The impact of the Incredible Years parent, child, and teacher training programs on children's co-occurring internalizing symptoms

Does behavioural parent training reduce internalising symptoms (or not) among children with externalising problems? Systematic review and meta-analysis

Behaviour parent training (BPT) is known to effectively reduce child externalising problems. However, evidence for BPT to have secondary benefits for reducing internalising symptoms remains unclear. To address this, electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, and SCOPUS) were systematically searched for studies examining internalising outcomes from BPT among children aged 2-12 years with clinically elevated externalizing problems. Outcomes for internalising problems following BPT were analysed by meta-analysis. Of 9105 studies identified, 24 studies met the eligibility criteria. Results from meta-analysis demonstrated a significant small treatment effect size (g = - 0.41) for reducing internalising symptoms immediately after treatment. Studies showed moderate heterogeneity (I2 = 44%). Moderation analyses indicated that the overall treatment effect was robust against variations in treatment and study design characteristics. However, a review of individual study methods indicate that these results are limited by significant heterogeneity and limitations in clinical assessment. Overall, the results suggest that BPT programmes for reducing externalising problems have the potential to improve internalising outcomes, but that there is limited information to determine the reliability of these effects, highlighting the need for further investigation.

Subtypes of Depressed Youth Admitted for Inpatient Psychiatric Care: A Latent Profile Analysis

Depressed youth frequently present with comorbid symptoms. Comorbidity is related to a poorer prognosis, including treatment resistance, academic problems, risk of suicide, and overall impairment. Studies examining the latent structure of depression support the notion of multiple presentations of depressed youth; however, it is unclear how these presentations are represented among acutely impaired youth. Participants (n = 457) in this naturalistic study were admitted to a psychiatric inpatient unit (Mean age = 14.33 years, SD = 1.94;76% female;46.6% Black/African-American). Selected subscales from the parent-report Behavior Assessment System for Children, Second Edition, were utilized as indicators in a latent profile analysis. Subgroups were validated based on their relationships with meaningful clinical correlates (e.g., family factors, discharge diagnosis) and further described by their associations with demographic variables. A five-class model provided the best balance of fit and parsimony. Subtypes of depressed youth included Predominantly Depressed (39.1%), Oppositional (28.2%), Severely Disruptive (12.3%), Anxious-Oppositional (11.6%), and Anxious-Withdrawn (8.8%). Comorbid symptoms were present in four of the five classes (60.9% of sample). High levels of externalizing symptoms were a prominent clinical feature associated with three classes (52.1% of the sample). Construct validity of the respective classes was demonstrated by differential association with clinical correlates, family characteristics, and demographics. Findings suggest that depressed youth presenting for acute inpatient psychiatric care displayed varied clinical presentations. The identified latent groups aligned with existing research reflecting comorbidity with anxiety, inattention, and externalizing disorders. Findings underscore the need for an increased clinical appreciation of comorbidity and encourage more targeted and effective prevention and treatment strategies.

Exploring pathways linking early childhood adverse experiences to reduced preadolescent school engagement

BACKGROUND

Cross-sectional studies link adverse childhood experiences (ACEs) with school disengagement, contributing to chronic absenteeism and underachievement.

OBJECTIVE

This prospective longitudinal study explored malleable mediators that might account for the developmental progression from early childhood ACEs to preadolescent school disengagement. Negative cascades were tested that explored student-teacher relationship quality and child behavior problems (internalizing and externalizing) as potential mediators.

PARTICIPANTS AND SETTING

556 children were recruited from Head Start preschool classrooms (Mage = 4.67 years old, SD = 0.32; 51% female; 58% European American, 25% African American, 19% Latinx) at which time parents reported on ACEs.

METHODS

Children were followed longitudinally; kindergarten and third grade teachers rated student-teacher relationship quality and classroom behavior problems. Students described their school engagement (i.e., academic involvement, school bonding, and teacher affiliation) in fifth grade as they prepared for the transition into middle school.

RESULTS

Path models documented a mediated cascade linking early childhood ACES through poor kindergarten student-teacher relationship quality to elevated third grade internalizing problems (mediation path β = 0.018, SE = 0.009, p < 0.05) which, in turn, led to reduced fifth-grade school engagement (mediation path β = 0.027, SE = 0.014, p = 0.05). Early childhood ACEs also predicted elevated externalizing problems in elementary school, but without mediation by student-teacher relationship quality or link to fifth-grade school engagement.

CONCLUSION

Results are discussed in light of understanding developmental processes that link early ACEs with school difficulties and informing the design of preventive interventions for children at risk.

The impact of parent-only interventions on child anxiety: A systematic review and meta-analysis

BACKGROUND

Parent-only interventions for childhood anxiety may be an important alternative to resource and time intensive child-focused cognitive behavioural therapy (CBT). This systematic review and meta-analysis aimed to investigate the efficacy of parent-only interventions in reducing symptoms of anxiety disorders in school-aged children.

METHODS

A systematic search of five databases (inception to March 2021) identified 29 eligible studies. A range of study designs were captured, including randomised controlled trials (RCTs) and case series. A narrative synthesis was conducted. Random effects meta-analyses were performed on parent- and child-reported outcomes and pre-test post-test effect sizes were calculated for uncontrolled studies.

RESULTS

Findings indicated a significant treatment effect for parent-only interventions compared to waitlist controls. No significant differences were found when comparing parent-only interventions with other active interventions; anxiety symptoms reduced in both conditions. No significant treatment effects were found for child-rated outcomes. Calculated effect sizes for uncontrolled studies were typically large, although sample sizes were small. No clear evidence was found for a superior type, duration or format of intervention.

LIMITATIONS

The methodological quality of many studies in this review (19/29) was rated 'weak'. Only English language papers were included.

CONCLUSIONS

To date, this is the first systematic review and meta-analysis of the efficacy of parent-only interventions for reducing symptoms of child anxiety disorders. Our results suggest that parent-only interventions may be effective in reducing child anxiety. These findings are important for clinical practice because they suggest that efficient, low intensity interventions delivered to parents may lead to positive outcomes for children.

Evaluation of a scalable online videogame-based biofeedback program to improve emotion regulation: A descriptive study assessing parent perspectives

Individuals and families increasingly turn to e-mental health apps for education, diagnosis, and treatment of mental health disorders and to promote mental wellness. These apps provide significant increases in convenience from existing services, since they can augment or replace services with on-demand access within the home. This raises important questions about self-selection of interventions. Who uses these applications? How do individuals perceive their own progress within applications? This study is a retrospective data analysis-based evaluation of a commercially available e-mental health program that includes biofeedback video games that help children build emotion regulation skills by demonstrating and prompting children to practice bodily focused emotion regulation techniques. The e-mental health program also provided parent psychoeducation-focused coaching at the time of the evaluation. Data collection instruments used to inform the retrospective study included parent intake surveys, gameplay engagement data, and notes from parent coaching calls. The evaluation revealed families presenting for common symptoms associated with emotion regulation deficits, as opposed to a wellness cohort looking for additional support. Families near-universally activated and engaged with the intervention, willing to carry out an extended "dose" of the e-mental health program in their home. Parents self-reported their perceptions of their children's emotion regulation progress, primarily in terms of children's increased use of emotion regulation skills, improved emotion awareness and communication, calmer demeanor, greater confidence, and improved relationships. More work is needed to understand the corresponding clinical progress from this in-home training, as well as its implications for how emotion regulation skills grow.

Evaluating an Evidence-Based Parenting Intervention Among Filipino Parents: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Filipino Americans underuse mental health and preventive care services even though studies have indicated that Filipino youth experience high rates of suicidal ideation, substance abuse, and teen pregnancies, whereas adults experience immigration stress, discrimination, and depression. Evidence-based parenting interventions provided in early childhood have proven to be effective in preventing the onset and escalation of child mental health disorders. In a pilot randomized controlled trial, we found that participation in the Incredible Years Basic Parent Training Program (IY) improved parenting stress and positive parenting practices and decreased child internalizing and externalizing symptoms among Filipino families. A fully powered trial is needed to determine the efficacy of IY as a prevention program among Filipino families.

OBJECTIVE

The aims of this study are to describe the design and rationale of a randomized controlled trial evaluating the effects of the web-based IY program among parents recruited from multiple community-based settings and its impact on parenting practices, parenting stress, and child problem behavior among Filipino Americans and describe the impact of COVID-19 on our study protocols.

METHODS

This study uses a randomized controlled 2-arm individually randomized group treatment pretest-posttest design for 180 parent-child dyads. Individuals are eligible if they are ≥18 years, live in California, and have at least one Filipino child aged 8-12 years. Consenting participants are randomly allocated to receive either the 12-week IY parenting intervention (intervention arm) or American Academy of Pediatrics' Bright Future handouts and placed on a waitlist to receive IY posttrial (waitlist control arm). Primary outcomes include the Parent Practices Interview and the Parenting Stress Index. Secondary outcomes will be measured using the Child Behavior Checklist (completed by parent) and will include child internalizing and externalizing behaviors and total problems. Data are collected at baseline and 3- and 6-month follow-ups.

RESULTS

Changes made to the protocol owing to COVID-19 include administration of surveys remotely and implementation of the intervention on the web. The pandemic has provided an opportunity to evaluate the effectiveness of a web-based version of IY that may improve access and increase use of the intervention. Recruitment and data collection procedures are still ongoing and are expected to be completed by December 2022.

CONCLUSIONS

Our research will determine whether IY promotes positive parenting practices and prevents child internalizing and externalizing behaviors in healthy but high-risk populations such as Filipino families. It will also uplift cultural narratives and add to the evidence base for web-based parenting programs and their implementation in real-world settings. If found efficacious, IY has the potential to prevent behavioral health disparities in this understudied and high-risk Filipino population and can be scaled, adapted, and implemented in other at-risk racial and ethnic minority communities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04031170; https://clinicaltrials.gov/ct2/show/NCT04031170.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21867.

Effects of Combing Group Executive Functioning and Online Parent Training on School-Aged Children With ADHD: A Randomized Controlled Trial

OBJECTIVE

The acceptance of drug treatment for younger children with attention-deficit/hyperactivity disorder (ADHD) in China remains low. Here, we explored the clinical benefits of a non-pharmaceutical intervention method combining a group and executive function training and an online parent training program, termed group executive functioning and online parent training (GEF-OPT), for school-aged students with ADHD through a randomized controlled trial.

METHOD

A total of 145 children (aged 6-8 years) were formally registered and randomized to the intervention group (n = 73) and waitlist group (n = 72). The enrolled children received eight sessions of GEF-OPT treatment, which consists of a hospital-based children executive function (EF) training program and an online parent training program. Treatment outcome was assessed by a parent/teacher report questionnaire and neurophysiological experiment.

RESULTS

After eight sessions of intervention, children in the intervention group showed a significant improvement in inattentive symptom compared to the waitlist group (14.70 ± 4.35 vs. 16.03 ± 2.93; p = 0.024), but an insignificant difference in hyperactive-impulsivity (9.85 ± 5.30 vs. 10.69 ± 5.10; p = 0.913). Comorbid oppositional defiant disorder was significantly reduced in the intervention group (7.03 ± 4.39 vs. 8.53 ± 4.41; p = 0.035). Children in the intervention group had greater reduction in the scores of behavioral regulation index (inhibition, emotional control) and metacognition index (working memory, planning/organization, monitoring) in executive function than those in the waitlist group (p < 0.05). Significant effects were also found in learning problem of Weiss Functional Impairment Scale-Parent form and parental distress between two groups at post-treatment (p < 0.05). In line with this, the result of go/no-go task showed significant improvements in accuracy change (4.45 ± 5.50% vs. 1.76 ± 3.35%; p = 0.001) and reaction time change (47.45 ± 62.25 s vs. 16.19 ± 72.22 s; p = 0.007) in the intervention group compared with the waitlist group.

CONCLUSION

We conclude that participants in the GEF-OPT program improved outcomes for inattentive symptom, executive function, learning problems, and parental distress. GEF-OPT is a promising non-pharmaceutical therapeutic option for younger children.

TRIAL REGISTRATION

ChiCTR2100052803.

TREINAMENTO DE HABILIDADES SOCIAIS EDUCATIVAS COM MÃES DE PRÉ-ADOLESCENTES COM DEFICIÊNCIA AUDITIVA

Desenvolveu-se um Programa de Treinamento de Habilidades Sociais Educativas com mães de pré-adolescentes com deficiência auditiva. Duas mães constituíram o Grupo Experimental (GE) e duas, o Controle (GC). Buscou-se avaliar os efeitos do Programa no repertório de comportamentos das mães e dos filhos por meio do Roteiro de Entrevista de Habilidades Sociais Educativas Parentais (RE-HSE-P) e o do Child Behavior Checklist (CBCL). Foi utilizado o método Jacobson Truax para análise dos dados do RE-HSE-P, obtendo mudanças confiáveis em relação ao incremento das habilidades sociais educativas positivas e das habilidades sociais infantis para o GE. Os dados do CBCL indicaram problemas de comportamento internalizantes no GE e em um participante do GC e problemas de comportamento externalizantes em um participante do GC na pré e na pós-intervenção e na avaliação follow up (para o GE). Acredita-se que o desenvolvimento de Programas nestes moldes pode se constituir em um importante aliado da fonoterapia.

Health Equity and Enrollment in Preventive Parenting Programs: A Qualitative Study of Filipino Parents

This qualitative study identified the parent health beliefs and normative beliefs related to child behavioral and mental health problems and examined the benefits and barriers of enrolling in an evidence-based parenting intervention among Filipino parents of school-aged children. A secondary aim was to also use the results to inform the development of a theory-based video intervention to increase enrollment in parenting interventions. Semi-structured interviews were conducted with fifteen parents who had or had not participated in the Incredible Years® parenting program, an evidence-based parenting intervention. Interviews were recorded and transcribed verbatim. Using a "Coding Consensus, Co-occurrence, and Comparison" methodology, emergent themes were mapped into a matrix against a priori-coded health belief model (HBM) and Theory of Planned Behavior (TPB) constructs. Parents believed that perceived susceptibility could be influenced by including knowledge of health disparities affecting Filipino youth in the U.S. Perceived severity was related to behavioral and mental health concerns about school, family dynamics, bullying and parent coping strategies. Perceived benefits included strengthening parent-child relationships, creating support systems, and learning positive parenting skills. Perceived barriers included logistics, stigma, and the perception of the relevance of the program, cultural factors such as generational differences about parenting, and family issues. Social norms and subjective norms related to parent participation were also discussed. Applying the HBM and TPB to enrollment in parenting interventions may explain low enrollment rates. Future interventions need to target perceived susceptibility to future behavioral health problems, barriers, and benefits to enrollment, and influence subjective and social norms.

Translating and Implementing Evidence-Based Mental Health Services in Child Welfare

Children in the child welfare system with mental health difficulties seldom receive evidence-based treatment (EBT) despite the abundance of validated interventions that exist. This manuscript describes two projects aimed at increasing access to EBTs. The first is a completed field trial of an adapted parent-child interaction therapy intervention with foster-parent child dyads. New findings are presented from variable- and person-centered analyses of impact on diverse symptom profiles. The second is an ongoing statewide initiative that is increasing access to multiple EBTs while navigating implementation barriers. Lessons learned for bridging gaps between children's mental health research, services, and policy are discussed.

Teacher Involvement Prevents Increases in Children's Depressive Symptoms: Bidirectional Associations in Elementary School

There is accumulating evidence that social relationships can buffer the development of depression in childhood and adolescence. However, few studies have focused on teacher-child relationships in the elementary school years. In addition, research that has examined bidirectional relations between teacher involvement and depressive symptoms is virtually absent in this age period. The participants in this study were 570 children and 30 teachers from 15 elementary schools. Data on children's depressive symptoms (peer- and teacher-reports) and teacher involvement (teacher-reports) were collected in the fall and spring of Grade 2 and Grade 3 (four waves). As expected, negative cross-time effects of teacher involvement on depressive symptoms were found within grade 2 and 3. In addition, a negative cross-time effect of depressive symptoms on teacher involvement was found in grade 3 only. The results thus indicate the protective role of teacher involvement in the development of depressive symptoms but also suggest that teachers may become less involved over time when they perceive a child as more depressed.

Family and Maternal Characteristics of Children With Co-Occurring ADHD and Depression

Objective: This study examined differences between children with ADHD and comorbid depression (n = 26), ADHD only (n = 111), and a community control group (n = 130) on measures of family and maternal characteristics. Method: The present study utilized a large, community sample. Diagnoses required positive endorsements from multiple sources. ANOVAs and chi-square tests were conducted to determine group differences. Results: Compared with children with ADHD alone and community controls, mothers of depressed ADHD children reported decreased family cohesion, limited participation in social/recreational activities, increased maternal depressive symptoms, difficulty coping with parenting roles, and higher rates of bipolar and anxiety disorders. Mothers of children with ADHD (with or without comorbid depression) reported increased conflict, decreased cohesion, and poor maternal coping compared with community controls. Conclusion: Findings are consistent with prior literature suggesting that families of children with ADHD and depression demonstrate both similar and unique characteristics. Clinical implications are discussed.

Child and parent outcomes following parent interventions for child emotional and behavioral problems in autism spectrum disorders: A systematic review and meta-analysis

There is growing interest in the development of behavioral parent interventions targeting emotional and behavioral problems in children with autism spectrum disorders. Such interventions have potential to improve a number of child and parental well-being outcomes beyond disruptive child behavior. This systematic review and meta-analysis assesses evidence for the efficacy of behavioral parent interventions for disruptive and hyperactive child behavior in autism spectrum disorders, as well as parenting efficacy and stress. A total of 11 articles from nine randomized controlled trials were included. Sufficient data were available to calculate standardized mean difference and show favorable effects of behavioral parent interventions on parent-reported measures of child disruptive behavior (standardized mean difference = 0.67), hyperactivity (standardized mean difference = 0.31) and parent stress (standardized mean difference = 0.37); effects on parent efficacy are less clear (standardized mean difference = 0.39, p = 0.17). There were insufficient data to explore intervention effects on internalizing behavior in autism spectrum disorders, parenting behaviors, or observational and teacher-reported outcomes, providing important avenues for future research. This review adds to growing evidence of the efficacy of behavioral parent interventions for child behavior and parental well-being in autism spectrum disorders (Prospero: CRD42016033979).

Does interparental conflict decrease following changes in observed parenting from a preventive intervention program?

Interparental conflict, which is common among families where a parent has a history of Major Depressive Disorder, is associated with deficits in parenting. Models of family functioning propose that interparental conflict and parenting behaviors are transactional in nature. Given the interdependent nature of family systems, increases in positive parenting practices may lead to subsequent decreases in interparental conflict. The current study was a secondary analysis of data from a preventive intervention to improve parenting, child coping skills, and child behavior in families with a history of parental depression. We hypothesized that increases in positive parenting strategies would be associated with decreases in interparental conflict 12 months later. Results supported the study hypothesis. Findings underscored the interdependent nature of parent-child and parent-parent subsystems.

Systematic Review and Meta-analysis of Parent Group Interventions for Primary School Children Aged 4-12 Years with Externalizing and/or Internalizing Problems

This systematic review and meta-analysis evaluates the efficacy of parent training group interventions to treat child externalizing and/or internalizing problems. A search identified 21 randomized controlled trials of parent group interventions aimed at ameliorating child externalizing and/or internalizing problems in children aged 4-12 years. Random effects meta-analyses yielded significant pooled treatment effect size (g) estimates for child externalizing (g = -0.38) and internalizing problems (g = -0.18). Child anxiety symptoms or internalizing problems evident in children with externalizing behavior problems did not change significantly following intervention. Study quality was a statistically significant moderator of treatment response for child externalizing problems, however hours of planned parent group treatment and treatment recipient were not. Findings support the use of parent group interventions as an effective treatment for reducing externalizing problems in children aged 4-12 years. Whilst statistically significant, programs had a limited impact on internalizing symptoms, indicating a need for further investigation.

Distilling Common History and Practice Elements to Inform Dissemination: Hanf-Model BPT Programs as an Example

There is a shift in evidence-based practice toward an understanding of the treatment elements that characterize empirically supported interventions in general and the core components of specific approaches in particular. The evidence base for behavioral parent training (BPT) and the standard of care for early-onset disruptive behavior disorders (oppositional defiant disorder and conduct disorder), which frequently co-occur with attention deficit hyperactivity disorder, are well established, yet an ahistorical, program-specific lens tells little regarding how leaders, University of Oregon Medical School, shaped the common practice elements of contemporary evidence-based BPT. Accordingly, this review summarizes the formative work of Hanf, as well as the core elements, evolution, and extensions of her work, represented in Community Parent Education (COPE; (Cunningham et al. in J Child Psychol Psychiatry 36:1141-1159, 1995; Cunningham et al. in COPE, the community parent education program: large group community-based workshops for parents of 3- to 18-year-olds, COPE Works, Hamilton, 2009), Defiant Children (DC; (Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 1987; Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 2013), Helping the Noncompliant Child (HNC; Forehand and McMahon in Helping the noncompliant child: a clinician's guide to parent training, Guilford Press, New York, 1981; McMahon and Forehand in Helping the noncompliant child: family-based treatment for oppositional behavior, 2nd ed., Guilford Press, New York, 2003), Parent-child interaction therapy (PCIT; Eyberg and Robinson in J Clin Child Adolesc Psychol 11:130-137, 1982. doi:10.1080/15374418209533076; Eyberg in Child Fam Behav Ther 10:33-46, 1988; Eyberg and Funderburk in Parent-child interaction therapy protocol, PCIT International, Gainesville, 2011), and the Incredible Years (IY; (Webster-Stratton in Behav Ther 12:634-642, 1981. doi:10.1016/S0005-7894(81)80135-9; Webster-Stratton in J Pediatr Psychol 7:279-294, 1982. doi:10.1093/jpepsy/7.3.279; Webster-Stratton in The incredible years: parents and children series. Leader's guide: preschool version of BASIC (ages 3-6 years, The Incredible Years, Seattle, 2008). Our goal is not to provide an exhaustive review of the evidence base for the Hanf-Model programs, rather our intention is to provide a template of sorts from which agencies and clinicians can make informed choices about how and why they are using one program versus another, as well as how to make inform flexible use one program or combination of practice elements across programs, to best meet the needs of child clients and their families. Clinical implications and directions for future work are discussed.

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Background

Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years®(IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects.

Objectives

To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings.

Design

Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention.

Settings

UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal.

Participants

Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys).

Interventions

IY Basic parenting programme.

Main outcome measures

Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms.

Results

There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximumn = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention.

Limitations

Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention.

Conclusions

There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions.

Funding

The National Institute for Health Research Public Health Research programme.

Latent national subpopulations of early education classroom disengagement of children from underresourced families

This research examined the latent developmental patterns for early classroom disengagement among children from some of the most underresourced families in the nation. Based on standardized teacher observations from the Head Start Impact Study, a nationally representative sample of children (N=1377) was assessed for manifestations of reticent/withdrawn and low energy behavior over four years spanning prekindergarten through first grade. For each form of disengagement, latent growth mixture modeling revealed three distinct subpopulations of change patterns featuring a dominant class associated with generally good classroom adjustment, a medial class that varied close to the population average over time, and a more extreme class (about 10% of the population) whose adjustment was relatively marginal and sometimes reached problematic levels. Whereas reticent/withdrawn behavior ordinarily subsided over time, low energy behavior increased. More extreme low energy behaviors tended to dissipate through schooling and extreme reticence/withdrawal became more accentuated, with both types associated with later academic and social problems. Attendant risk and protective factors are identified and mitigating assessment and prevention measures are discussed.

Distilling Common History and Practice Elements to Inform Dissemination: Hanf-Model BPT Programs as an Example

There is a shift in evidence-based practice toward an understanding of the treatment elements that characterize empirically supported interventions in general and the core components of specific approaches in particular. The evidence base for behavioral parent training (BPT) and the standard of care for early-onset disruptive behavior disorders (oppositional defiant disorder and conduct disorder), which frequently co-occur with attention deficit hyperactivity disorder, are well established, yet an ahistorical, program-specific lens tells little regarding how leaders, University of Oregon Medical School, shaped the common practice elements of contemporary evidence-based BPT. Accordingly, this review summarizes the formative work of Hanf, as well as the core elements, evolution, and extensions of her work, represented in Community Parent Education (COPE; (Cunningham et al. in J Child Psychol Psychiatry 36:1141-1159, 1995; Cunningham et al. in COPE, the community parent education program: large group community-based workshops for parents of 3- to 18-year-olds, COPE Works, Hamilton, 2009), Defiant Children (DC; (Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 1987; Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 2013), Helping the Noncompliant Child (HNC; Forehand and McMahon in Helping the noncompliant child: a clinician's guide to parent training, Guilford Press, New York, 1981; McMahon and Forehand in Helping the noncompliant child: family-based treatment for oppositional behavior, 2nd ed., Guilford Press, New York, 2003), Parent-child interaction therapy (PCIT; Eyberg and Robinson in J Clin Child Adolesc Psychol 11:130-137, 1982. doi:10.1080/15374418209533076; Eyberg in Child Fam Behav Ther 10:33-46, 1988; Eyberg and Funderburk in Parent-child interaction therapy protocol, PCIT International, Gainesville, 2011), and the Incredible Years (IY; (Webster-Stratton in Behav Ther 12:634-642, 1981. doi:10.1016/S0005-7894(81)80135-9; Webster-Stratton in J Pediatr Psychol 7:279-294, 1982. doi:10.1093/jpepsy/7.3.279; Webster-Stratton in The incredible years: parents and children series. Leader's guide: preschool version of BASIC (ages 3-6 years, The Incredible Years, Seattle, 2008). Our goal is not to provide an exhaustive review of the evidence base for the Hanf-Model programs, rather our intention is to provide a template of sorts from which agencies and clinicians can make informed choices about how and why they are using one program versus another, as well as how to make inform flexible use one program or combination of practice elements across programs, to best meet the needs of child clients and their families. Clinical implications and directions for future work are discussed.

Mediators of the Associations Between Externalizing Behaviors and Internalizing Symptoms in Late Childhood and Early Adolescence

This study tests the predictive associations between externalizing behaviors and internalizing symptoms and examines the mediating roles of social competence, parent-child conflicts, and academic achievement. Using youth-, parent-, and teacher-reported longitudinal data on a sample of 523 boys and 460 girls from late childhood to early adolescence, we found evidence for pathways between externalizing behaviors and internalizing symptoms in both directions. Parent-child conflict, but not social competence and academic achievement, was found to be a significant mediator such that externalizing behaviors predicted parent-child conflicts, which in turn, predicted internalizing symptoms. Internalizing symptoms showed more continuity during early adolescence for girls than boys. For boys, academic achievement was unexpectedly, positively predictive of internalizing symptoms. The results highlight the importance of facilitating positive parental and caregiver involvement during adolescence in alleviating the risk of co-occurring psychopathology.

A randomized controlled trial of the impact of a teacher classroom management program on the classroom behavior of children with and without behavior problems

This randomized controlled trial (RCT) evaluated the efficacy of the Incredible Years (IY) Teacher Classroom Management (TCM; Webster-Stratton & Reid, 2002) program to assess whether training teachers in IY-TCM principles improve teacher behavior, whether any observed improvements impact pupil behavior classroom-wide, and whether these effects can be demonstrated with children at risk of developing conduct problems. Six intervention and six control classrooms comprising 12 teachers and 107 children (aged 3 to 7years) were recruited. Children were screened for high or low behavior problems using the cut-off points of the teacher-rated Strengths and Difficulties Questionnaire (Goodman, 1997). The primary outcome measure was independent classroom observations using the Teacher-Pupil Observation Tool (Martin et al., 2010). Multilevel modeling analyses were conducted to examine the effect of the intervention on teacher, classroom, and child behavior. Results showed a significant reduction in classroom off-task behavior (d=0.53), teacher negatives to target children (d=0.36), target child negatives towards the teacher (d=0.42), and target child off-task behavior (d=0.48). These preliminary results demonstrate the potential impact of IY-TCM on both teacher and child behavior.

Connecting, learning, leaving: supporting young parents in the community

Providing support and parenting education through home visiting is a key early intervention strategy with young parents. Less is known about what home visitors do that makes a difference. The purpose of this paper is to describe the role and experiences of professional staff working with young parents participating in a multicomponent parent support programme (home visiting and supported parenting groups) provided by a non-government organisation in a socially disadvantaged area of Sydney, Australia. This was a qualitative descriptive study. Data were collected through three focus groups conducted with the same six staff over an 18-month period. Participant descriptions of their role and experiences working with young mothers were analysed thematically. Additional data from 20 anonymised client records were analysed through content analysis. Analysis of the focus group data revealed two themes, 'Connecting' and 'Facilitating Learning'. The theme 'Connecting' reflected the development of a relationship with the young mother commencing with 'how do we engage them?', 'building trust' through to formation of a relationship described as 'they know we're not friends, they know we're workers'. The second theme, 'Facilitating Learning' was informed by the analysis of both group and client record data and comprised a number of themes around what and how mothers learnt, through to 'ending the relationship' as the mothers left the programme. The quality of a mothers' learning was dependent on the quality of the connection between herself and the staff, similarly their capacity and, or confidence to leave the programme was dependent on the relationship, 'connecting' and the learning undertaken. Role modelling through interactions with children as well as with each other was seen as the most effective way to facilitate social and parenting skill development, while formal education sessions were evaluated by the workers to be less successful than informal ones.

Preventing mental health problems in children: the Families in Mind population-based cluster randomised controlled trial

Background

Externalising and internalising problems affect one in seven school-aged children and are the single strongest predictor of mental health problems into early adolescence. As the burden of mental health problems persists globally, childhood prevention of mental health problems is paramount. Prevention can be offered to all children (universal) or to children at risk of developing mental health problems (targeted). The relative effectiveness and costs of a targeted only versus combined universal and targeted approach are unknown. This study aims to determine the effectiveness, costs and uptake of two approaches to early childhood prevention of mental health problems ie: a Combined universal-targeted approach, versus a Targeted only approach, in comparison to current primary care services (Usual care).

Methods/design

Three armed, population-level cluster randomised trial (2010–2014) within the universal, well child Maternal Child Health system, attended by more than 80% of families in Victoria, Australia at infant age eight months.

Participants were families of eight month old children from nine participating local government areas. Randomised to one of three groups: Combined, Targeted or Usual care.

The interventions comprises (a) the Combined universal and targeted program where all families are offered the universal Toddlers Without Tears group parenting program followed by the targeted Family Check-Up one-on-one program or (b) the Targeted Family Check-Up program. The Family Check-Up program is only offered to children at risk of behavioural problems.

Participants will be analysed according to the trial arm to which they were randomised, using logistic and linear regression models to compare primary and secondary outcomes. An economic evaluation (cost consequences analysis) will compare incremental costs to all incremental outcomes from a societal perspective.

Discussion

This trial will inform public health policy by making recommendations about the effectiveness and cost-effectiveness of these early prevention programs. If effective prevention programs can be implemented at the population level, the growing burden of mental health problems could be curbed.

Trial registration

ISRCTN61137690