Behavioural Parent Training Versus Dietary Education in the Treatment of Children with Persistent Feeding Difficulties

Caregiver training improves child feeding behaviours in children with paediatric feeding disorder and may reduce caregiver stress: A systematic review and meta-analysis

PURPOSE

The purpose of this systematic review and meta-analysis was to synthesise the evidence from randomised controlled trials for caregiver training on child and family outcomes for children with paediatric feeding disorder.

METHOD

A systematic review was conducted in accordance with PRISMA guidelines. Searches of Medline, CINAHL, PsychInfo, and EMBASE were conducted using the key concepts of paediatrics, feeding disorders, parents/caregivers, and training. Eligible studies included randomised controlled trials published in peer-reviewed articles, testing the impact of caregiver training on outcomes for children with paediatric feeding disorder.

RESULT

Eight articles met the inclusion criteria, involving 575 participants from three countries. Seven articles were included in the meta-analyses, providing high certainty evidence that caregiver training improves child feeding behaviours and reduces unhelpful caregiver mealtime strategies compared with no intervention. Uncertainty remains in regard to impact on caregiver stress and intervention intensity.

CONCLUSION

Caregiver training is an effective strategy for improving outcomes in children with paediatric feeding disorder. Further research is required to determine the most effective methods of caregiver training, including the intensity of treatment required to attain clinically important benefits for families with different levels of need.

Online occupational therapy group training for mothers of children with feeding problems: A randomized controlled trial

AIM

The aim of this study was to scrutinize how online occupational therapy group training for mothers influenced their attitudes and stress levels relating to feeding their children and the eating behaviours of the children. The secondary purpose of the study is to evaluate the satisfaction of the participants of this program. Twenty-nine mothers of children aged 3-6 years, experiencing feeding issues, were randomly allocated to either an intervention or control group.

BACKGROUND

Feeding problems including selective eating, loss of appetite, and mealtime behaviour problems are prevalent during childhood. Parents play a fundamental role in acquiring knowledge about feeding. Problems in the feeding process may lead to parental stress, feelings of despair, and incorrect attitudes.

RESULTS

The mothers in the research group participated in the 4-week training. Results indicated positive effects on both maternal attitudes and their children's eating behaviours (p < 0.05). No significant change was found in mothers' state and trait anxiety levels (p > 0.05). Participants were asked to score their satisfaction level with the program between 1 and 10, and the average of the scores was 9.78 ± 0.42.

CONCLUSION

This study shows that online group education for mothers can support existing treatments and guide clinicians working with children with feeding problems.

Harnessing the Power of Positive Parenting to Promote Wellbeing of Children, Parents and Communities Over a Lifetime

Evidence-based parenting support (EBPS) programs derived from social learning theory, cognitive behavioural principles, and developmental theory are among the most successful innovations in the entire field of psychological intervention. EBPS programs have been at the cutting edge of global dissemination efforts to increase community access to evidence-based parenting programs. Despite the widely recognised success of these efforts, existing models of parenting intervention are not a panacea, and much can be done to improved outcomes. Efforts to improve outcomes have included the emergence of a population-based approach to increase reach of intervention. This has included the development of flexible delivery modalities, including online parenting interventions, the incorporation of strategies to enhance cultural relevance and acceptability of programs, and more recently, applications with parents in very low resource settings. Further enhancements of outcomes are likely to be forthcoming as we gain a better understanding of the mechanisms that explain positive intervention effects and non-response to interventions. More cost-effective online professional training models are needed to disseminate and promote the sustained use of EBPS programs. New interventions are required for the most vulnerable parents when parenting concerns are complicated by other problems such as trauma, addictions, relationship conflict, family violence, mental health problems and intergenerational poverty. However, to scale effective programs, Commonwealth and state government policies and funding priorities need to respond to evidence about what works and make sustained investments in the implementation of parenting programs. Possible strategies to enhance the policy impact of intervention research are discussed.

Group-based parent training programmes for improving emotional and behavioural adjustment in young children

BACKGROUND

Emotional and behavioural problems in children are common. Research suggests that parenting has an important role to play in helping children to become well-adjusted, and that the first few months and years are especially important. Parenting programmes may have a role to play in improving the emotional and behavioural adjustment of infants and toddlers, and this review examined their effectiveness with parents and carers of young children.

OBJECTIVES

1. To establish whether group-based parenting programmes are effective in improving the emotional and behavioural adjustment of young children (maximum mean age of three years and 11 months); and2. To assess whether parenting programmes are effective in the primary prevention of emotional and behavioural problems.

SEARCH METHODS

In July 2015 we searched CENTRAL (the Cochrane Library), Ovid MEDLINE, Embase (Ovid), and 10 other databases. We also searched two trial registers and handsearched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Two reviewers independently assessed the records retrieved by the search. We included randomised controlled trials (RCTs) and quasi-RCTs of group-based parenting programmes that had used at least one standardised instrument to measure emotional and behavioural adjustment in children.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data and a second reviewer checked the extracted data. We presented the results for each outcome in each study as standardised mean differences (SMDs) with 95% confidence intervals (CIs). Where appropriate, we combined the results in a meta-analysis using a random-effects model. We used the GRADE (Grades of Recommendations, Assessment, Development, and Evaluation) approach to assess the overall quality of the body of evidence for each outcome.

MAIN RESULTS

We identified 22 RCTs and two quasi-RCTs evaluating the effectiveness of group-based parenting programmes in improving the emotional and behavioural adjustment of children aged up to three years and 11 months (maximum mean age three years 11 months).The total number of participants in the studies were 3161 parents and their young children. Eight studies were conducted in the USA, five in the UK, four in Canada, five in Australia, one in Mexico, and one in Peru. All of the included studies were of behavioural, cognitive-behavioural or videotape modelling parenting programmes.We judged 50% (or more) of the included studies to be at low risk for selection bias, detection bias (observer-reported outcomes), attrition bias, selective reporting bias, and other bias. As it is not possible to blind participants and personnel to the type of intervention in these trials, we judged all studies to have high risk of performance bias. Also, there was a high risk of detection bias in the 20 studies that included parent-reported outcomes.The results provide evidence that group-based parenting programmes reduce overall emotional and behavioural problems (SMD -0.81, 95% CI -1.37 to -0.25; 5 studies, 280 participants, low quality evidence) based on total parent-reported data assessed at postintervention. This result was not, however, maintained when two quasi-RCTs were removed as part of a sensitivity analysis (SMD -0.67, 95% CI -1.43 to 0.09; 3 studies, 221 participants). The results of data from subscales show evidence of reduced total externalising problems (SMD -0.23, 95% CI -0.46 to -0.01; 8 studies, 989 participants, moderate quality evidence). Single study results show very low quality evidence of reductions in externalising problems hyperactivity-inattention subscale (SMD -1.34; 95% CI -2.37 to -0.31; 19 participants), low quality evidence of no effect on total internalising problems (SMD 0.34; 95% CI -0.12 to 0.81; 73 participants), and very low quality evidence of an increase in social skills (SMD 3.59; 95% CI 2.42 to 4.76; 32 participants), based on parent-reported data assessed at postintervention. Results for secondary outcomes, which were also measured using subscales, show an impact on parent-child interaction in terms of reduced negative behaviour (SMD -0.22, 95% CI -0.39 to -0.06; 7 studies, 941 participants, moderate quality evidence), and improved positive behaviour (SMD 0.48, 95% CI 0.17 to 0.79; 4 studies, 173 participants, moderate quality evidence) as rated by independent observers postintervention. No further meta-analyses were possible. Results of subgroup analyses show no evidence for treatment duration (seven weeks or less versus more than eight weeks) and inconclusive evidence for prevention versus treatment interventions.

AUTHORS' CONCLUSIONS

The findings of this review, which relate to the broad group of universal and at-risk (targeted) children and parents, provide tentative support for the use of group-based parenting programmes to improve the overall emotional and behavioural adjustment of children with a maximum mean age of three years and 11 months, in the short-term. There is, however, a need for more research regarding the role that these programmes might play in the primary prevention of both emotional and behavioural problems, and their long-term effectiveness.

Parents' perception of children's fear: from FSSC-IT to FSSC-PP

Studies involving parents' reports about children's fears and multiple informant comparisons are less extended than investigations on children's self-reporting fear schedules. Starting with the Italian version of FSSC-R, the FSSC-IT, the main aims of this study were to adapt a schedule for parents' perception of their children's fear: the FSSC-Parent Perception. Its psychometric properties were examined in a large sample of parents (N = 2970) of children aged 8-10 years. Exploratory and confirmatory factorial structures were examined and compared with the Italian children's ones. Mother vs. father, children's gender and school age group effects were analyzed. The confirmatory factor analysis confirmed a four correlated factors solution model (Fear of Danger and Death; Fear of Injury and Animals; Fear of Failure and Criticism; Fear of the unknown and Phobic aspects). Some effects related to child gender, age group, mother vs. father, were found. The FSSC-PP properties supported its use by parents to assess their children's fears. A qualitative analysis of the top 10 fears most endorsed by parents will be presented and compared with children's fears. Clinical implications about the quality of parent-child relationships where discussed, comparing mothers and fathers, and parents' perception about daughters' and sons' most endorsed fears.

Mealtime Observations and Parent-Report: Correspondence Across Measurement and Implications for Intervention

This study explored the relationship between self-reported and observed mealtime behaviour and examined concurrent predictors of observed child and parent mealtime behaviour. The sample consisted of 67 parents of 1.5- to 6-year-old children experiencing difficulties with their child's mealtime, and 33 parents who were not concerned with their child's mealtime behaviour. Parent-reported and observed mealtime data, and parent-reported mealtime cognitions were collected. Regression analyses indicated that consistent with hypotheses, observed and parent-reported mealtime behaviour were related. Observed child behaviour was predicted by self-reported parenting behaviour and observed positive parent behaviour, as well as parental cognitions. Observed parent behaviour was predicted only by self-reported parenting mealtime behaviour.

Childhood feeding difficulties: a randomized controlled trial of a group-based parenting intervention

BACKGROUND

Difficulty with feeding is common during early childhood. Behavioral techniques have shown considerable utility for difficult feeding, although large-scale studies of behavioral parenting interventions with typically developing young children, and in group formats, are limited.

OBJECTIVE

The current study aimed to evaluate the efficacy of a group-based, behavioral family intervention for typically developing healthy children with problem eating via a fully randomized 2-group design.

METHODS

: Ninety-six families of children aged 1.5 to 6 years with feeding difficulties participated in a trial of Hassle Free Mealtimes Triple P (A. Morawska and M.R. Sanders, unpublished data, 2008) in regional and metropolitan Queensland (Australia).

RESULTS

Results support the utility of a group-based behavioral parenting program for childhood feeding issues, with significant improvements to the mealtime and general behavior of target children, the mealtime and general practices of parents, parental confidence and cognitions, compared with a waitlist control. Six-month follow-up data and clinical and reliable change indices support the intervention's utility. Parents were also highly satisfied with the program.

CONCLUSION

The current study provides evidence of the efficacy of a group-based behavioral family intervention for mealtime difficulties, including observational and more extended outcome measures. Future directions and clinical implications of this research are discussed.

How evidence-based is an 'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of Triple P

BACKGROUND

Interventions to promote positive parenting are often reported to offer good outcomes for children but they can consume substantial resources and they require rigorous appraisal.

METHODS

Evaluations of the Triple P parenting program were subjected to systematic review and meta-analysis with analysis of biases. PsychInfo, Embase and Ovid Medline were used as data sources. We selected published articles reporting any child-based outcome in which any variant of Triple P was evaluated in relation to a comparison condition. Unpublished data, papers in languages other than English and some book chapters were not examined. Studies reporting Eyberg Child Behavior Inventory or Child Behavior Checklist scores as outcomes were used in the meta-analysis.

RESULTS

A total of 33 eligible studies was identified, most involving media-recruited families. Thirty-one of these 33 studies compared Triple P interventions with waiting list or no-treatment comparison groups. Most papers only reported maternal assessments of child behavior. Twenty-three papers were incorporated in the meta-analysis. No studies involved children younger than two-years old and comparisons of intervention and control groups beyond the duration of the intervention were only possible in five studies. For maternally-reported outcomes the summary effect size was 0.61 (95%CI 0.42, 0.79). Paternally-reported outcomes following Triple P intervention were smaller and did not differ significantly from the control condition (effect size 0.42 (95%CI -0.02, 0.87)). The two studies involving an active control group showed no between-group differences. There was limited evidence of publication bias, but there was substantial selective reporting bias, and preferential reporting of positive results in article abstracts. Thirty-two of the 33 eligible studies were authored by Triple-P affiliated personnel. No trials were registered and only two papers contained conflict of interest statements.

CONCLUSIONS

In volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions. See related commentary: http://www.biomedcentral.com/1741-7015/10/145.

A review of parenting programs in developing countries: opportunities and challenges for preventing emotional and behavioral difficulties in children

Many children in developing countries are at risk of emotional and behavioral difficulties, which are likely to be elevated due to the effects of poverty. Parenting programs have shown to be effective preventative strategies in high-income countries, but to date the research on their effectiveness in lower-income countries is limited. International organizations such as the World Health Organization have called for the implementation of programs to prevent behavioral difficulties through the development of stable relationships between children and their parents. The aim of the present paper was to review the literature on parenting programs in developing countries in order to identify challenges, opportunities and directions for further research. First, reports of international organizations were reviewed in order to gain a preliminary overview of the field. In a second stage, a non-systematic review was carried out. Databases were searched in order to identify empirical evaluations of parenting programs in low-income countries. Finally, a systematic review was carried out to specifically identify evaluations of programs targeting emotional or behavioral outcomes. Only one study had a strong methodology among those designed to prevent emotional and behavioral outcomes. Opportunities for further program development and research are identified.

Pediatric feeding disorders: a quantitative synthesis of treatment outcomes

A systematic review of the literature regarding treatment of pediatric feeding disorders was conducted. Articles in peer-reviewed scientific journals (1970-2010) evaluating treatment of severe food refusal or selectivity were identified. Studies demonstrating strict experimental control were selected and analyzed. Forty-eight single-case research studies reporting outcomes for 96 participants were included in the review. Most children presented with complex medical and developmental concerns and were treated at multidisciplinary feeding disorders programs. All studies involved behavioral intervention; no well-controlled studies evaluating feeding interventions by other theoretical perspectives or clinical disciplines met inclusion criteria. Results indicated that behavioral intervention was associated with significant improvements in feeding behavior. Clinical and research implications are discussed, including movement toward the identification of key behavioral antecedents and consequences that promote appropriate mealtime performance, as well as the need to better document outcomes beyond behavioral improvements, such as changes in anthropometric parameters, generalization of treatment gains to caregivers, and improvements in nutritional status.

Group-based parent-training programmes for improving emotional and behavioural adjustment in children from birth to three years old

BACKGROUND

Emotional and behavioural problems in children are common. Research suggests that parenting has an important role to play in helping children to become well-adjusted, and that the first few months and years are especially important. Parenting programmes may have a role to play in improving the emotional and behavioural adjustment of infants and toddlers. This review is applicable to parents and carers of children up to three years eleven months although some studies included children up to five years old.

OBJECTIVES

To:a) establish whether group-based parenting programmes are effective in improving the emotional and behavioural adjustment of children three years of age or less (i.e. maximum mean age of 3 years 11 months); b) assess the role of parenting programmes in the primary prevention of emotional and behavioural problems.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Sociofile, Social Science Citation Index, ASSIA, National Research Register (NRR) and ERIC. The searches were originally run in 2000 and then updated in 2007/8.

SELECTION CRITERIA

Randomised controlled trials of group-based parenting programmes that had used at least one standardised instrument to measure emotional and behavioural adjustment.

DATA COLLECTION AND ANALYSIS

The results for each outcome in each study have been presented, with 95% confidence intervals. Where appropriate the results have been combined in a meta-analysis using a random-effects model.

MAIN RESULTS

Eight studies were included in the review. There were sufficient data from six studies to combine the results in a meta-analysis for parent-reports and from three studies to combine the results for independent assessments of children's behaviour post-intervention. There was in addition, sufficient information from three studies to conduct a meta-analysis of both parent-report and independent follow-up data. Both parent-report (SMD -0.25; CI -0.45 to -0.06), and independent observations (SMD -0.54; CI -0.84 to -0.23) of children's behaviour produce significant results favouring the intervention group post-intervention. A meta-analysis of follow-up data indicates a significant result favouring the intervention group for parent-reports (SMD -0.28; CI -0.51 to -0.04) but a non-significant result favouring the intervention group for independent observations (SMD -0.19; CI -0.42, 0.05).

AUTHORS' CONCLUSIONS

The findings of this review provide some support for the use of group-based parenting programmes to improve the emotional and behavioural adjustment of children with a maximum mean age of three years eleven months. There is, insufficient evidence to reach firm conclusions regarding the role that such programmes might play in the primary prevention of such problems. There are also limited data available concerning the long-term effectiveness of these programmes. Further research is needed.

Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3 year old children

BACKGROUND

Emotional and behavioural problems in children are common. Research suggests that parenting has an important role to play in helping children to become adjusted, and that the first few months and years of a child's life are especially important in establishing patterns of emotional, cognitive and social functioning which will in turn influence the child's future development and in particular, their mental health. Parenting programmes may therefore have a role to play in improving the emotional and behavioural adjustment of infants and toddlers.

OBJECTIVES

The objectives of this review are as follows: a) To establish whether group-based parenting programmes are effective in improving the emotional and behavioural adjustment of children less than three years of age b) To assess the role of parenting programmes in the primary prevention of emotional and behavioural problems.

SEARCH STRATEGY

A range of biomedical and social science databases were searched including MEDLINE, EMBASE, CINAHL, PsychLIT, Sociofile, Social Science Citation Index, ASSIA, the Cochrane Library including SPECTR, CENTRAL, National Research Register (NRR) and ERIC.

SELECTION CRITERIA

Only randomised controlled trials of group based parenting programmes were included, and studies that had used at least one standardised instrument to measure emotional and behavioural adjustment.

DATA COLLECTION AND ANALYSIS

The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group by the pooled standard deviation, to obtain an effect size. The results for each outcome in each study have been presented, with 95% confidence intervals. Where appropriate the results have been combined in a meta-analysis using a random effect model.

MAIN RESULTS

Five studies were included in the review, and there was sufficient data from five studies to combine the results in a meta-analysis. Meta-analyses were conducted for both parent-reports and independent assessments of children's behaviour. The result for parent reports shows a non-significant result favouring the intervention group (ES -0.5, CI -1.06 to 0.08). The result for independent observations of children's behaviour shows a significant result favouring the intervention group (ES -0.54, CI -0.84 to -0.23). A meta-analysis of the limited follow-up data available shows a small non-significant result favouring the intervention group (ES -0.24, CI -0.56 to 0.09).

REVIEWER'S CONCLUSIONS

The findings of this review provide some support for the use of group-based parenting programmes to improve the emotional and behavioural adjustment of children under the age of 3 years. There is, however, insufficient evidence to reach any firm conclusions regarding the role that such programmes might play in the primary prevention of such problems. Furthermore, there is limited data available concerning the long-term effectiveness of these programmes, and the results from the two studies for which data was available produced borderline insignificant findings. Further research is required.

Psychological Treatment of Food Refusal in Young Children

Feeding and eating problems in young children are the result of a complex aetiology that often combines biological and psychological factors. The aim of this review is to describe psychological techniques of intervention used in the management of eating problems in young children that draw on a number of theoretical approaches and should be applied within a developmental framework.

Parenting interventions and the prevention of serious mental health problems in children

The reduction of coercive or inadequate parenting is essential if the mental health status of Australian children and adolescents is to be improved. Of the available approaches that address parenting practices, behavioural family interventions have the strongest empirical support and are effective in reducing parenting practices that contribute to the development of behavioural and emotional problems in children. However, only a small proportion of parents access such interventions. A comprehensive multilevel, evidence-based parenting and family support strategy needs to be implemented on a wide scale to reduce the prevalence of mental health problems in children and youth. The Triple P - Positive Parenting Program is an example of a population-level strategy that can be used to improve the mental health status of children and their parents.

Fütter- und Gedeihstörungen bei kleinen und/oder behinderten Kindern

Zusammenfassung Behandlungsbedürftige Fütter- und Gedeihstörungen (Prävalenz 2-4%) haben selten eine isolierte Ursache, meist ist ein Bündel von ungünstigen Bedingungen an der Entstehung und vor allem Aufrechterhaltung der Störung beteiligt. Das können organische Ursachen wie chronische Erkrankungen, Auffälligkeiten in der Person oder dem Verhalten des Kindes oder der Bezugsperson oder in der Interaktion sein. Fütter- und Gedeihstörungen können eine längerdauernde Zusatz- oder Vollsondierung erfordern, oder das Kind lehnt altersgemäß grobe Kost ab, hat ein sehr selektives Essverhalten oder es gibt massive Interaktionsstörungen während des Fütterns. Fütter- und Gedeihstörungen können neben den direkten körperlichen Auswirkungen auch längerdauernde ungünstige Einflüsse auf andere Verhaltensbereiche und auf mentale Fähigkeiten haben. Die Diagnostik der Fütter- und Gedeihstörungen umfasst neben der Abklärung einer organischen Grunderkrankung die Klärung der Schluck- und der oralmotorischen Fähigkeiten sowie den Ausschluss eines gastroösophagealen Refluxes. Das differenzierte Fütterprotokoll muss die orale und die Sondenernährung umfassen. Die Verhaltensbeobachtung umfasst die Füttersituation und wenn nötig auch breitere Interaktionsbereiche. Neben einer Therapie der Grunderkankung steht die direkte Anleitung der Bezugspersonen in der Füttersituation im Vordergrund. Daneben können eine Therapie der Oralmotorik sowie der Bezugsperson und Interaktionsanleitungen in verschiedenen Verhaltensbereichen erforderlich sein.