ODD represents an important focus for research, practice and policy concerning early intervention and prevention in mental health.

Community-Delivered Collaborative and Proactive Solutions and Parent Management Training for Oppositional Youth: A Randomized Trial

The aim of this study was to examine the relative effectiveness of Collaborative and Proactive Solutions (CPS) and Parent Management Training (PMT) for youth with oppositional defiant disorder (ODD) in a community setting. Based on a semistructured diagnostic interview, 160 youth with ODD (ages 7-14; 72% male; ethnicity representative of the wider Australian population) were randomized to CPS (n = 81) or PMT (n = 79) for up to 16 weekly sessions. The primary hypothesis was that participants in the CPS group, treated in a community setting, would exhibit significant improvement in ODD, equivalent to that of an evidence-based treatment, PMT. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semistructured diagnostic interviews, parent ratings of ODD symptoms, and global ratings of severity and improvement. Analyses were conducted with hierarchical growth linear modeling, ANCOVA, and equivalence testing using an intent-to-treat sample. Both treatments demonstrated similar outcomes, with 45-50% of youth in the nonclinical range after treatment, and 67% considered much improved. No differences were found between groups, and group equivalency was shown on the independent clinician and parent-rated measures. Gains were maintained at the 6-month follow-up. In conclusion, CPS works as effectively as the well-established treatment, PMT, for youths with ODD, when implemented in a community-based setting. As such, CPS provides a viable choice for families who seek alternate treatments.

Conceptualizing the Role of Parent and Child Emotion Regulation in the Treatment of Early-Onset Behavior Disorders: Theory, Research, and Future Directions

Behavior disorders (BDs) are common and costly, making prevention and early-intervention a clinical and public health imperative. Behavioral Parent Training (BPT) is the standard of care for early-onset (3-8 years old) BDs, yet effect sizes vary and wane with time suggesting the role of underlying factors accounting for variability in outcomes. The literature on emotion regulation (ER), which has been proposed as one such underlying factor, is reviewed here, including a brief overview of ER, theory and research linking ER, externalizing symptoms, and/or BDs, and still largely preliminary work exploring the role of parent and child ER in BPT outcomes. Research to date provides clues regarding the interrelationship of ER, BDs, and BPT; yet, determining whether adaptations to BPT targeting ER are necessary or useful, for whom such adaptations would be most important, and how those adaptations would be implemented requires addressing mixed findings and methodological limitations. To guide such work, we propose a conceptual model elucidating how standard BPT may impact ER and processes linked to ER, which we believe will be useful in organizing and advancing both basic and applied research in future work.

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

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

Exploring Parenting Profiles to Understand Who Benefits from the Incredible Years Parenting Program

Behavioral parenting programs are a theory-driven and evidence-based approach for reducing disruptive child behavior. Although these programs are effective on average, they are not equally effective in all families. Decades of moderation research has yielded very few consistent moderators, and we therefore still have little knowledge of who benefits from these programs and little understanding why some families benefit more than others. This study applied a baseline target moderation model to a parenting program, by (1) identifying parenting profiles at baseline, (2) exploring their correlations with other family characteristics and their stability, and (3) assessing whether they moderate intervention effects on child behavior. Individual participant data from four Dutch studies on the Incredible Years (IY) parenting program were used (N = 785 caregiver-child dyads). Children (58.2% boys) were at risk of disruptive behavior problems and aged between 2 and 11 years of age (M = 5.85 years; SD = 1.59). Latent profile analyses indicated three distinct baseline parenting profiles, which we labeled as follows: Low Involvement (81.4%), High Involvement (8.4%), and Harsh Parenting (10.1%). The profiles caregivers were allocated to were associated with their education, minority status, being a single caregiver, and the severity of disruptive child behavior. We found neither evidence that baseline parenting profiles changed due to participation in IY nor evidence that the profiles predicted program effects on child behavior. Our findings do not support the baseline target moderation hypothesis but raise new questions on how parenting programs may work similarly or differently for different families.

Parenting Behaviors as Mediators of the Association Between Parental Internalizing Symptoms and Child Externalizing Symptoms

This study analyzes whether the association between parental internalizing symptoms (depression, anxiety, stress) and child symptoms of attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) is mediated by positive and negative parenting behaviors. Cross-sectional data of 420 parents of children (age 6-12 years) with elevated levels of externalizing symptoms were collected in a randomized controlled trial. Measures included parent ratings of their internalizing symptoms and parenting behaviors and of their child's externalizing symptoms. Two mediation models were examined, one including ADHD symptoms and one including ODD symptoms as the dependent variable. Parental internalizing symptoms were modeled as the independent variable and positive and negative parenting behaviors were modeled as parallel mediators. Regression analyses support negative parenting behavior as a mediator of the association between parental internalizing symptoms and child ODD symptoms. For the ADHD model, no significant mediator could be found. Future studies should use prospective designs and consider reciprocal associations.

Mediating Effects of Discipline Approaches on the Relationship between Parental Mental Health and Adolescent Antisocial Behaviours: Retrospective Study of a Multisystemic Therapy Intervention

Poor parental mental health is one of the risk factors for child emotional and behavioural problems because it reduces caregiver's ability to provide appropriate care for their child. This study aimed to measure changes in parenting factors and adolescent behaviours after Multisystemic Therapy (MST), and to explore the mediating role of discipline approaches on the relationship between parental mental health and adolescent behavioural problems. This retrospective study extracted data collected from 193 families engaged with the MST research program during 2014-2019. Data was collected at different time points (pre-treatment, post-treatment, 6- and 12-months follow-up). Statistically significant changes were found in adolescent behaviours and parenting factors following the MST intervention and these positive changes were maintained over the following 12 months. Results of the parallel multiple mediator model analysis confirmed mediating effects of discipline approaches on the relationship between parental mental health and adolescent's behavioural problems. The findings suggested that parental mental well-being significantly contributes to effectiveness of parenting, which resulted in positive changes in adolescent's behavioural problems. It is recommended caregiver's parental skills and any mental health issues are addressed during the intervention to enhance positive outcomes in adolescent behaviour.

Behavioral Parent Training for Preschool ADHD: Family-Centered Profiles Predict Changes in Parenting and Child Outcomes

OBJECTIVE

Behavioral parent training (BPT) is the first line of treatment for preschool-aged children with attention-deficit hyperactivity disorder (ADHD); however, clinically significant improvements are not universal. In the current study, we employ a person-centered approach to create subgroups of families based on the intersection of multiple parent, child, and family pre-treatment factors. Further, we explore the utility of pre-treatment family profiles in predicting post-treatment differences in observed parenting behavior (i.e., behavioral control, parental warmth) and clinically significant change in child ADHD and oppositional symptoms.

METHOD

Longitudinal data were collected using observational and parent-, teacher- and clinician-reported assessments from 130 parent-child dyads (Mage= 3.57, range = 3.0- 4.11, 73.8% male, 69.2% White, 25.6% Hispanic) participating in BPT.

RESULTS

Findings from the current study suggest three distinct family profiles, which consisted of one profile with high family stress (HFS) as evidenced by elevated symptomatology across parent, child, and family-level domains, a second profile with elevated parental anxiety (PA), and a final profile with elevated parental depression (PD). These family-centered profiles were differentially associated with changes in observed parenting practices. Specifically, the PD profile (39%) demonstrated minimal improvements in behavioral control and warmth following treatment. In contrast, the HFS profile (30%) only improved in behavioral control and the PA profile (31%) improved in both parenting domains following treatment. In addition, marginally significant differences in child oppositional and ADHD symptoms were observed across profiles.

CONCLUSIONS

Family-centered approaches may be useful for selecting and implementing interventions.

Attachment- and Emotion-Focused Parenting Interventions for Child and Adolescent Externalizing and Internalizing Behaviors: A Meta-Analysis

Attachment- and emotion-focused parenting interventions (AE) have grown in popularity as an alternative to behavioral parent training (BPT) for children and adolescents. AE go beneath behavior by helping parents understand and respond to their child’s underlying attachment and emotional needs. Past reviews have examined their effects on attachment security and caregiver sensitivity, though less is known regarding their effects on child mental health symptoms. Reported here is the first systematic review and meta-analysis of individual and group AE on externalizing behavior (EXT) and internalizing behavior (INT) for children aged 0–18 years. A search of four databases prior to July 2021 elicited 43 studies that met eligibility criteria. Meta-analysis revealed that AE were superior to waitlist controls for EXT (SMD = − 0.17) and INT (SMD = − 0.34). Effects were sustained at follow-up periods of 6 months and greater, and AE considered to target child mental health were significantly more effective than those that did not in reducing EXT and INT. Two studies retrieved directly compared AE to BPT, which showed no evidence of a difference for follow-up measures of EXT. No studies compared AE to BPT on INT. AE demonstrated no evidence of superiority compared to controls for parent mental health. Findings support the potential for AE to reduce EXT and INT in children and adolescents; however, future research should consider the relative effectiveness of AE.

Mechanisms of Change in Population-Based Parenting Interventions for Children and Adolescents

OBJECTIVE

Developing an effective population-level system of evidence-based parenting support capable of shifting (at a population level) rates of child maltreatment and social, emotional, and behavioral problems in children requires an integrated theory of change. This paper presents a systems-contextual model of change and identifies modifiable mechanisms that can potentially explain population-level changes in parenting and child outcomes.

METHOD

Using the Triple P-Positive Parenting Program as an exemplar of a tiered, multi-level system of evidence-based parenting interventions, we discuss the putative mechanisms of change necessary to produce change in child behavior, parenting, practitioner behavior, and organizational changes to support the sustained implementation of an intervention.

RESULTS

A model of change is proposed that blends theoretical perspectives derived from social learning theory, self-regulation theory, applied behavior analysis, cognitive behavior principles, developmental theory, and principles derived from the fields of public health, implementation science, and economics to explain change in the behavior at the community wide level. Different types of interventions targeting different populations and mechanisms are used to illustrate how sustainable change in child and parent outcomes can be achieved.

CONCLUSIONS

Evidence supporting specific mechanisms and moderators of intervention effects are discussed as well as directions for future research on mechanisms.

Does Parenting Explain the Link Between Cumulative SES Risk and Child Problems in the Context of Parental Depression?

The accumulation of socioeconomic stressors, such as being a single parent and having a limited income, is associated with childhood maladjustment and prospective poor health. Evidence suggests both positive and negative parenting strategies (e.g., warmth and praise; criticism and neglect) may account for the relationship between socioeconomic adversity and child outcomes. However, despite the common co-occurrence of parental depression and socioeconomic stress, models of cumulative socioeconomic risk and parenting have yet to be tested in parents who are also coping with depression. In a sample of children whose parents have a history of depression, this study extends findings from a previous report (i.e., Sullivan et al. in J Fam Psychol 33:883-893, 2019) to test whether behavioral observations of parenting account for the association between a cumulative risk index of socioeconomic stress and child psychological problems in the same sample of 179 children (M_age = 11.46 years, SD_age = 2.00) of parents with depression. Both positive and negative parenting accounted for the relationship between socioeconomic risk and both child- and parent-reported externalizing problems, whereas no evidence emerged for parenting accounting for the relation between cumulative risk and internalizing problems. This study highlights the central role socioeconomic stress plays in child maladjustment among parents coping with depression, as well as how parenting may be a critical mechanism linking socioeconomic stress and child externalizing problems.

Investigating active ingredients of the GenerationPMTO intervention: Predictors of postintervention change trajectories in parenting practices

Empirically determining the active ingredients of evidence-based parenting interventions is a promising means for strengthening interventions and enhancing their public health impact. This study aimed to determine which distinct ingredients of the GenerationPMTO (GenPMTO) intervention were associated with subsequent changes in parenting practices. Using a sample of 153 participants randomly assigned to the GenPMTO condition, we employed multilevel modeling to identify intervention ingredients empirically linked with change trajectories in parenting practices observed across the 2 years following intervention exposure. Coercive parenting and positive parenting outcomes were examined. Study results indicated that emotion regulation, effective communication, problem solving, and monitoring each demonstrated a significant pattern of findings for coercive parenting. Differential exposure to each of these ingredients significantly predicted the level of coercive parenting immediately postintervention and/or trajectories of change in coercive parenting across the subsequent 2-year period, controlling for coercive parenting at baseline. No significant predictors were found for positive parenting trajectories. Our findings suggest four components as active ingredients of the GenPMTO intervention for coercive parenting. Identification of these active ingredients may lead to strengthening future iterations of GenPMTO by expanding the set of core components specified in the model, which may further improve public health benefits. Implications for further understanding change stemming from evidence-based parenting interventions are also discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review

BACKGROUND

Externalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old).

METHODS

A systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis.

RESULTS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent-adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively.

CONCLUSIONS

Family variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified.

ETHICS AND DISSEMINATION

Ethical approval was not required. PROSPERO registration number: CRD42021231835.

ARFID Parent Training Protocol: A randomized pilot trial evaluating a brief, parent-training program for avoidant/restrictive food intake disorder

Evidence-based treatment approaches for avoidant/restrictive food intake disorder (ARFID) remain limited and may be inaccessible to families due to geographic, financial, and/or time constraints. This study aims to establish the acceptability and feasibility of a brief ARFID Parent Training Program (ARFID-PTP), modified from other evidence-based approaches, using a randomized controlled trial design. Participants (n = 30) will be children aged 5-12 who meet diagnostic criteria for ARFID and their parents/guardians. Participants will be randomized to receive treatment immediately or following a 4-week wait (waitlist control). Treatment consists of two, 2-hr virtual treatment sessions with the family and a therapist plus an optional booster session. Primary aims include evaluating the (a) feasibility of ARFID-PTP as indicated by recruitment and retention rates, as well as treatment adherence at home and (b) acceptability as determined by ratings on the Credibility and Expectancy Questionnaire and satisfaction questions. A secondary aim is to assess the preliminary efficacy of ARFID-PTP via changes in scores on the Pica, ARFID, and Rumination Disorder Interview. If results indicate appropriate feasibility and acceptability, the proposed protocol will form the basis for larger scale trials of treatment efficacy in efforts to increase accessibility of evidence-based treatment for ARFID.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

COVID-19 and the Acceleration of Behavioral Parent Training Telehealth: Current Status and Future Directions

The SARS-COV-2 (COVID-19) pandemic and associated social distancing guidelines have accelerated the telehealth transition in mental health. For those providing Behavioral Parent Training (BPT), this transition has called for moving sessions that are traditionally clinic-based, active, and directive to engaging, supporting, and treating families of children with behavior disorders remotely in their homes. Whereas many difficulties accompany this transition, the lessons learned during the current public health crisis have the potential to transform BPT service delivery on a large scale in ways that address many of its long-standing limitations. We describe both challenges and opportunities and consider the possibilities inherent in a large scale BPT service delivery model capable of increasing the reach and impact of evidence-based treatment for all families.

Development and Evaluation of a Component Level Implementation Fidelity Rating System for the GenerationPMTO Intervention

Empirically determining the components of evidence-based interventions contributing to positive change is a crucial, yet understudied area of research. In support of this aim, we describe the development and evaluation of an observational rating system for measuring fidelity to specific components of the evidence-based GenerationPMTO parenting intervention. A five-step process was employed to systematically develop the rating system, which included consultation with the intervention developer and input from additional GenerationPMTO experts. The rating system was then tested using 247 h of video data from 184 parenting group intervention sessions. Study findings support the psychometric properties of the new measure with regard to item performance, reliability (i.e., inter-rater reliability of items, dimensionality of components, internal consistency of component scales), and validity (i.e., content validity, convergent validity, discriminant validity, and predictive validity of the component scales) for seven of the eight scales evaluated. The seven components include clear directions, skill encouragement, emotion regulation, limit setting, effective communication, problem solving, and monitoring. Data did not support the psychometric properties of the positive involvement scale. Overall, the ability to assess component-specific fidelity allows for a more nuanced examination of change processes, with meaningful implications for research and practice.

Training Community Therapists to Deliver an Individualized Mental Health Intervention for Autism Spectrum Disorder: Changes in Caregiver Outcomes and Mediating Role on Child Outcomes

OBJECTIVE

This study examines the impact of training therapists to deliver "An Individualized Mental Health Intervention for Autism Spectrum Disorder (ASD)" (AIM HI) for children with autism spectrum disorder on caregiver outcomes and the mediating role of changes in caregiver outcomes on child outcomes.

METHOD

Data were drawn from a cluster randomized trial conducted in 29 publicly funded mental health programs randomized to receive AIM HI training or usual care. Therapists were recruited from enrolled programs and child/caregiver participants enrolled from therapists' caseloads. Participants included 202 caregivers of children 5 to 13 years of age with autism spectrum disorder. Caregiver strain and sense of competence were assessed at baseline and 6 month postbaseline. Child behaviors were assessed at baseline and 6, 12, and 18 months postbaseline. Therapist delivery of evidence-based intervention strategies were assessed between baseline and 6 months.

RESULTS

A significant training effect was observed for caregiver sense of competence, with AIM HI caregivers reporting significantly greater improvement relative to usual care. There was no significant training effect for caregiver strain. Observer-rated therapist delivery of evidence-based interventions strategies over 6 months mediated training effects for sense of competence at 6 months. Changes in sense of competence from baseline to 6 months was associated with reduced child challenging behaviors at 6 months and mediated child outcomes at 12 and 18 months.

CONCLUSION

Combined with research demonstrating effectiveness of therapist AIM HI training on child outcomes, this study provides further evidence of the positive impact of training community therapists in the AIM HI intervention.

CLINICAL TRIAL REGISTRATION INFORMATION

Effectiveness and Implementation of a Mental Health Intervention for ASD (AIM HI); https://clinicaltrials.gov/; NCT02416323.

Negative parenting behaviour as a mediator of the effects of telephone-assisted self-help for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder

A previous randomised controlled trial demonstrated the effects of a telephone-assisted self-help (TASH) intervention for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder (ADHD) on ADHD symptoms, oppositional symptoms, functional impairment, and negative parenting behaviour (per-protocol analyses). In the current study, we examined whether changes in positive and negative parenting behaviour mediated the effects on symptoms and impairment. Parents in an enhancement group (n = 51) participated in a 12-month TASH intervention (eight booklets plus up to 14 telephone consultations) as an adjunct to routine clinical care, whereas parents in a waitlist control group (n = 52) received routine clinical care only. Parents completed measures of child symptoms, child functional impairment, and parenting behaviour at baseline, at 6 months, and at 12 months. The mediating effects of parenting behaviour were examined using regression analyses. Per-protocol analyses (n = 74) revealed a significant indirect intervention effect on functional impairment through negative parenting behaviour at 6 months as well as indirect intervention effects on oppositional symptoms and functional impairment through negative parenting behaviour at 12 months. The indirect effect on ADHD symptoms through negative parenting behaviour at 12 months just failed to reach significance. The analyses yielded no indirect intervention effects through positive parenting behaviour. The study provides some, albeit limited, support for the importance of changes in negative parenting behaviour to achieve changes in symptoms and functional impairment during parent training. In consideration of the inconsistent results of previous studies concerning the mediating role of positive and negative parenting behaviour, further research is required to better understand the mechanisms of change during parent training, also including other possible mediators like parenting stress and parental self-efficacy.

Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis

Various Cognitive Behavioral Therapy (CBT) programs for externalizing disorders in children and adolescents are supported by a substantial body of empirical evidence. Most of the research evidence comes from efficacy studies conducted in university settings, but there is less knowledge about the effect of these treatments in routine clinical care. The purpose of this meta-analysis was to investigate the effectiveness of CBT in non-university settings for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Embase OVID, Ovid MEDLINE and PsycINFO were systematically searched for eligible studies published up to May 2020. In total, 51 treatment effectiveness studies involving 5295 patients were included. The average within-group effect size at post-treatment was significant (g = 0.91), and there were large effect sizes for both ADHD (g = 0.80) and CD/ODD (g = 0.98). At post treatment, remission rates were 38% for ADHD and 48% for CD/ODD, and the overall attrition rate was 14%. Benchmarking against efficacy studies showed that CBT in routine clinical care yields remission rates, within-group effect sizes and attrition rates that are very similar to those found in university settings. The findings support the transportability of CBT for externalizing disorders from university settings to routine clinical care. PROSPERO registration: CRD42020147524.

Mediators of Change in a Parent Training Program for Early ADHD Difficulties: The Role of Parental Strategies, Parental Self-Efficacy, and Therapeutic Alliance

Objective: The aim was to explore mediators of change in parent training (PT) for 3- to 8-year-old children with ADHD difficulties. Method: Parents of 64 children received PT with Incredible Years® and assessed child ADHD symptoms and conduct problems and their parenting strategies, parental self-efficacy, and therapeutic alliance before, during, and after PT. Product-of-coefficients mediation analyses in multilevel models were applied, and causal relations between mediators and outcome were investigated in time-lagged analyses. Results: Increased parental self-efficacy and reduced negative parenting statistically mediated reductions in ADHD and conduct problems in the product-of-coefficient analyses. However, time-lagged analyses were unable to detect a causal relation between prior change in mediators and subsequent child symptom reduction. There was limited evidence of therapeutic alliance as mediator of child symptom reduction or change in parenting variables. Conclusion: Parental self-efficacy and reductions in negative parenting may mediate change in PT, but more fine-grained time-lagged analyses are needed to establish causality.

Parenting, mental health and economic pathways to prevention of violence against children in South Africa

BACKGROUND

Parenting programs based on social learning theory have increasing empirical evidence for reducing violence against children. Trials are primarily from high-income countries and with young children. Globally, we know little about how parenting programs work to reduce violence, with no known studies in low or middle-income countries (LMICs). This study examines mechanisms of change of a non-commercialized parenting program, Parenting for Lifelong Health for Teens, designed with the World Health Organization and UNICEF. A cluster randomized trial showed main effects on parenting and other secondary outcomes. We conducted secondary analysis of trial data to investigate five potential mediators of reduced violence against children: improved parenting, adolescent behaviour, caregiver mental health, alcohol/drug avoidance, and family economic strengthening.

METHODS

The trial was implemented in rural South Africa with 40 sites, n = 552 family dyads (including adolescents aged 10-18 and primary caregivers). Intervention sites (n = 20) received the 14-session parenting program delivered by local community members, including modules on family budgeting and savings. Control sites (n = 20) received a brief informational workshop. Emotional and physical violence against children/adolescents and each potential mediator were reported by adolescents and caregivers at baseline and 9-13 months post-randomisation. Structural equation modelling was used to test simultaneous hypothesized pathways to violence reduction.

RESULTS

Improvements in four pathways mediated reduced violence against children: 1) improved parenting practices, 2) improved caregiver mental health (reduced depression), 3) increased caregiver alcohol/drug avoidance and 4) improved family economic welfare. Improved child behaviour was not a mediator, although it was associated with less violence.

CONCLUSIONS

Simultaneously bolstering a set of family processes can reduce violence. Supporting self-care and positive coping for caregivers may be essential in challenging contexts. In countries with minimal or no economic safety nets, linking social learning parenting programs with economic strengthening skills may bring us closer to ending violence against children.

Intergenerational Transmissions of Mother-Adolescent Smartphone Dependency: The Mediating Role of Negative Parenting and the Moderating Role of Gender

Given the prevalence and undesirable consequences of smartphone dependency among adolescents, it is necessary to explore the influencing factors of adolescent smartphone dependency. The aim of this study was to examine the intergenerational transmission of mother–adolescent smartphone dependency and the mediating role of negative parenting, moderated by adolescent gender. Data for 2541 middle school students (mean aged = 13 years)–mother dyads were obtained from the first wave of the Korean Children and Youth Panel Survey 2018 (KCYPS 2018). The moderated mediation model using Hayes PROCESS macro (Model 14) was employed to test the study hypothesis. The moderated mediation model revealed that maternal smartphone dependency was associated with adolescent smartphone dependency. Perceived negative parenting mediated this link and adolescent gender moderated the relationship between negative parenting and adolescent smartphone dependency, especially for adolescent girls. Our findings showed that both maternal smartphone dependency and negative parenting were determinants of adolescent smartphone dependency, suggesting that both factors were important for understanding these issues. Moreover, the mediating role of negative parenting (between maternal and adolescent smartphone dependency) implies that parental education programs designed to improve negative parenting may reduce adolescent smartphone dependency, especially for adolescent girls.

Randomized cluster trial of a parenting program in Chile: Key mediators in the decrease in behavior problems in preschool children

BACKGROUND

Parenting training is a proven strategy for the promotion of positive parenting practices and for the prevention and treatment of behavior problems in children. The processes that explain this efficacy are less clear. The aim of this study was to assess the mediating role of parenting practice modification, encouraged through the implementation of a universal parenting training program, for the decrease of behavior problems in 3- to 6-year-old children.

METHOD

A cluster randomized trial was carried out in 19 educational centers in low and middle socioeconomic areas. A total of 178 families received the program and 154 of them were the control group. The following parenting practices were assessed: positive reinforcement, involvement, inconsistency, unsuitable treatment behaviors and physical punishment, as well as hostility and humiliation behaviors. Parent-child interaction was also assessed using an observational instrument. A multiple mediation analysis was carried out, identifying the indirect effects.

RESULTS

Reduction of harsh discipline and physical punishment, and parental inconsistency mediated the effects observed in the reduction of child behavior problems during the program.

CONCLUSION

Within Chilean families, harsh discipline, physical punishment, and parental inconsistency are important aspects to be considered in the implementation of universal parenting training programs.

Manual-Based Personalized Intervention for Mothers of Children With SLD/ADHD: Effects on Maternal and Family Resources and Children's Internalizing/Externalizing Behaviors

Objective: This study explored manual-based personalized intervention for mothers of children with SLD and/or ADHD, as possibly contributing to (a) mothers' parenting-related emotional/coping resources, (b) family functioning, and (c) child adjustment, compared with a control group of mothers. Method: Participants were 73 mothers of a child formally diagnosed with SLD and/or ADHD ages 7-17. Mothers were assigned to an experimental (n=40) or control (n=33) group. Short-term intervention utilized a three-stage emotion-cognition-behavior model. Pre-post assessments included maternal affective resources (positive/negative affect, parenting stress), maternal coping resources (general coping strategies, coping specifically with diagnosed child's negative emotions), family cohesion/adaptability, and diagnosed child's externalizing/internalizing syndromes. Results: Significant interactions emerged between group (experimental/control) and time (pre/post) for most study variables. Conclusion: Findings clearly revealed the intervention's significant impact. Only the trained mothers demonstrated significant gains over time for most of the maternal, family, and child indices, whereas the untrained mothers did not.

Are parental changes related to improvements in preschool children's disruptive behaviours?

OBJECTIVE

To investigate whether changes in parenting after behavioural parent training in routine clinical care are associated with improvements in preschool children's disruptive behaviours.

METHOD

We evaluated changes after parent training in maternal and paternal self-reports of parental discipline practices parenting sense of competence, and parents' ratings of child disruptive behaviours in parents of 63 children, with a one group pretest-posttest design. We also compared parenting parameters in this clinical sample with a nonclinical sample (n = 121).

RESULTS

Mothers' self-reports of parental discipline practices and parenting sense of competence significantly improved after behavioural parent training. Less over-reactivity in both mothers and fathers was associated with fewer disruptive behaviours in children. After parent training, mothers' ratings of their discipline techniques did not differ anymore from those in the nonclinical sample.

CONCLUSION

Positive changes in parental discipline practices, particularly less over-reactive parental behaviours, were related to a decrease of disruptive child behaviours.

Cumulative socioeconomic status risk and observations of parent depression: Are there associations with child outcomes?

Parental depression (Goodman et al., 2011) and low socioeconomic status (SES) are important risk factors for child maladjustment. Further, depression and low SES are linked; low SES adults are more likely to experience depression. Whereas studies commonly covary out noise associated with SES variability, research on the association of SES with child outcomes after controlling for parental depression is limited. This study aimed to extend the literature by observing parent depressive affect and evaluating the relationship between cumulative SES risk and child problems as well as whether child gender moderates this association using multigroup nested model comparisons. Findings suggested that cumulative SES risk status explained significant variance in child- and parent-reported internalizing problems and parent-reported externalizing problems after accounting for observed parent depressive affect. Of importance, child gender moderated 2 of these significant findings (i.e., child-reported internalizing and parent-reported externalizing behaviors), such that girls, but not boys, were at higher risk of problems in the context of high cumulative SES risk. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

South African adult caregivers as "protective shields": Serving as a buffer between stressful neighborhood conditions and youth risk behaviors

Low-income youths in KwaZulu-Natal, South Africa, face elevated risks to their well-being from exposure to neighborhood conditions correlated with engaging in risky behaviors. These risks can be mitigated through adult caregivers who serve as protective shields, buffering adverse conditions. However, this protective role is dependent on the caregivers' mental health and well-being. This secondary analysis uses baseline data from 475 child-caregiver dyads in an HIV-prevention program to examine the mediating effects of caregiver mental health on the relationship between neighborhood conditions and child risk-behaviors. Multivariate analyses identify the direct and indirect effects of neighborhood stressors and caregiver mental health on child risk-behavior. Findings suggest that caregivers mitigate the impact of neighborhood conditions on their children, but caregivers' mental health is directly affected by neighborhood conditions. Therefore, caregivers' mental health and well-being must be considered key elements in developing youth risk-behavior interventions.

Deconstructing noncompliance: parental experiences of children's challenging behaviours in a clinical sample

Purpose: This study explored the phenomenon of children’s nonconforming behaviours from the perspective of parents who sought clinical services for children’s severe noncompliance. Method: Mothers from 25 families who accessed clinical services were interviewed about their relationship with their children aged 8–13 and their experiences of their children’s challenging behaviours. Results: Mothers distinguished two different types of challenging behaviour: normative resistance and extreme aggression. Mothers described normative resistance as an expected part of children’s developing autonomy and treated resistance with behavioural management strategies. Mothers also described occasions when children displayed emotionally dis-regulated extreme aggression, which were consistent with clinical descriptions of children’s difficult to manage behaviour. Conclusion: Contrary to clinical recommendations mothers used relational strategies to reconnect children with their agency. The distinction between two different child behaviours, and strategies for each challenging behaviours have theoretical and practical implications.

Conduct disorder

Conduct disorder (CD) is a common and highly impairing psychiatric disorder that usually emerges in childhood or adolescence and is characterized by severe antisocial and aggressive behaviour. It frequently co-occurs with attention-deficit/hyperactivity disorder (ADHD) and often leads to antisocial personality disorder in adulthood. CD affects ~3% of school-aged children and is twice as prevalent in males than in females. This disorder can be subtyped according to age at onset (childhood-onset versus adolescent-onset) and the presence or absence of callous-unemotional traits (deficits in empathy and guilt). The aetiology of CD is complex, with contributions of both genetic and environmental risk factors and different forms of interplay among the two (gene-environment interaction and correlation). In addition, CD is associated with neurocognitive impairments; smaller grey matter volume in limbic regions such as the amygdala, insula and orbitofrontal cortex, and functional abnormalities in overlapping brain circuits responsible for emotion processing, emotion regulation and reinforcement-based decision-making have been reported. Lower hypothalamic-pituitary-adrenal axis and autonomic reactivity to stress has also been reported. Management of CD primarily involves parent-based or family-based psychosocial interventions, although stimulants and atypical antipsychotics are sometimes used, especially in individuals with comorbid ADHD.

After Deployment, Adaptive Parenting Tools: 1-Year Outcomes of an Evidence-Based Parenting Program for Military Families Following Deployment

Despite significant stressors facing military families over the past 15 years of wars in Iraq and Afghanistan, no parenting programs adapted or developed for military families with school-aged children have been rigorously tested. We present outcome data from the first randomized controlled trial of a behavioral parent training program for families with a parent deployed to Iraq or Afghanistan. In the present study, 336 primarily National Guard and Reserve families with 4-12-year-old children were recruited from a Midwestern state. At least one parent in each family had deployed to the recent conflicts: Operations Iraqi or Enduring Freedom, or New Dawn (OIF/OEF/OND). Families were randomized to a group-based parenting program (After Deployment, Adaptive Parenting Tools (ADAPT)) or web and print resources-as-usual. Using a social interaction learning framework, we hypothesized an indirect effects model: that the intervention would improve parenting, which, in turn, would be associated with improvements in child outcomes. Applying intent-to-treat analyses, we examined the program's effect on observed parenting, and children's adjustment at 12-months post baseline. Controlling for demographic (marital status, length, child gender), deployment variables (number of deployments), and baseline values, families randomized to the ADAPT intervention showed significantly improved observed parenting compared to those in the comparison group. Observed parenting, in turn, was associated with significant improvements in child adjustment. These findings present the first evidence for the effectiveness of a parenting program for deployed military families with school-aged children.

Do Less Mindful Mothers Show Better Parenting via Improvements in Trait Mindfulness Following a Military Parent Training Program?

Parental deployment to war poses risks to children's healthy adjustment. The After Deployment Adaptive Parenting Tools (ADAPT) program was developed for post-deployed military families to promote children's well-being through improving effective parenting. ADAPT combines behavior management with emotion socialization skills for parents, using brief mindfulness practices to strengthen emotion regulation. We used a three-wave longitudinal, experimental design to examine whether ADAPT improved parental trait mindfulness (PTM), and whether the effect was moderated by baseline PTM. We also investigated whether improved PTM was associated with behavioral, cognitive, and emotional aspects of parenting such as self-reported parental locus of control (PLOC), self-reported parental emotion socialization (PES), self-reported and observed behavioral parenting skills. We analyzed data from a randomized controlled trial (RCT) of the ADAPT, with a focus on mothers (n = 313) who were either deployed (17.9%) or non-deployed and partnered with a husband who had been recently deployed to Iraq and/or Afghanistan and returned (82.1%). Families identified a 4-13-year-old target child (Mean age = 8.34, SD = 2.48; 54.3% girls) and were randomized into ADAPT (a group-based 14-week program) or a control condition (services as usual). At baseline, 1-year, and 2-year follow-up, PTM, PLOC, PES, and parenting skills were self-reported, whereas home-based family interactions involving parents and the child were video-taped and assessed for observed behavioral parenting skills such as discipline and problem-solving using a theory-based coding system. Results showed that mothers with lower baseline PTM reported higher PTM at 1-year while mothers with higher baseline PTM reported lower PTM at 1-year. PTM at 1-year was associated with improved self-reported parenting skills and supportive PES at 2-year, as well as indirectly associated with improved PLOC and reduced nonsupportive PES at 2-year through PTM at 2-year. No associations between PTM and observed parenting skills were detected. We discuss the implications of these findings for incorporating mindfulness practices into behavioral parenting interventions and for personalized prevention considering parents' pre-existing levels of trait mindfulness as a predictor of intervention responsivity.

Effectiveness of a Positive Parental Practices Training Program for Chilean Preschoolers' Families: A Randomized Controlled Trial

Background: Evidence for the effectiveness of parental training as a strategy for promotion of positive parental practices and prevention of child behavior problems in low and middle income countries is not conclusive. This study aims to assess the effectiveness of a universal positive parental training program designed for this context, “Día a Día” UdeC © (“Day by Day” University of Concepción), in Chilean preschoolers’ families (3–6 years old children).

Methods: A cluster randomized controlled trial (cRCT) was carried out in 19 preschool education centers. There were two treatment arms: 10 centers (including 178 families) were randomly assigned to the intervention group and nine centers (including 154 families) were assigned to the waiting list control condition. Intervention groups received Day by Day UdeC, a six group sessions program for parents, including two group sessions for preschool educators, focused in affective communication; daily and child-directed play; directed attention; routines and transitions; reinforcement and incentive programs; planned inattention-ignore and time out; and logical consequences. Parental practices, parental satisfaction, and presence of children behavioral problems were examined at two-time points: T1 (4 weeks before intervention) and T2 (5–6 weeks after intervention).

Results: Intention-to-treat analysis shows a reduction in physical punishment and an increase in parental involvement, as well as a reduction in children behavioral problems. A per-protocol analysis revealed an additional effect: increase in observed parental practices.

Conclusion: This cRCT provided evidence for the effectiveness of a parental training program for the promotion of positive parental practices in low and middle income countries. The observed effects of the program in decreasing physical punishment and children’s behavioral problems make it a promising strategy for prevention purposes.

Trial Registration: This study was registered under ISRCTN.com (ISRCTN90762146; https://doi.org/10.1186/ISRCTN90762146).

Testing the Social Interaction Learning Model's Applicability to Adolescent Substance Misuse in an Australian Context

BACKGROUND

Parents and peers both influence the development of adolescent substance misuse, and the Social Interaction Learning (SIL) model provides a theoretical explanation of the paths through which this occurs.

OBJECTIVE

The SIL model has primarily been tested with conduct outcomes and in US samples. This study adds to the literature by testing the SIL model with four substance use outcomes in a sample of Australian youth.

METHOD

We used structural equation modeling to test the fit of the SIL model to a longitudinal sample (n = 907) of students recruited in grade 5 in Victoria, Australia participating in the International Youth Development Study, who were resurveyed in grades 6 and 10.

RESULTS

The model fit was good (χ2(95) = 248.52, p < .001; RMSEA = .04 [90% CI: .036 - .049]; CFI = .94; SRMR = .04). Path estimates from parenting to antisocial behavior and from antisocial behavior to antisocial peers were significant. In turn, having antisocial peers was significantly related to alcohol use, binge drinking, tobacco use, and marijuana use. From parenting, only the direct path to marijuana use was significant, but indirect effects were significant.

CONCLUSIONS

The SIL model illustrates that parenting plays an early role in the formation of adolescent peer relations that influence substance misuse and identifies etiological pathways that can guide the targets of prevention. The SIL pathways appear robust to the Australian social and policy context.

Mechanisms of child behavior change in parent training: Comment on Weeland et al. (2018)

Recently in this journal, Weeland et al. (2018) published a thought-provoking article reporting moderating effects of children's serotonin transporter-linked polymorphisms (5-HTTLPR) on negative parenting during prevention with the Incredible Years series. Participants were parents and young children of 387 families enrolled in the Observational Randomized Control Trial of Childhood Differential Susceptibility study. An equally important finding, which we focus on in this comment, involved null effects for all tests of parenting as a mediator of prevention-induced improvements in children's externalizing behavior. Although such findings may seem surprising, both confirmations of and failures to confirm parenting change as a mediator of child behavior change are common in the prevention and intervention literatures. In this comment, we explore likely reasons for heterogeneity in findings, including both moderators of treatment effect size and methods used to test mediation. Common moderators of prevention and intervention response to Incredible Years include dose, parenting problems at intake, high-risk versus clinical nature of samples, how parenting is measured, and whether child training is included with parent training. All of these moderators affect power to detect mediation. We then discuss conceptual criteria for testing mediation in randomized clinical trials, and problems with interpreting mediating paths in cross-lag panel models. Although the gene effect reported by Weeland et al. is important, their cross-lag panel models do not provide strong tests of parenting as a mediator of child behavior change. We conclude with recommendations for testing mediation in randomized clinical trials.