Preventing emotional and behavioural problems: the effectiveness of parenting programmes with children less than 3 years of age

A cost-effectiveness analysis of a universal, preventative-focused, parent and infant programme

BACKGROUND

This study assessed whether a relatively newly developed Parent and Infant (PIN) parenting support programme was cost-effective when compared to services as usual (SAU).

METHODS

The cost-effectiveness of the PIN programme versus SAU was assessed from an Irish health and social care perspective over a 24-month timeframe and within the context of a non-randomised, controlled before-and-after trial. In total, 163 parent-infant dyads were included in the study (86 intervention, 77 control). The primary outcome measure for the economic evaluation was the Parenting Sense of Competence Scale (PSOC).

RESULTS

The average cost of the PIN programme was €647 per dyad. The mean (SE) cost (including programme costs) was €7,027 (SE €1,345) compared to €4,811 (SE €593) in the control arm, generating a (non-significant) mean cost difference of €2,216 (bootstrap 95% CI -€665 to €5,096; p = 0.14). The mean incremental cost-effectiveness of the PIN service was €614 per PSOC unit gained (bootstrap 95% CI €54 to €1,481). The probability that the PIN programme was cost-effective, was 87% at a willingness-to-pay of €1,000 per one unit change in the PSOC.

CONCLUSIONS

Our findings suggest that the PIN programme was cost-effective at a relatively low willingness-to-pay threshold when compared to SAU. This study addresses a significant knowledge gap in the field of early intervention by providing important real world evidence on the implementation costs and cost-effectiveness of a universal early years parenting programme. The challenges involved in assessing the cost-effectiveness of preventative interventions for very young children and their parents are also discussed.

TRIAL REGISTRATION

ISRCTN17488830 (Date of registration: 27/11/15). This trial was retrospectively registered.

Child Adult Relationship Enhancement in Primary Care (PriCARE): study design/protocol for a randomized trial of a primary care-based group parenting intervention to prevent child maltreatment

BACKGROUND

Child maltreatment (CM) is a pervasive public health problem and there is a critical need for brief, effective, scalable prevention programs. Problematic parent-child relationships lie at the heart of CM. Parents who maltreat their children are more likely to have punitive parenting styles characterized by high rates of negative interaction and ineffective discipline strategies with over-reliance on punishment. Thus, parenting interventions that strengthen parent-child relationships, teach positive discipline techniques, decrease harsh parenting, and decrease child behavioral problems hold promise as CM prevention strategies. Challenges in engaging parents, particularly low-income and minority parents, and a lack of knowledge regarding effective implementation strategies, however, have greatly limited the reach and impact of parenting interventions. Child Adult Relationship Enhancement in Primary Care (PriCARE)/Criando Niños con CARIÑO is a 6-session group parenting intervention that holds promise in addressing these challenges because PriCARE/CARIÑO was (1) developed and iteratively adapted with input from racially and ethnically diverse families, including low-income families and (2) designed specifically for implementation in primary care with inclusion of strategies to align with usual care workflow to increase uptake and retention.

METHODS

This study is a multicenter randomized controlled trial with two parallel arms. Children, 2-6 years old with Medicaid/CHIP/no insurance, and their English- and Spanish-speaking caregivers recruited from pediatric primary care clinics in Philadelphia and North Carolina will be enrolled. Caregivers assigned to the intervention regimen will attend PriCARE/CARIÑO and receive usual care. Caregivers assigned to the control regimen will receive usual care only. The primary outcome is occurrence of an investigation for CM by child protective services during the 48 months following completion of the intervention. In addition, scores for CM risk, child behavior problems, harsh and neglectful parenting behaviors, caregiver stress, and caregiver-child interactions will be assessed as secondary outcome measures and for investigation of possible mechanisms of intervention-induced change. We will also identify PriCARE/CARIÑO implementation factors that may be barriers and facilitators to intervention referrals, enrollment, and attendance.

DISCUSSION

By evaluating proximal outcomes in addition to the distal outcome of CM, this study, the largest CM prevention trial with individual randomization, will help elucidate mechanisms of change and advance the science of CM prevention. This study will also gather critical information on factors influencing successful implementation and how to optimize intervention referrals, enrollment, and attendance to inform future dissemination and practical applications.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov (NCT05233150) on February 1, 2022, prior to enrolling subjects.

A preliminary evaluation of Kids Matter: A community-based parenting intervention

Parents living in deprived communities are more likely to report lower parental self-efficacy and wellbeing. Poor parental wellbeing and self-efficacy are known risk factors in the development of a range of health and behavioural problems in childhood, adolescence and adulthood. Parenting interventions are key to prevent adverse outcomes in children, however, the mechanisms by which parents learn to understand and support their children are still not well understood. This study evaluated the acceptability of Kids Matter, a parenting intervention targeting parents who are struggling with financial adversity. Secondarily, the relationship between parental wellbeing and and self-efficacy was examined. The present is a retrospective, consecutive case series design study, comparing routinely collected data at pre-intervention, post-intervention, and at 3-month follow-up. Descriptive frequencies were drawn to explore parents' impressions of the programme. Multivariate analysis of variance and regression modelling were used to evaluate associations between parental wellbeing and self-efficacy at different time points. Parents found the programme enjoyable and useful. The intervention led to significant improvements in parental wellbeing and self-efficacy. Improvements in parental wellbeing were significantly associated with improvements in self-efficacy. This study provides evidence of the acceptability and effectiveness of Kids Matter.

Criando Niños Con Cariño : Primary Care-Based Group Parenting Program Adaptation and Pilot

OBJECTIVE

This study culturally adapted and piloted a primary care-based group parenting program (Child-Adult Relationship Enhancement in Primary Care, PriCARE) for Spanish-speaking, Hispanic parents of 2- to 6-year-old children.

METHODS

The process was informed by the cultural adaptation literature, expert consultation, and focus group data from 18 previous PriCARE, eligible Cariño , and initial Cariño test participants. As adaptations were made, an implementation framework was applied to systematically record all changes. Finally, parents of children aged 2 to 6 years participated in the Cariño pilot study (n = 32). Enrollment and attendance data were used to examine feasibility, and the Therapy Attitude Inventory (TAI) was administered postintervention to measure acceptability.

RESULTS

Most adaptations were minor changes to make the adapted program, Criando Niños con Cariño , more appropriate, applicable, or acceptable. Some changes required reframing Cariño concepts (e.g., child-led play) or incorporating new concepts (e.g., respeto , armonía , and educación ) to better align Cariño goals with parents' values. Among the 121 dyads invited to participate in the Cariño pilot study, 52 (43%) enrolled. Among the 52 enrolled, 32 (62%) attended at least 4 of the 6 sessions and reported high satisfaction on the TAI (mean 47/50, range 33-50).

CONCLUSION

Cariño is the result of a rigorous adaption process and incorporates multiple changes to ensure the translation reflects the intended meaning and to reframe the program goals and concepts in a culturally congruent manner. Pilot data suggest Cariño is feasible and acceptable to parents.

Early Childhood Caries Is Causally Attributed to Developing Psychomotor Deficiency in Pre-School Children: The Resultant Covariate and Confounder Analyses in a Longitudinal Cohort Study

Background: Causality has recently been suggested to associate early childhood caries with psychomotor deficiency in preschoolers, where their causal interactions via other risk determinants remain unclear. Methods: To analyze such causality, we randomly recruited 123 three-to-six-year-old children in a three-year longitudinal study, where the caries/dmft measures, age/gender, BMI, amended comprehensive scales for psychomotor development (CCDI-aspects), parental education/vocation, and diet were collected for assessment of their inter-relationships. Subsequently, t-tests, multiple/linear-regressions, and R2-analyses were utilized to compare the differences of variables between age/gender, BMI, and dmft vs. relationships among all variables and CCDI-aspects. Results: In the regression modeling, there were significant differences between gender vs. age (p < 0.05; not BMI) regarding established associations between caries and CCDI manifests for psychomotor deficiency. As for diet vs. socio-economic status, there were significant differences when caries/dmft were at lower- vs. higher-scales (<4 and 6−10), associated with expressive language and comprehension-concept (p~0.0214−0.0417) vs. gross-motor and self-help (p~0.0134−0.0486), respectively. Moreover, diet vs. socio-economic-status contributed significantly different CCDI-spectra via expressive language and comprehension-concept (adjusted-R2~0.0220−0.2463) vs. gross-motor and self-help (adjusted-R2~0.0645−0.0994), respectively, when the caries detected were at lower- vs. higher-scales (<4 and 6−10), in contrast to those depicted without both SES diet variables (adjusted-R2~0.0641−0.0849). Conclusion: These new findings confirm that early childhood caries is causally attributed to developing psychomotor deficiency in preschoolers, whereas biological gender/age, not BMI, may act as viable confounders during interactions, in contrast to diet and socio-economic status, via differential low−high scales of caries activity with significant interference, respectively. Collectively, ECC-psychomotor interactions may underpin some distinct biologic vs. socio-mental/psyche attributes towards different determinants for vulnerable children.

A proportionate, universal parenting programme to enhance social-emotional well-being in infants and toddlers in England: the E-SEE Steps RCT

Background

Mental disorders have become a public health crisis. Early prevention is key. Parenting programmes are effective for children aged ≥ 3 years; however, there is a lack of evidence of their effectiveness for children aged ≤ 2 years.

Objectives

To establish if the model named Enhancing Social–Emotional Health and Well-being in the Early Years (E-SEE) Steps can (1) enhance child social emotional well-being and establish whether or not it is cost-effective at 20 months of age when compared with services as usual; and (2) be delivered as a proportionate universal model with fidelity.

Design

A pragmatic two-arm randomised controlled trial and economic appraisal, with an embedded process evaluation to examine the outcomes, implementation and cost-effectiveness of the intervention, and intervention uptake, compared with services as usual. The study had an external pilot phase (which was originally planned as an internal pilot).

Setting

The intervention was delivered in community settings by early years children’s services and/or public health staff in four sites.

Participants

A total of 341 parents of infants aged ≤ 8 weeks were randomised in a ratio of 5 : 1 (intervention, n = 285; control, n = 56). The target sample was 606 parents.

Intervention

Two Incredible Years® parenting programmes (i.e. infant and toddler) delivered in a proportionate universal model with three levels [one universal (book) and two targeted group-based parenting programmes].

Main outcome measures

Child social and emotional well-being (primary outcome) was assessed using the Ages and Stages Questionnaire: Social and Emotional, 2nd edition, at 2, 9 and 18 months after randomisation. Parent depression (secondary key outcome) was assessed using the Patient Health Questionnaire-9 items. Both questionnaires were eligibility screeners for targeted groups.

Results

The primary outcome analysis provided no evidence that the E-SEE Steps model was effective in enhancing child social and emotional well-being. The adjusted mean difference was 3.02 on the original Ages and Stages Questionnaire: Social and Emotional, 2nd edition, in favour of the control [95% confidence interval –0.03 to 6.08; p = 0.052; N = 321 (intervention, n = 268; control, n = 53)]. Analysis of the key secondary outcome (i.e. parent depression levels as assessed by the Patient Health Questionnaire-9 items) provided weak evidence on the Patient Health Questionnaire-9 items in favour of the intervention (adjusted mean difference –0.61, 95% confidence interval –1.34 to 0.12; p = 0.1). Other secondary outcomes did not differ between arms. The economic analysis showed that the E-SEE Steps model was associated with higher costs and was marginally more effective (0.031 quality-adjusted life-years gained from E-SEE Steps compared with SAU, 95% confidence interval –0.008 to 0.071) than services as usual, resulting in an incremental cost-effectiveness ratio of approximately £20,062 per quality-adjusted life-year compared with services as usual. Overall take-up of the targeted parenting programmes was low. Sites, although enthusiastic, identified barriers to delivering the intervention.

Limitations

The target sample size was not met and the study was not powered to explore the effectiveness of each level of intervention. Most parents in the sample were well educated and, therefore, the results are unlikely to be generalisable, particularly to those at greatest risk of poor social and emotional well-being.

Conclusions

The E-SEE Steps proportionate universal model did not enhance child social and emotional well-being, but generated non-significant improvements in parent health outcomes, resulting in considerable uncertainty around the cost-effectiveness of the intervention. The primary and key secondary outcome gave inconsistent signals. Although, with system changes, increased resources and adaptations to the intervention, the model could be implemented, evidence for positive outcomes from the E-SEE Steps model is poor.

Future work

The universal-level E-SEE Step data (i.e. the Incredible Years book) from the external pilot will be pooled with the main trial data for further exploration up to follow-up 1, which is the time point at which most change was seen.

Trial registration

This trial is registered as ISRCTN11079129.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 8. See the NIHR Journals Library website for further project information.

Developing and applying synergistic multilevel implementation strategies to promote reach of an evidence-based parenting intervention in primary care

Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed.

Plain Language Summary

There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.

Cultural Adaptation of Group Parenting Programs: Review of the Literature and Recommendations for Best Practices

Group parenting programs based on cognitive-behavioral and social learning principles are effective in improving child behavior problems and positive parenting. However, most programs target non-Hispanic, White, English-speaking families and are largely inaccessible to a growing Hispanic and non-White population in the United States. We sought to examine the extent to which researchers have culturally adapted group parenting programs by conducting a systematic review of the literature. We identified 41 articles on 23 distinct culturally adapted programs. Most cultural adaptations focused on language translation and staffing, with less focus on modification of concepts and methods, and on optimizing the fit between the target cultural group and the program goals. Only one of the adapted programs engaged a framework to systematically record and publish the adaptation process. Fewer than half of the culturally adapted programs were rigorously evaluated. Additional investment in cultural adaptation and subsequent evaluation of parenting programs is critical to meet the needs of all US families.

Effects of self-healing intervention on quality of life and mother-child interaction among female breadwinners

OBJECTIVES

This study aimed to investigate the effectiveness of self-healing (the healing codes) intervention on quality of life (QoL) and mother-child interaction among female breadwinners.

METHODS

The study population comprised all female breadwinners who referred to the welfare centers of Isfahan in 2020; using convenience sampling, we selected 30 women and divided them into experimental and control groups (n = 15 per group). The experimental group underwent fourteen sessions (90-min sessions per week) of self-healing training.

RESULTS

The mean ± SD of QoL and mother-child interaction for experimental and control groups in the post-test stage were 84.33 ± 3.92 and 160.86 ± 8.74 respectively. Self-healing intervention had significant effects on QoL and mother-child interaction among female breadwinners. The intervention program improved the components of QoL and mother-child interaction among female breadwinners (p < 0.01).

CONCLUSIONS

Self-healing training can be used as a novel approach to enhance QoL and mother-child interaction in this group of women.

Universal and Selective Interventions to Prevent Poor Mental Health Outcomes in Young People: Systematic Review and Meta-analysis

BACKGROUND

Much is not known about the efficacy of interventions to prevent poor mental health outcomes in young people by targeting either the general population (universal prevention) or asymptomatic individuals with high risk of developing a mental disorder (selective prevention).

METHODS

We conducted a PRISMA/MOOSE-compliant systematic review and meta-analysis of Web of Science to identify studies comparing post-test efficacy (effect size [ES]; Hedges' g) of universal or selective interventions for poor mental health outcomes versus control groups, in samples with mean age <35 years (PROSPERO: CRD42018102143). Measurements included random-effects models, I2 statistics, publication bias, meta-regression, sensitivity analyses, quality assessments, number needed to treat, and population impact number.

RESULTS

295 articles (447,206 individuals; mean age = 15.4) appraising 17 poor mental health outcomes were included. Compared to control conditions, universal and selective interventions improved (in descending magnitude order) interpersonal violence, general psychological distress, alcohol use, anxiety features, affective symptoms, other emotional and behavioral problems, consequences of alcohol use, posttraumatic stress disorder features, conduct problems, tobacco use, externalizing behaviors, attention-deficit/hyperactivity disorder features, and cannabis use, but not eating-related problems, impaired functioning, internalizing behavior, or sleep-related problems. Psychoeducation had the highest effect size for ADHD features, affective symptoms, and interpersonal violence. Psychotherapy had the highest effect size for anxiety features.

CONCLUSION

Universal and selective preventive interventions for young individuals are feasible and can improve poor mental health outcomes.

Parents' Perceptions and Experiences of Parenting Programmes: A Systematic Review and Metasynthesis of the Qualitative Literature

Supporting parents to meet the challenges of their caregiving role is identified as a public health concern and a priority in policies internationally. Quantitative research has established the efficacy of parenting programmes but less is understood about the key aspects that make interventions meaningful and helpful to families. We aimed to explore parents' experiences and perceptions of parenting programmes in order to highlight the parent voice and identify key factors that parents perceive to be meaningful and improve our understanding of the acceptability and perceived benefits of parenting programmes. Six key electronic databases were searched systematically for qualitative research and eligibility for inclusion was established. A thematic synthesis was undertaken. Twenty-six studies were included, spanning 17 years of parenting research and involving 822 parents. Three main themes and nine subthemes were identified: (1) a family's journey (prior to the parenting programme, outcomes (including changes in the parent, child and wider family) and post-intervention), (2) aspects perceived to be important or valuable (group leader or facilitator, programme content and delivery and value of the group) and (3) challenges or difficulties (barriers to engagement or attendance, programme content and suggestions for improvement). Reported outcomes of parenting programmes included changes in the parent alongside changes in the child and family more widely. Key recommendations to improve provision of accessible, clinically and cost-effective interventions for parents include ensuring high-quality training and supervision of facilitators, balancing flexibility and fidelity to ensure tailored content to meet individual needs, a sensitivity to parental adversity, the need for wider familial support and the availability of ongoing support following the end of a parenting programme.

Harsh Parenting and Violence Against Children: A Trial with Ultrapoor Families in Francophone West Africa

Few culturally congruent interventions are available to reduce abusive practices in families living in abject poverty in francophone West Africa. This study tests the effects of economic intervention-alone and in combination with a family-focused component-on parenting outcomes and children's reports of violence in rural Burkina Faso. Female caregivers and their 10- to 15-year-old children from 360 ultrapoor families were recruited to participate in a parallel cluster randomized control trial with 3 study arms: the waitlist (control) group, the economic intervention group (Trickle Up [TU]), and the economic intervention plus family coaching group (TU+). Effects were tested using repeated-measures mixed-effects regressions. At 12 months from baseline, caregivers from the TU+ group reported a reduced use of harsh discipline compared to the control group (Cohen's d = -0.57, p = .001) and the TU group (d = -0.48, p = .001). Changes were maintained at 24 months. TU+ caregivers also expressed more supportive parenting attitudes at 12 months compared to the control group (d = 0.39, p = .022) and the TU group (d = 0.55, p = .001). Compared to TU caregivers, caregivers in the TU+ group also reported a better quality of child-parent relationship (d = 0.40, p = .041). At 24 months, children in the TU+ group had lower odds of experiencing physical (odds ratio = 0.35, p = .050), 95% confidence interval [0.12, 1.00], and emotional (odds ratio = 0.52, p = .033), 95% confidence interval [0.28, 0.95], violence at home, compared to the control group children. The evidence suggests that involving all family members in sessions on child protection in addition to economic strengthening strategies can foster supportive parenting environments and reduce family violence among children living in ultralevel poverty in West Africa.

Longitudinal trajectories of mental health in Australian children aged 4-5 to 14-15 years

Mental health can affect young people's sense of wellbeing and life satisfaction, their ability to participate in employment and education, and their onward opportunities in life. This paper offers a rare opportunity to longitudinally examine mental health in a population-representative study of children aged 4-5 years to 14-15 years. Using data from the Longitudinal Study of Australian Children (LSAC), this study examined maternally-reported child mental health over a 10 year period, in order to understand their initial mental health status early in life and its change over time, as measured by the Strengths and Difficulties Questionnaire. Longitudinal models were fitted from ages 4-5 to 14-15 years. Results showed that child sex, maternal mental health, socio-economic status (family income, maternal education, neighbourhood disadvantage), maternal hostility, and child temperament (persistence, sociability, reactivity) are all independent contributors to child mental health at age 4. These effects largely persist over time, with the effects of maternal mental health increasing slightly over time. Persistence of these effects suggests the need for early intervention and supports. The independent contribution of these factors to child mental health suggests that multi-faceted approaches to child and maternal mental health are needed.

Group Work Intervention for the Parents of Children with Mental Health Issues Admitted in the Tertiary Care Center

OBJECTIVES

The objective of this study was to develop a structured curriculum for a group-based parenting program for parents/caregivers of children or adolescents treated in the inpatient child and adolescent mental health unit of a national health institute.

METHODS

Data from group session reports of 3 years of conducting group-based parenting programs in the same setting were analyzed and prominent themes of discussions were shortlisted before finally arriving at a six-session group parenting program module.

RESULTS

A six-session intervention module was designed by psychiatric social workers experienced in group work. The content followed combination of various theoretical approaches and methodologies ultimately aiming in improving the overall knowledge and understanding of parents or caregivers on various child and adolescent mental health issues, and enhancing their skills and competence in dealing with various emotional and behavioral problems in children.

CONCLUSION

Group-based parenting programs are found to be effective in improving the over psychosocial health of parents and the emotional and behavioral problems of children and adolescents as a result of better parenting. Development and standardization of culture appropriate group intervention curriculums would help in the development of this cost effective method as a medium of change.

Does Engaging in a Group-Based Intervention Increase Parental Self-efficacy in Parents of Preschool Children? A Systematic Review of the Current Literature

As the preschool years are a formative period for long-term physical and mental health, this period is recognised as an important window for early effective intervention. Parenting behaviour is a key factor to target in order to optimise child development. Group-based interventions for parents are considered efficient and cost effective methods of early intervention and have been found to improve child behaviour and adjustment. Self-efficacy is key to behaviour change and as such parental self-efficacy should be a consideration in interventions aimed at influencing parenting behaviour. Therefore, the purpose of this systematic review was to examine the impact of group-based early interventions for parents of preschool children on parental self-efficacy. Nine databases were searched (ASSIA, CINAHL, EMBASE, Maternity and Infant Care, Ovid Medline, PsycINFO, Pubmed, Science Direct and Web of Science). Studies were included if they were a randomised controlled trial of a group-based intervention for parents of preschool children and measured change in parental self-efficacy. Fifteen studies were identified. Although changes in parental self-efficacy following a group-based intervention were noted in the majority of studies reviewed, the methodological quality of the studies included in the review means these findings have to be interpreted with caution; only seven studies were rated to be methodologically adequate. Further research is needed to understand the mechanisms by which these interventions may improve parental self-efficacy. Studies specifically examining the impact of such interventions on paternal self-efficacy are also warranted.

Client Self-Management: Promoting Self-Help for Parents of Children in Foster-Care

Drawing upon Foucault's concepts of power, this article shows how a course given to parents whose children are in foster-care encourages a particular form of self-management-most notably, that their internal dialogues must be altered so that the parents can view themselves as people in control of their behaviour who are in a position to choose new behaviour. The article is based on a qualitative study conducted in Norway and centres on the support and development of participants in the course. Study results show increased self-confidence and self-respect in the participants, both as individuals and as parents. In addition, significant benefits were stated as finding that they could verbalise and describe difficult events and emotions, experiencing being 'normal' within a group and receiving feedback. From the perspective of child protective services, dialogue with parents is central, as it not only commits clients to specific behaviours, but-more importantly-commits them to a particular inner dialogue about parenthood. The course can be seen as a management tool in which the parent's 'self' becomes the central object, seeking to contradict the conventional conception of parents with children in foster-care as having nothing to contribute to their children's upbringing.

Promotion, prevention and protection: interventions at the population- and community-levels for mental, neurological and substance use disorders in low- and middle-income countries

BACKGROUND

In addition to services within the health system, interventions at the population and community levels are also important for the promotion of mental health, primary prevention of mental, neurological and substance use (MNS) disorders, identification and case detection of MNS disorders; and to a lesser degree treatment, care and rehabilitation. This study aims to identify "best practice" and "good practice" interventions that can feasibly be delivered at these population- and community-levels in low- and middle-income countries (LMICs), to aid the identification of resource efficiencies and allocation in LMICs.

METHODS

A narrative review was conducted given the wide range of relevant interventions. Expert consensus was used to identify "best practice" at the population-level on the basis of existing quasi-experimental natural experiments and cost effectiveness, with small scale emerging and promising evidence comprising "good practice". At the community-level, using expert consensus, the ACE (Assessing Cost-Effectiveness in Prevention Project) grading system was used to differentiate "best practice" interventions with sufficient evidence from "good practice" interventions with limited but promising evidence.

RESULTS

At the population-level, laws and regulations to control alcohol demand and restrict access to lethal means of suicide were considered "best practice". Child protection laws, improved control of neurocysticercosis and mass awareness campaigns were identified as "good practice". At the community level, socio-emotional learning programmes in schools and parenting programmes during infancy were identified as "best practice". The following were all identified as "good practice": Integrating mental health promotion strategies into workplace occupational health and safety policies; mental health information and awareness programmes as well as detection of MNS disorders in schools; early child enrichment/preschool educational programs and parenting programs for children aged 2-14 years; gender equity and/or economic empowerment programs for vulnerable groups; training of gatekeepers to identify people with MNS disorders in the community; and training non-specialist community members at a neighbourhood level to assist with community-based support and rehabilitation of people with mental disorders.

CONCLUSION

Interventions provided at the population- and community-levels have an important role to play in promoting mental health, preventing the onset, and protecting those with MNS disorders. The importance of inter-sectoral engagement and the need for further research on interventions at these levels in LMICs is highlighted.

Mental Disorders in Early Childhood

BACKGROUND

About 17% of all children suffer from a mental disorder in early childhood, defined as the period up to the age of 6 years.

METHODS

This review is based on publications retrieved by a selective search in PubMed and the Web of Science, as well as on the authors' clinical and scientific experience.

RESULTS

In children up to age 2, disorders of emotional and motor regulation are common (ca. 7%), as are feeding problems (25%), which persist in 2% of children to meet the diagnostic criteria for a feeding disorder. Reactive attachment disorder, a serious mental illness, has a prevalence of about 1%: it is more common among children in situations of increased risk, e.g., orphanages and foster homes. Preschool children can develop anxiety disorder and depressive disorder, as well as hyperactivity and behavioral disorders (the latter two mainly in boys). Parent training and parent-child psychotherapy have been found to be effective treatments. There is no evidence that psychotropic drugs are effective in early childhood.

CONCLUSION

The diagnostician should act cautiously when assigning psychopathological significance to symptoms arising in early childhood but should still be able to recognize mental disorders early from the way they are embedded in the child's interactive relationships with parents or significant others, and then to initiate the appropriate treatment. Psychotherapy in this age group is still in need of validation by efficacy studies and longitudinal studies of adequate quality.

Meta-Analyse zur Wirkung familienbezogener Präventionsmaßnahmen in Deutschland

Theoretischer Hintergrund. In Deutschland wird eine Vielzahl von Programmen angeboten, die Eltern bei der Wahrnehmung ihrer Erziehungsaufgaben unterstützen und kindlichen Erlebens- und Verhaltensproblemen vorbeugen sollen. Internationale Befunde bescheinigen derartigen Maßnahmen positive Effekte, insbesondere bei kurzem Follow-up. Inwieweit die primär anglo-amerikanischen Ergebnisse auf andere Länder übertragen werden können, ist aber weitgehend unklar. Fragestellung. Der Beitrag berichtet über eine Meta-Analyse, die ausschließlich in Deutschland durchgeführte Kontrollgruppenstudien zu familienbezogenen Präventionsmaßnahmen integriert. Methode. Aus zirka 4.000 gefundenen Publikationen erfüllten 45 kontrollierte Evaluationen die Einschlusskriterien. Diese betrafen insgesamt 4.213 Personen. Meistens wurden Elternkurse evaluiert; zu anderen Maßnahmen wie Eltern-Kind-Gruppen oder Geburtsvorbereitungskursen fanden wir kaum kontrollierte Studien. Ergebnisse. Es ergab sich ein signifikant positiver mittlerer Effekt (d = .35), der auch in den Follow up-Analysen weitgehend bestehen blieb. Die Effekte auf das elterliche Erziehungsverhalten waren größer als die Veränderungen beim Kind. Außerdem zeigten sich größere Effekte bei gezielter vs. universeller Prävention, kleineren vs. größeren Stichproben und methodisch schwächer vs. stärker kontrollierten Studien. Schlussfolgerungen. Insgesamt ähneln die Ergebnisse jenen internationaler Meta-Analysen, doch sind in Deutschland noch mehr gut kontrollierte und langfristige Evaluationen erforderlich.

Efficacy of preventative parenting interventions for parents of preterm infants on later child behavior: a systematic review and meta-analysis

The aim of this systematic review was to determine the efficacy of parenting interventions for parents of preterm infants to improve child behavior. Randomized controlled trials (RCTs) of parenting interventions for parents of preterm infants were included. Searchers were conducted of PubMed from 1951 to April 2013, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1982 to April 2013, Scopus from 1966 to April 2013, PsycINFO from 1840 to April 2013, the Web of Science, and the Cochrane Library. Twelve RCTs were identified that assessed child behavior. Of these studies, only data from three were able to be pooled for meta-analysis: the Infant Health and Development Program (IHDP) at 3 years, the Mother-Infant Transaction Program (modified; MITP-M) at 5 years, and the Victorian Infant Brain Studies (VIBeS Plus) at 4 years. Outcome from this analysis revealed a small, but significant, effect on child behavior favoring the intervention (95% CI: 0.08-0.32; p = .001). There is evidence that preterm parenting interventions can improve child behavior. Streamlined interventions such as MITP-M and VIBeS Plus that have a strong focus on the mother-infant relationship may have greatest potential.

Facilitators and barriers to engagement in parenting programs: a qualitative systematic review

Parenting programs have the potential to improve the health and well-being of parents and children. A challenge for providers is to recruit and retain parents in programs. Studies researching engagement with programs have largely focused on providers', policy makers', or researchers' reflections of their experience of parents' participation. We conducted a systematic review of qualitative studies where parents had been asked why they did or did not choose to commence, or complete programs, and compared these perceptions with those of researchers and those delivering programs. We used data-mining techniques to identify relevant studies and summarized findings using framework synthesis methods. Six facilitator and five barrier themes were identified as important influences on participation, with a total of 33 subthemes. Participants focused on the opportunity to learn new skills, working with trusted people, in a setting that was convenient in time and place. Researchers and deliverers focused on tailoring the program to individuals and on the training of staff. Participants and researchers/deliverers therefore differ in their opinions of the most important features of programs that act as facilitators and barriers to engagement and retention. Program developers need to seek the views of both participants and deliverers when evaluating programs.

A survey of parental self-efficacy experiences: maximising potential through health visiting and universal parenting support

AIMS AND OBJECTIVES

To examine parental self-efficacy experiences for users of a parenting support programme and consider the pertinence of self-efficacy theory to health visiting (public health nursing) practice.

BACKGROUND

Commonly, successful parenting training programmes are underpinned by social learning principles and aim to strengthen parental self-efficacy. However, research examining programme effectiveness rarely discusses how self-efficacy outcomes are achieved.

DESIGN

A descriptive survey was completed as the first part of a realistic evaluation study examining how a UK parenting support programme worked.

METHODS

The first part of the realistic evaluation involved validating outcome measures (the Parenting Self-Agency Measure and Self-Efficacy for Parenting Tasks Index subscales) and administering a questionnaire survey. The questionnaire was completed by adults accessing a parenting support programme during a 10-month period (n = 168). Data were analysed using descriptive and inferential statistics.

RESULTS

  Women were the main users of the programme, which included informal drop-in groups as well as more formalised health visiting services and parenting training courses. The Parenting Self-Agency Measure results indicated good general parental self-efficacy; however, the task-specific Self-Efficacy for Parenting Tasks Indexes scales suggested that parents were less self-efficacious in disciplining children. Lower self-efficacy scores correlated with high ratings for 'feeling tired', 'receiving negative comments' and 'giving-in to a child's demands'.

CONCLUSIONS

Study results indicate that the domain general and task-specific measures provide different, but helpful, insights into parental self-efficacy experiences. By identifying factors associated with the levels of general and task-specific parental self-efficacy, health visitors can gain a fuller appreciation of support needs.

RELEVANCE TO PRACTICE

To maximise potential through parenting support, attention should be given to addressing factors associated with poorer self-efficacy experiences, including parental tiredness. Equally, practice should be directed at developing community environments that offer exposure to positive praise and the opportunity to practice new skills without facing criticism.

The First-aid Advice and Safety Training (FAST) parents programme for the prevention of unintentional injuries in preschool children: a protocol

BACKGROUND

Unintentional injury is the leading cause of preventable death in children in the UK, and 0-4-year-olds frequently attend emergency departments following injuries in the home. Parenting programmes designed to support parents, promote behaviour change and enhance parent-child relationships have been shown to improve health outcomes in children. It is not known whether group-based parenting programmes have the potential to prevent unintentional injuries in preschool children.

METHODS

A study to develop a group-based parenting programme to prevent unintentional home injuries in preschool children, and assess the feasibility of evaluation through a cluster-randomised controlled trial. The intervention, designed for parents of children who have sustained a medically attended injury, will be developed with two voluntary sector organisations. The feasibility study will assess ability to recruit parents, deliver the programme and follow-up participants. Participants will complete questionnaires at baseline, 3 months and 6 months, and report injuries in their preschool children using a tool designed and validated for this study. Qualitative methods will assess user and deliverer perceptions of the programme.

DISCUSSION

This study will develop the first group-based parenting programme to prevent injuries in preschool children, and design tools for parent-reported injury outcomes. A key challenge will be to recruit parents to participate in a manner that is non-stigmatising, and does not result in feelings of guilt or belief that they are perceived to be a bad parent. The findings will be used to prepare a trial to assess the effectiveness and cost-effectiveness of the intervention.

Engaging fathers in behavioral parent training: listening to fathers' voices

This is a qualitative study documenting the experiences of fathers who participated in the Helping Our Toddlers, Developing Our Children's Skills (HOT DOCS) behavioral parent training (BPT) series and later agreed to participate in a focus group. Focus groups methodology was used to capture the voices and perspectives of fathers regarding the benefits and barriers to their participation in BPT. The focus group interviews were conducted in both English and in Spanish, with three cohorts of male caregivers who were participants in HOT DOCS from 2006 to 2008. An analysis of their responses coded from transcripts of the focus groups identified five major themes, which are discussed as (a) motivational factors for joining BPT, (b) fathers' experiences with BPT, (c) barriers regarding fathers' participation, (d) changes in parenting as a result of BPT, and (e) perceived changes in children's behavior as a result of BPT. In addition, recommendations for improvement of BPT are presented. This research may be helpful in improving efforts to engage male caregivers in BPT and thereby reduce children's challenging behavior problems and improve program outcomes.

Early childhood health promotion and its life course health consequences

OBJECTIVE

To explore whether health promotion efforts targeted at preschool-age children can improve health across the life span and improve future economic returns to society.

METHODS

We selected 4 health topics to review-tobacco exposure, unintentional injury, obesity, and mental health-because they are clinically and epidemiologically significant, and represent the complex nature of health problems in this early period of life. The peer-reviewed literature was searched to assess the level of evidence for short- and long-term health impacts of health promotion and disease prevention interventions for children from before birth to age 5. This review sought to document the monetary burden of poor child health, the cost implications of preventing and treating child health problems, and the net benefit of the interventions.

RESULTS

The evidence is compelling that these 4 topics-tobacco exposure, unintentional injury, obesity, and mental health-constitute a significant burden on the health of children and are the early antecedents of significant health problems across the life span. The evidence for the cost consequences of these problems is strong, although more uneven than the epidemiological data. The available evidence for the effectiveness of interventions in this age group was strongest in the case of preventing tobacco exposure and injuries, was limited to smaller-scale clinical interventions in the case of mental health, and was least available for efforts to prevent obesity among preschoolers.

CONCLUSIONS

Currently available research justifies the implementation of health interventions in the prenatal to preschool period-especially to reduce tobacco exposure and prevent injuries. There is an urgent need for carefully targeted, rigorous research to examine the longitudinal causal relationships and provide stronger economic data to help policy makers make the case that the entire society will benefit from wise investment in improving the health of preschool-age children and their families.

Immediate and short-term outcomes of the 'COPEing with Toddler Behaviour' parent group

BACKGROUND

Controlling, uninvolved, and rejecting parenting in early childhood are strong predictors of later disruptive behavior disorders. However, there have been no evaluations of non-targeted groups for parents of very young children, despite their potential advantages.

METHODS

We randomly assigned 79 mothers of 12- to 36-month-olds to an 8-session parent training program (called 'COPEing with Toddler Behaviour') or to a waiting list control condition. We investigated the immediate and short-term impact on parent-reported child behavior problems, observed parent-child interaction, and self-reported parenting behavior and parent functioning.

RESULTS

In an intent-to-treat design, the program yielded significant effects on child behavior problems, positive parent-child interaction, and parental overreactivity and depression but not observed negative child behavior or parental laxness. Most effects were significant at both post-test and 1-month follow-up and effects sizes were small to medium for the intervention group and inverse to small for the control group.

CONCLUSIONS

The potential of the program to prevent later behavior problems is supported by improvements in six of the eight outcomes. As part of a community strategy, groups such as COPEing with Toddler Behaviour may promote positive parent-child interaction and children's mental health.

Universal parenting programme to prevent early childhood behavioural problems: cluster randomised trial

OBJECTIVE

To determine whether a parenting programme, offered universally in primary care, can prevent behavioural problems in children and improve parenting and maternal mental health.

DESIGN

Cluster randomised trial.

SETTING

40 primary care nursing centres (clusters) in Victoria, Australia.

PARTICIPANTS

733 English speaking mothers of 8 month old children sequentially recruited from well child appointments; 656 retained at 24 months.

INTERVENTION

Structured three session programme at age 8-15 months, co-led by well child providers and a parenting expert. The programme covered normal development and behaviour, strategies to increase desired behaviour, and strategies to reduce unwanted behaviour.

MAIN OUTCOME MEASURES

Maternal report of child externalising behaviour (child behavior checklist 1(1/2)-5 year old), parenting (parent behavior checklist), and maternal mental health (depression anxiety stress scales) at 18 and 24 months.

RESULTS

At 18 months, child behaviour and parenting scores were similar in the two groups. At 24 months, externalising scores in the intervention and control groups were similar (mean 11.9 (SD 7.2) v 12.9 (7.4)); however, on the parent behavior checklist subscale scores, intervention group parents were less likely to report harsh/abusive parenting (mean 38.9 (SD 7.7) v 40.5 (8.8); adjusted mean difference -1.83, 95% confidence interval -3.12 to -0.55) and unreasonable expectations of child development (40.9 (9.9) v 42.7 (9.6); -2.18, -3.74 to -0.62). Mean scores for nurturing parenting and maternal mental health were similar in the two groups at both times.

CONCLUSIONS

A universal parenting programme resulted in modest improvement in parenting factors that predict behavioural problems in children but did not reduce externalising behavioural problems or affect maternal mental health at 2 years. Trial registration ISRCTN 77531789.

Prevention of behavioral disorders in primary care

PURPOSE OF REVIEW

This article reviews selected parenting programs for children aged 2-8 years old to inform primary-care pediatricians about options for families of children with behavior problems.

RECENT FINDINGS

Young children with aggressive and oppositional behavior are at risk for serious antisocial behavior that may persist into adolescence and adulthood. Most parents wish to discuss parenting difficulties and their child's social and emotional development during well-child visits. Parent training programs are an effective option to promote positive parenting and discipline strategies and enhance a child's social skills, emotional self-regulatory skills, and problem-solving ability. Key parenting principles can be incorporated into developmental surveillance and anticipatory guidance during periodic well-child visits to prevent disruptive behavior problems, address parenting concerns, and nurture the optimal development of children's social-emotional competency.

SUMMARY

The literature on the effectiveness of evidence-based parenting programs is growing. This information can enhance practicing pediatricians' understanding of available community resources and parenting support. These programs are feasible with families of various cultures and those at risk for parenting difficulties. Pediatricians can easily incorporate positive parenting principles into primary-care visits and developmental surveillance.

Parenting styles and overweight status in first grade

OBJECTIVE

The goal was to determine the relationship between the 4 parenting styles (authoritative, authoritarian, permissive, and neglectful) and overweight status in first grade.

METHODS

Data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development were analyzed. Children with complete data for parenting parameters at 54 months and measured weight and height in first grade were included in the analysis. Overweight was defined as BMI of > or =95th percentile. The 4 parenting styles were constructed with 2 scales, namely, maternal sensitivity and maternal expectations for child self-control. Multivariate logistic regression analysis was used to evaluate the relationship between parenting style and overweight in first grade, controlling for gender, race, maternal education, income/needs ratio, marital status, and child behavior problems.

RESULTS

A total of 872 children, 11.1% overweight and 82.8% white, were included in the analysis. Children of authoritarian mothers (n = 298) had an increased risk of being overweight, compared with children of authoritative mothers (n = 179). Children of permissive (n = 132) and neglectful (n = 263) mothers were twice as likely to be overweight, compared with children of authoritative mothers. Of the covariates, only income/needs ratio was significant and did not alter the relationship between parenting style and overweight risk.

CONCLUSIONS

Among the 4 parenting styles, authoritarian parenting was associated with the highest risk of overweight among young children. Understanding the mechanisms through which parenting styles are associated with overweight risk may lead to the development of more-comprehensive and better-targeted interventions.

Wirksamkeit von Präventionsmaßnahmen bei Kindern und Jugendlichen:

Zusammenfassung. Theoretischer Hintergrund: In den letzten Jahren finden wir international eine sehr umfangreiche Präventionsforschung. Fragestellung und Methode: Die vorliegende Arbeit fasst die Ergebnisse von 23 quantitativen Überblicksarbeiten und Meta-Analysen zu dieser Thematik zusammen. Ergebnisse: Die meisten Arbeiten lagen zur Prävention externalisierender Störungen, zur Suchtprävention und zur Wirksamkeit von Programmen zur allgemeinen Entwicklungsförderung vor. Als generelle Wirksamkeitsschätzung kann von durchschnittlichen Effekten von einer drittel bis einer halben Standardabweichung ausgegangen werden. Gezielte Präventionsmaßnahmen wiesen in der Regel höhere Effektstärken auf als universelle Strategien. Ebenso ergaben Pilotprojekte und Eigen-Evaluationen eine höhere Wirksamkeit der Programme. Schlussfolgerungen: Präventive Maßnahmen haben signifikante und zum Teil beträchtliche Wirkungen auf die Entwicklung von Kindern und Jugendlichen. Weitere Untersuchungen zu den längerfristigen Effekten, zu Fragen der Programm-Implementation, zu Kosten-Nutzen-Aspekten und vergleichenden Analysen von Präventionsalternativen sowie zur Integration erfolgreicher Präventionsprogramme in die Versorgungspraxis sind jedoch dringend erforderlich.