Impact of a general practice based group parenting programme: quantitative and qualitative results from a controlled trial at 12 months

Impact on Maternal Postpartum Depressive Symptoms of a Primary Care Intervention Promoting Early Language: A Pilot Study

OBJECTIVES

Maternal depressive symptoms are an important risk factor for adverse child outcomes, especially in the perinatal period. We studied whether introducing finger puppets in the primary care setting to promote infant language improves maternal postpartum depressive symptoms.

METHODS

An intervention cohort was enrolled and given a finger puppet at the 2-month infant well visit. Two usual care cohorts were enrolled at either the 6- or 12-month well visit as part of a larger study. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), which was administered by clinic providers as part of routine screening done at both the 2- and 4-month well visits. EPDS scores were obtained retrospectively through the electronic medical record.

RESULTS

Included mothers (n = 127) completed the EPDS at 2 and 4 months postpartum. Most children (83%) were on government-sponsored insurance. Mean EPDS scores and scores classified as possible depression (≥ 10) did not differ between cohorts. However, the change in scores between visits was significantly different for intervention (n = 46) compared to usual care (n = 81) participants (-1.1 vs. +0.4, p = 0.001). More intervention scores improved (n = 17, 37%) compared to usual care (n = 14, 17%), while more usual care scores worsened (n = 28, 35%) compared to intervention (n = 6, 13%) (p = 0.008).

CONCLUSION

Finger puppets introduced during infant primary care visits to support language-rich maternal-infant interactions may provide a simple, low-cost way to improve maternal postpartum depressive symptoms. Larger studies with more diverse populations are needed to determine if effects are replicable, generalizable, and translate into better clinical outcomes.

Impact of a culturally tailored parenting programme on the mental health of Somali parents and children living in Sweden: a longitudinal cohort study

OBJECTIVES

This study aimed to evaluate the long-term impact (3-year follow-up) of a culturally tailored parenting support programme (Ladnaan) on the mental health of Somali-born parents and their children living in Sweden.

METHODS

In this longitudinal cohort study, Somali-born parents with children aged 11-16 were followed up 3 years after they had participated in the Ladnaan intervention. The Ladnaan intervention comprises two main components: societal information and the Connect parenting programme delivered using a culturally sensitive approach. It consists of 12 weekly group-based sessions each lasting 1-2 hours. The primary outcome was improved mental health in children, as measured by the Child Behaviour Checklist (CBCL). The secondary outcome was improved mental health in parents, as measured by the General Health Questionnaire-12. Data were collected from the parent's perspective.

RESULTS

Of the 60 parents who were originally offered the intervention, 51 were included in this long-term follow-up. The one-way repeated measures (baseline to the 3-year follow-up) analysis of variance for the CBCL confirmed maintenance of all the treatment gains for children: total problem scores (95% CI 11.49 to 18.00, d=1.57), and externalising problems (95% CI 2.48 to 5.83, d=0.86). Similar results were observed for the parents' mental health (95% CI 0.40 to 3.11, d=0.46).

CONCLUSION

Positive changes in the mental health of Somali-born parents and their children were maintained 3 years after they had participated in a parenting support programme that was culturally tailored and specifically designed to address their needs. Our findings highlight the long-term potential benefits of these programmes in tackling mental health issues in immigrant families.

TRIAL REGISTRATION NUMBER

NCT02114593.

Longer-Term Outcomes of the Incredible Years Parenting Intervention

Conduct problems can develop into behavior disorders and put children at risk for other mental health problems. Parenting interventions have been shown to successfully reduce conduct problems and are often expected to prevent the development of broader mental health problems. Few studies have evaluated the longer-term and broader effects of these interventions. To what extent are parenting intervention effects sustained in the years after the intervention? And do effects pertain to conduct problems specifically, or do they also affect broader aspects of children's mental health? We used a randomized controlled trial to assess the longer-term (2.5 years) effects of the Incredible Years parenting intervention on children's conduct problems in an indicated prevention setting (N = 387; 79% retention rate). Using a multi-method (survey and computerized tasks) and multi-informant (parents, teachers, and children) approach, we tested whether initial effects on conduct problems were sustained, and whether Incredible Years had broader effects on children's peer problems, emotional problems, attention-deficit/hyperactivity disorder (ADHD) symptoms, attention and inhibition deficits, and service use. Incredible Years, relative to control (no intervention), led to sustained reductions in parent-reported conduct problems (Cohen's d = 0.31), but not teacher- and child-reported conduct problems. There were no broader benefits: Incredible Years did not reduce children's peer problems, emotional problems, ADHD-symptoms, attention and inhibition deficits, or their service use. Improvements in parents' perceptions of child conduct problems sustained until 2.5 years later. Our findings do not show benefits of Incredible Years as a preventive intervention for children's broader mental health.

Parent- and teacher-reported long-term effects of parent training on child conduct problems in families with child protection and other support services: a randomized controlled trial

BACKGROUND

This randomized controlled trial (RCT) evaluated the long-term effectiveness of the Incredible Years^® (IY) Parenting Program in modifying children's externalizing problems among families in Child Protection Services (CPS) and using other special support services. We also examined whether parent-reported effects of the IY^® generalize to the daycare/school setting as reported by teachers.

METHODS

Participants in the study were 3-7-year-old children with behavioural problems (N = 102 at baseline, N = 89 at one-year follow-up). Participants were randomized to intervention (N = 50) and control groups (N = 52) after the baseline assessment. The intervention group received 19-week IY^® Parenting Program. The effectiveness of the intervention was analyzed using linear mixed model.

RESULTS

Our previously reported pre-post intervention effects on CBCL (Child Behavior Checklist) and ECBI (Eyberg Child Behavior Inventory) were not sustained to the one-year follow-up. Child conduct problems decreased from baseline to follow-up in both intervention and control groups. The positive changes were not observed at daycare/school from baseline to post-intervention or to the one-year follow-up, and there were no significant differences in changes between the groups.

CONCLUSIONS

Evidence-based parenting program IY^® seems to be an effective intervention for child conduct problems in the short term in families in the CPS context, but sustaining the positive effects and generalizing them to the daycare/school context are challenging.

TRIAL REGISTRATION

The trial is registered in the ClinicalTrials.gov registry (NCT03239990), Registered August 4th, 2017; https://clinicaltrials.gov/ct2/results?cond=&term=NCT03239990&cntry=&state=&city=&dist=.

A Systematic Review of External Validity in Pediatric Integrated Primary Care Trials

OBJECTIVE

We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to conduct a systematic review of external validity reporting in integrated primary care (IPC) interventions for mental health concerns.

METHODS

We searched Medline, CINAHL, PsycINFO, the Cochrane Center Register of Controlled Trials, and relevant literature to identify publications from 1998 to 2018 reporting on open, randomized, or quasi-randomized trials of IPC interventions that targeted child (ages 0-18 years) psychological symptoms. For each publication, we extracted the information reported in each RE-AIM domain and calculated the proportion of the total studies reviewed.

RESULTS

Thirty-nine publications describing 25 studies were included in the review. Publications rarely reported some indicators of external validity, including the representativeness of participants (12%), rate of adoption clinics or providers (16%), cost of implementation (8%), or evidence of maintenance (16%). Few studies reported on key pragmatic factors such as cost or organizational change processes related to implementation and maintenance. Strengths of some studies included comparisons of multiple active treatments, use of tailorable interventions, and implementation in "real world" settings.

CONCLUSIONS

Although IPC interventions appear efficacious under research conditions, there are significant knowledge gaps regarding the degree to which they reach and engage target recipients, what factors impact adoption and implementation of IPC interventions by clinicians, how fidelity can be maintained over time, and cost-effectiveness. Pediatric IPC researchers should embrace dissemination and implementation science methods to balance internal and external validity concerns moving forward.

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.

Adapting and pre-testing the World Health Organization's Caregiver Skills Training programme for autism and other developmental disorders in a very low-resource setting: Findings from Ethiopia

The World Health Organization’s Caregiver Skills Training programme for children with developmental disorders or delays teaches caregivers strategies to help them support their child’s development. Ethiopia has a severe lack of services for children with developmental disorders or delays. This study explored the perspectives of Ethiopian caregivers, professionals and other stakeholders to inform adaptation and implementation of the World Health Organization’s Caregiver Skills Training in Ethiopia. Data collection included (1) a consultation and review, comprising stakeholder meetings, review of draft Caregiver Skills Training materials and feedback from Ethiopian Master Trainees and (2) a pre-pilot including quantitative feasibility and acceptability measures and qualitative interviews with caregivers (n = 9) and programme facilitators/observers (n = 5). The consultation participants indicated that the Caregiver Skills Training addresses an urgent need and is relevant to the Ethiopian context. Several adaptations were proposed, including more emphasis on psycho-education, stigma, parental feelings of guilt and expectations of a cure. The adapted Caregiver Skills Training was pre-piloted with excellent participation (100%) and retention (90%) rates. Four themes were developed from the qualitative data: (1) Programme acceptability and relevance, (2) Perceived programme benefits, (3) Challenges and barriers and (4) Suggestions for improvement. The World Health Organization’s Caregiver Skills Training addresses a local need and, with careful adaptations, is feasible and acceptable to be implemented in Ethiopia. These findings may have relevance to low-resource settings worldwide.

A scoping review of the problems and solutions associated with contamination in trials of complex interventions in mental health

Background

In a randomised controlled trial, contamination is defined as the receipt of active intervention amongst participants in the control arm. This review assessed the processes leading to contamination, its typical quantity, methods used to mitigate it, and impact of use of cluster randomisation to prevent it on study findings in trials of complex interventions in mental health.

Methods

This is a scoping review of trial design approaches and methods of study conduct to address contamination. Studies included were randomised controlled trials of complex interventions in mental health that described the process leading to, amount of, or solution used to counter contamination. The Medline, Embase, and PsycInfo databases were searched for trials published between 2000 and 2015. Risk of bias was assessed using the Jadad score and domains recommended by Cochrane plus some relevant to cluster randomised trials.

Results

Two hundred and thirty-four articles were included in the review. The main processes that led to contamination were health professionals delivering both active and comparator treatments and communication among clinicians and participants from the different trial arms. Twenty-three trials (10%) measured binary treatment receipt in the control arm with median 13% of participants found to be contaminated (IQR 5–33%). The most common design approach for dealing with contamination was the use of cluster randomisation (n = 93). In addition, many researchers used simple trial conduct methods to minimise contamination due to suspected contamination processes, such as organising for each clinician to provide only one treatment and separating trial arms spatially or temporally. There was little evidence for a relationship between cluster randomisation to avoid contamination and size of treatment effect estimate.

Conclusion

There was some evidence of modest levels of treatment contamination with a large range, although a minority of studies reported the amount of contamination. A limitation was that many trials described the problem in little detail. Overall there is a need for greater measurement and reporting of treatment receipt in the control arm of trials. Researchers should be aware of trial conduct methods that can be used to minimise contamination without resorting to cluster randomisation.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0646-z) contains supplementary material, which is available to authorized users.

Preventive Behavioral Health Programs in Primary Care: A Systematic Review

CONTEXT

Early childhood is a critical period for socioemotional development. Primary care is a promising setting for behavioral health programs.

OBJECTIVES

To identify gaps in the literature on effectiveness and readiness for scale-up of behavioral health programs in primary care.

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Evidence-Based Medicine Reviews, and Scopus databases were searched for articles published in English in the past 15 years. Search terms included terms to describe intervention content, setting, target population, and names of specific programs known to fit inclusion criteria.

STUDY SELECTION

Inclusion criteria were: (1) enrolled children 0 to 5 years old, (2) primary care setting, (3) measured parenting or child behavior outcomes, and (4) clinical trial, quasi-experimental trial, pilot study, or pre-post design.

DATA EXTRACTION

Data were abstracted from 44 studies. The rigor of individual studies and evidence base as a whole were compared with the Society of Prevention Research's standards for efficacy, effectiveness, and scale-up research.

RESULTS

Gaps in the literature include: study findings do not always support hypotheses about interventions' mechanisms, trust in primary care as a mediator has not been sufficiently studied, it is unclear to which target populations study findings can be applied, parent participation remains an important challenge, and the long-term impact requires further evaluation.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and an incomplete search.

CONCLUSIONS

Targeting gaps in the literature could enhance understanding of the efficacy, effectiveness, and readiness for scale-up of these programs.

Effects of a culturally tailored parenting support programme in Somali-born parents' mental health and sense of competence in parenting: a randomised controlled trial

OBJECTIVES

To evaluate the effectiveness of a culturally tailored parenting support programme on Somali-born parents' mental health and sense of competence in parenting.

DESIGN

Randomised controlled trial.

SETTING

A city in the middle of Sweden.

PARTICIPANTS

Somali-born parents (n=120) with children aged 11-16 years and self-perceived stress in their parenting were randomised to an intervention group (n=60) or a waiting-list control group (n=60).

INTERVENTION

Parents in the intervention group received culturally tailored societal information combined with the Connect parenting programme during 12 weeks for 1-2 hours per week. The intervention consisted of a standardised training programme delivered by nine group leaders of Somali background.

OUTCOME

The General Health Questionnaire 12 was used to measure parents' mental health and the Parenting Sense of Competence scale to measure parent satisfaction and efficacy in the parent role. Analysis was conducted using intention-to-treat principles.

RESULTS

The results indicated that parents in the intervention group showed significant improvement in mental health compared with the parents in the control group at a 2-month follow-up: B=3.62, 95% CI 2.01 to 5.18, p<0.001. Further, significant improvement was found for efficacy (B=-6.72, 95% CI -8.15 to -5.28, p<0.001) and satisfaction (B=-4.48, 95% CI -6.27 to -2.69, p<0.001) for parents in the intervention group. Parents' satisfaction mediated the intervention effect on parental mental health (β=-0.88, 95% CI -1.84 to -0.16, p=0.047).

CONCLUSION

The culturally tailored parenting support programme led to improved mental health of Somali-born parents and their sense of competence in parenting 2 months after the intervention. The study underlines the importance of acknowledging immigrant parents' need for societal information in parent support programmes and the importance of delivering these programmes in a culturally sensitive manner.

CLINICAL TRIAL REGISTRATION

NCT02114593.

A Support Program for Somali-born Parents on Children's Behavioral Problems

OBJECTIVES

The objectives of this study were to evaluate a culturally tailored parenting support program (Ladnaan) for Somali-born parents and to determine its effectiveness on children's emotional and behavioral problems.

METHODS

This randomized controlled trial included 120 Somali-born parents with children aged 11 to 16 years. The parents reported self-perceived stress in relation to parenting practices. The intervention consisted of culturally tailored societal information combined with the parenting program Connect. Parents received 12 weeks of intervention, 1 to 2 hours each week, in groups of 12 to 17 parents. Nine group leaders with a Somali background who received a standardized training program delivered the intervention. The primary outcome was a decrease in emotional and behavioral problems based on a Child Behavior Checklist. Parents were randomly allocated either to an intervention group or a wait-list control group. Covariance analyses were conducted according to intention-to-treat principles.

RESULTS

The results showed significant improvement in the children in the intervention group for behavioral problems after a 2-month follow-up. The largest effect sizes according to Cohen's d were in aggressive behavior (95% confidence interval [CI], 1.06 to 3.07), social problems (95% CI, 0.64 to 1.70), and externalizing problems (95% CI, 0.96 to 3.53).

CONCLUSIONS

The large effect sizes in this study show that this 12-week culturally tailored parenting support program was associated with short-term improvements in children's behavior. The study adds to the field of parenting interventions by demonstrating how to culturally tailor, engage, and retain parenting programs for immigrant parents.

Assessment of contamination and misclassification biases in a randomized controlled trial of a social network peer education intervention to reduce HIV risk behaviors among drug users and risk partners in Philadelphia, PA and Chiang Mai, Thailand

Controlled trials of HIV prevention and care interventions are susceptible to contamination. In a randomized controlled trial of a social network peer education intervention among people who inject drugs and their risk partners in Philadelphia, PA and Chiang Mai, Thailand, we tested a contamination measure based on recall of intervention terms. We assessed the recall of test, negative and positive control terms among intervention and control arm participants and compared the relative odds of recall of test versus negative control terms between study arms. The contamination measures showed good discriminant ability among participants in Chiang Mai. In Philadelphia there was no evidence of contamination and little evidence of diffusion. In Chiang Mai there was strong evidence of diffusion and contamination. Network structure and peer education in Chiang Mai likely led to contamination. Recall of intervention materials can be a useful method to detect contamination in experimental interventions.

The longer term experiences of parent training: a qualitative analysis

BACKGROUND

Child conduct problems are a major public health priority. Group-based parenting programmes are popular in addressing such problems, but evidence for their longer-term effectiveness is limited. Moreover, process evaluations are rare and little is understood about the key facilitative and inhibitive factors associated with maintaining outcomes in the longer term.

METHOD

This study involved the use of qualitative methods as part of a larger process evaluation to explore the longer-term experiences of parents who participated in a randomized controlled trial (RCT) of the Incredible Years Parenting Programme (IYPP) in disadvantaged settings in Ireland. A series of one-to-one in-depth interviews was conducted with parents at 12- (n = 20) and 18-month follow-up (n = 8) and analysed using constructivist grounded theory.

RESULTS

Most parents reported positive child behaviour despite several challenges, but a substantial subset reported periods of relapse in positive outcomes. A relapse in child behaviour was linked to relinquishing skills in stressful times, the negative influence of an unsupportive environment, and the perceived ineffectiveness of parenting skills. Resilience in implementing skills despite adversity, and the utilization of available social supports, were associated with the maintenance of positive outcomes.

CONCLUSIONS

Strengthening resilience and social support capacities may be important factors in maintaining positive longer-term outcomes. Those who design, research and deliver parenting programmes might consider the possibility of including a relapse-prevention module and/or the provision of post-intervention supports for more vulnerable families.

A pilot effectiveness study of the Enhancing Parenting Skills (EPaS) 2014 programme for parents of children with behaviour problems: study protocol for a randomised controlled trial

Background

The Enhancing Parenting Skills (EPaS) 2014 programme is a home-based, health visitor-delivered parenting support programme for parents of children with identified behaviour problems. This trial aims to evaluate the effectiveness of the EPaS 2014 programme compared to a waiting-list treatment as usual control group.

Methods/Design

This is a pragmatic, multicentre randomised controlled trial. Sixty health visitors will each be asked to identify two families that have a child scoring above the clinical cut-off for behaviour problems using the Eyberg Child Behaviour Inventory (ECBI). Families recruited to the trial will be randomised in a 1:1 ratio into an intervention or waiting-list control group. Randomisation will occur within health visitor to ensure that each health visitor has one intervention family and one control family. The primary outcome is change in child behaviour problems as measured by the parent-reported ECBI. Secondary outcomes include other measures of child behaviour, parent behaviour, and parental depression as measured by parent-reports and an independent observation of parent and child behaviour. Follow-up measures will be collected 6-months after the collection of baseline measures.

Discussion

This is the first rigorous evaluation of the EPaS 2014 programme. The trial will provide important information on the effectiveness of a one-to-one home-based intervention, delivered by health visitors, for pre-school children with behaviour problems. It will also examine potential mediating (improved parent behaviour and/or improved parental depression) and moderating (single parent, teenage parent, poverty, low education level) factors.

Trial registration

Current Controlled Trials ISRCTN06867279 (18 June 2014)

Programs for Prevention of Externalizing Problems in Children: Limited Evidence for Effect Beyond 6 Months Post Intervention

Background

Preventing externalizing problems in children is a major societal concern, and a great number of intervention programs have been developed to this aim. To evaluate their preventive effects, well-controlled trials including follow-up assessments are necessary.

Methods

This is a systematic review of the effect of prevention programs targeting externalizing problems in children. The review covered peer reviewed publications in English, German, French, Spanish and Scandinavian languages. Experimental studies of standardized programs explicitly aiming at preventing externalizing mental ill-health in children (2–19 years), with outcome assessments at ≥6 months post intervention for both intervention and control groups, were included. We also included long-term trials with consecutive observations over several years, even in the absence of follow-up ≥6 months post intervention. Studies of clinical populations or children with impairments, which substantially increase the risk for mental disorders, were excluded.

Results

Thirty-eight controlled trials assessing 25 different programs met inclusion criteria. Only five programs were supported by scientific evidence, representing selective parent training (Incredible Years and Triple-P), indicated family support (Family Check-Up), and school-based programs (Good Behavior Game, universally delivered, and Coping Power, as an indicated intervention). With few exceptions, effects after 6–12 months were small. Long-term trials showed small and inconsistent effects.

Conclusions

Despite a vast literature, the evidence for preventive effects is meager, largely due to insufficient follow-up post intervention. Long-term follow up assessment and effectiveness studies should be given priority in future evaluations of interventions to prevent externalizing problems in children.

Bringing life course home: a pilot to reduce pregnancy risk through housing access and family support

Proponents of life course comment that while the theory is persuasive, translating theory to practice is daunting. This paper speaks to the challenges and possibilities of intervention based on life course theory. It describes Healthy Start in Housing (HSiH), a partnership between the Boston Public Health Commission (BPHC) and the Boston Housing Authority (BHA) to reduce stress due to housing insecurity among low-income, pregnant women. HSiH seeks improved birth outcomes and long term health of mothers and infants. BHA goals are improved quality of life for participants, greater public housing stability and enhanced impact of housing on community well-being. HSiH is a 1 year pilot offering 75 housing units to pregnant women at risk of adverse birth outcomes and homelessness. BHA provides housing and expedites processing of HSiH applications; BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Of 130 women referred to HSiH to date, 53 were ineligible, 59 have submitted applications, 13 are preparing applications and 5 dropped out. Nineteen women have been housed. Among eligible women, 58 % had medical conditions, 56 % mental health conditions, and 14 % prior adverse outcomes; 30 % had multiple risks. Standardized assessments reflected high levels of depressive symptoms; 41 % had symptoms consistent with post-traumatic stress disorder. Life course theory provides both the framework and the rationale for HSiH. HSiH experience confirms the salience of daily social experience to women's health and the importance of addressing stressors and stress in women's lives.

Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature

INTRODUCTION

There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities.

OBJECTIVES

Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)?

DESIGN

The paper draws upon a scoping study and narrative review.

REVIEW METHODS

We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards).

RESULTS

The analysis revealed health visiting practice as potentially characterized by a particular 'orientation to practice.' This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent-health visitor relationships. The detailed description of health visitors' skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities.

CONCLUSIONS

Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Background

The mental health of children and young people (CYP) is a major UK public health concern. Recent policy reviews have identified that service provision for CYP with mental health needs is not as effective, responsive, accessible or child-centred as it could be. Following on from a previous National Institute for Health Research (NIHR) study into self-care support for CYP with long-term physical health needs, this study explored self-care support’s potential in CYP’s mental health.

Objectives

To identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision.

Design

Two inter-related systematic literature reviews (an effectiveness review with meta-analysis and a perceptions review), together with a service mapping exercise and case study.

Setting

Global (systematic reviews); England and Wales (mapping exercise and case study).

Participants (case study)

Fifty-two individuals (17 CYP, 16 family members and 19 staff) were interviewed across six sites.

Main outcome measures (meta-analysis)

A measure of CYP’s mental health symptomatology.

Data sources (literature reviews)

MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, All Evidence-Based Medicine (EBM) Reviews, Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC).

Review methods

Titles and abstracts of papers were screened for relevance then grouped into studies. Two independent reviewers extracted data from studies meeting the inclusion criteria. A descriptive analysis and meta-analysis were conducted for the effectiveness review; descriptive analyses were conducted for the perceptions review. These analyses were integrated to elicit a mixed-methods review.

Results

Sixty-five of 71 included studies were meta-analysable. These 65 studies elicited 71 comparisons which, when meta-analysed, suggested that self-care support interventions were effective at 6-month [standardised mean difference (SMD) = −0.20; 95% confidence interval (CI) −0.28 to −0.11] and 12-month (SMD = −0.12; 95% CI −0.17 to −0.06) follow-ups. However, judged against Cochrane criteria, the studies were mostly low quality. Key elements of self-care support identified in the perceptions review were the acquisition of knowledge and skills, peer support and the relationship with the self-care support agent; CYP also had different perceptions from adults about what is important in self-care support. The mapping exercise identified 27 providers of 33 self-care support services. According to the case study data, effective self-care support services are predicated on flexibility; straightforward access; non-judgemental, welcoming organisations and staff; the provision of time and attention; opportunities to learn and practise skills relevant to self-care; and systems of peer support.

Conclusions

Mental health self-care support interventions for CYP are modestly effective in the short to medium term. Self-care support can be conceptualised as a process which has overlap with ‘recovery’. CYP and their families want choice and flexibility in the provision of such interventions and a continued relationship with services after the nominal therapy period. Those delivering self-care support need to have specific child-centred attributes.

Future work

Future work should focus on under-represented conditions (e.g. psychosis, eating disorders, self-harm); the role of technology, leadership and readiness in self-care support; satisfaction in self-care support; the conceptualisation of self-care support in CYP’s mental health; and efficacy and cost-effectiveness.

Study registration

PROSPERO number (for the effectiveness review) CRD42012001981.

Funding

The NIHR Health Services and Delivery Research programme.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2011: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Review)

BACKGROUND

Early-onset child conduct problems are common and costly. A large number of studies and some previous reviews have focused on behavioural and cognitive-behavioural group-based parenting interventions, but methodological limitations are commonplace and evidence for the effectiveness and cost-effectiveness of these programmes has been unclear.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of behavioural and cognitive-behavioural group-based parenting programmes for improving child conduct problems, parental mental health and parenting skills.

SEARCH METHODS

We searched the following databases between 23 and 31 January 2011: CENTRAL (2011, Issue 1), MEDLINE (1950 to current), EMBASE (1980 to current), CINAHL (1982 to current), PsycINFO (1872 to current), Social Science Citation Index (1956 to current), ASSIA (1987 to current), ERIC (1966 to current), Sociological Abstracts (1963 to current), Academic Search Premier (1970 to current), Econlit (1969 to current), PEDE (1980 to current), Dissertations and Theses Abstracts (1980 to present), NHS EED (searched 31 January 2011), HEED (searched 31 January 2011), DARE (searched 31 January 2011), HTA (searched 31 January 2011), mRCT (searched 29 January 2011). We searched the following parent training websites on 31 January 2011: Triple P Library, Incredible Years Library and Parent Management Training. We also searched the reference lists of studies and reviews.

SELECTION CRITERIA

We included studies if: (1) they involved randomised controlled trials (RCTs) or quasi-randomised controlled trials of behavioural and cognitive-behavioural group-based parenting interventions for parents of children aged 3 to 12 years with conduct problems, and (2) incorporated an intervention group versus a waiting list, no treatment or standard treatment control group. We only included studies that used at least one standardised instrument to measure child conduct problems.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and the methodological quality of health economic studies. Two authors also independently extracted data. We contacted study authors for additional information.

MAIN RESULTS

This review includes 13 trials (10 RCTs and three quasi-randomised trials), as well as two economic evaluations based on two of the trials. Overall, there were 1078 participants (646 in the intervention group; 432 in the control group). The results indicate that parent training produced a statistically significant reduction in child conduct problems, whether assessed by parents (standardised mean difference (SMD) -0.53; 95% confidence interval (CI) -0.72 to -0.34) or independently assessed (SMD -0.44; 95% CI -0.77 to -0.11). The intervention led to statistically significant improvements in parental mental health (SMD -0.36; 95% CI -0.52 to -0.20) and positive parenting skills, based on both parent reports (SMD -0.53; 95% CI -0.90 to -0.16) and independent reports (SMD -0.47; 95% CI -0.65 to -0.29). Parent training also produced a statistically significant reduction in negative or harsh parenting practices according to both parent reports (SMD -0.77; 95% CI -0.96 to -0.59) and independent assessments (SMD -0.42; 95% CI -0.67 to -0.16). Moreover, the intervention demonstrated evidence of cost-effectiveness. When compared to a waiting list control group, there was a cost of approximately $2500 (GBP 1712; EUR 2217) per family to bring the average child with clinical levels of conduct problems into the non-clinical range. These costs of programme delivery are modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems.

AUTHORS' CONCLUSIONS

Behavioural and cognitive-behavioural group-based parenting interventions are effective and cost-effective for improving child conduct problems, parental mental health and parenting skills in the short term. The cost of programme delivery was modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems. Further research is needed on the long-term assessment of outcomes.

The effects and costs of the universal parent group program - all children in focus: a study protocol for a randomized wait-list controlled trial

Background

In recent decades, parents have been involved in programs that aim to improve parenting style and reduce child behavior problems. Research of preventive parenting programs has shown that these interventions generally have a positive influence on both parents and children. However, to our knowledge there is a gap in the scientific literature when it comes to randomized controlled trials of brief, manual-based structured programs which address general parenting among the population, and focus on promoting health. A four-session universal health promotion parent group program named All Children in Focus was developed. It aims at promoting parental competence and children’s positive development with the parent–child relationship as the target. There is currently no randomized controlled trial existing of the program.

Methods/Design

A prospective multicenter randomized wait-list controlled trial is being conducted. Approximately 600 parents with children ranging in age from 3–12 years have been recruited in eleven municipalities and city districts in the County of Stockholm, Sweden. Parents are randomized at baseline to an intervention group, which receives the program directly, or to a waiting-list control group, which participates in the program six months later. Changes in parenting and child health and development are assessed with measures immediately post-intervention and six months after the baseline. Observations of a minor group of parents and children are conducted to explore possible relations between parental reports and observed behaviors, as well as changes in the interaction between parent and child. Further, data collected within the evaluation will also be applied to evaluate the possible cost-effectiveness of the program.

Discussion

This paper describes a study protocol of a randomized controlled trial. Except for the quantitative outcome measures to evaluate the effectiveness of All Children in Focus, this protocol also describes health economic and qualitative analyses to deepen the knowledge of the program. We further discuss some issues regarding the implementation of the program in municipalities and city districts.

Trial registration

Current Controlled Trials ISRCTN70202532

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 Pilot Web Based Positive Parenting Intervention to Help Bipolar Parents to Improve Perceived Parenting Skills and Child Outcomes

Background: Children of bipolar parents are at elevated risk for psychiatric disorders including bipolar disorder. Helping bipolar parents to optimize parenting skills may improve their children's mental health outcomes. Clear evidence exists for benefits of behavioural parenting programmes, including those for depressed mothers. However, no studies have explored web-based self-directed parenting interventions for bipolar parents. Aims: The aim of this research was to conduct a pilot study of a web-based parenting intervention based on the Triple P-Positive Parenting Programme. Method: Thirty-nine self-diagnosed bipolar parents were randomly allocated to the web-based intervention or a waiting list control condition. Parents reported on their index child (entry criterion age 4–10 years old). Perceived parenting behaviour and child behaviour problems (internalizing and externalizing) were assessed at inception and 10 weeks later (at course completion). Fifteen participants (4 control group and 11 intervention group) did not provide follow-up data. Results: Levels of child behaviour problems (parent rated; Strengths and Difficulties Questionnaire) were above clinical thresholds at baseline, and problematic perceived parenting (self-rated; Parenting Scale) was at similar levels to those in previous studies of children with clinically significant emotional and behavioural problems. Parents in the intervention group reported improvements in child behaviour problems and problematic perceived parenting compared to controls. Conclusions: A web-based positive parenting intervention may have benefits for bipolar parents and their children. Initial results support improvement in child behaviour and perceived parenting. A more definitive study addressing the limitations of the current work is now called for.

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.

Approaches used in investigating family support in transition to parenthood

Early support has been acknowledged to be needed in the phase of transition to parenthood, and increasing knowledge is available on the factors enhancing this transition. The issue is to translate the knowledge into practices of preventive care. In this article, our aim is to map out recent research on supporting parents in maternity and child health care and to analyse how the subject of family support has been studied. The data consist of 98 scientific articles published in peer-reviewed journals during 2000-09. Most of the reported research was Anglo-American, and fell within the academic fields of nursing studies, medicine and public health. The studies were categorized into three groups according to the epistemic perspective that was taken on the subject of family support, the studies focusing on (i) views and perceptions on family support of both clients and professionals (63 studies), (ii) the effectiveness of interventions (27 studies) and (iii) activities in the practices and processes of MCH (8 studies). First, the groups were described with regard to the study participants and the data and methods used. A bias towards the perspectives of risk groups and mothers was detected. Second, we examined the potential of different epistemic perspectives to describe care practices. The article contributes to the discussion about how to examine the practices and processes of health promotion and preventive care in such a way that the 'good practices' identified could be implemented in other contexts than the one studied.

Parents as agents of change (PAC) in pediatric weight management: the protocol for the PAC randomized clinical trial

BACKGROUND

There is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP).

METHODS/DESIGN

This study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children's BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8-12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up.

DISCUSSION

This study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01267097.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2012: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years

BACKGROUND

Early-onset child conduct problems are common and costly. A large number of studies and some previous reviews have focused on behavioural and cognitive-behavioural group-based parenting interventions, but methodological limitations are commonplace and evidence for the effectiveness and cost-effectiveness of these programmes has been unclear.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of behavioural and cognitive-behavioural group-based parenting programmes for improving child conduct problems, parental mental health and parenting skills.

SEARCH METHODS

We searched the following databases between 23 and 31 January 2011: CENTRAL (2011, Issue 1), MEDLINE (1950 to current), EMBASE (1980 to current), CINAHL (1982 to current), PsycINFO (1872 to current), Social Science Citation Index (1956 to current), ASSIA (1987 to current), ERIC (1966 to current), Sociological Abstracts (1963 to current), Academic Search Premier (1970 to current), Econlit (1969 to current), PEDE (1980 to current), Dissertations and Theses Abstracts (1980 to present), NHS EED (searched 31 January 2011), HEED (searched 31 January 2011), DARE (searched 31 January 2011), HTA (searched 31 January 2011), mRCT (searched 29 January 2011). We searched the following parent training websites on 31 January 2011: Triple P Library, Incredible Years Library and Parent Management Training. We also searched the reference lists of studies and reviews.

SELECTION CRITERIA

We included studies if: (1) they involved randomised controlled trials (RCTs) or quasi-randomised controlled trials of behavioural and cognitive-behavioural group-based parenting interventions for parents of children aged 3 to 12 years with conduct problems, and (2) incorporated an intervention group versus a waiting list, no treatment or standard treatment control group. We only included studies that used at least one standardised instrument to measure child conduct problems.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and the methodological quality of health economic studies. Two authors also independently extracted data. We contacted study authors for additional information.

MAIN RESULTS

This review includes 13 trials (10 RCTs and three quasi-randomised trials), as well as two economic evaluations based on two of the trials. Overall, there were 1078 participants (646 in the intervention group; 432 in the control group). The results indicate that parent training produced a statistically significant reduction in child conduct problems, whether assessed by parents (standardised mean difference (SMD) -0.53; 95% confidence interval (CI) -0.72 to -0.34) or independently assessed (SMD -0.44; 95% CI -0.77 to -0.11). The intervention led to statistically significant improvements in parental mental health (SMD -0.36; 95% CI -0.52 to -0.20) and positive parenting skills, based on both parent reports (SMD -0.53; 95% CI -0.90 to -0.16) and independent reports (SMD -0.47; 95% CI -0.65 to -0.29). Parent training also produced a statistically significant reduction in negative or harsh parenting practices according to both parent reports (SMD -0.77; 95% CI -0.96 to -0.59) and independent assessments (SMD -0.42; 95% CI -0.67 to -0.16). Moreover, the intervention demonstrated evidence of cost-effectiveness. When compared to a waiting list control group, there was a cost of approximately $2500 (GBP 1712; EUR 2217) per family to bring the average child with clinical levels of conduct problems into the non-clinical range. These costs of programme delivery are modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems.

AUTHORS' CONCLUSIONS

Behavioural and cognitive-behavioural group-based parenting interventions are effective and cost-effective for improving child conduct problems, parental mental health and parenting skills in the short term. The cost of programme delivery was modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems. Further research is needed on the long-term assessment of outcomes.

Measuring the impact and costs of a universal group based parenting programme: protocol and implementation of a trial

Background

Sub-optimal parenting is a common risk factor for a wide range of negative health, social and educational outcomes. Most parenting programmes have been developed in the USA in the context of delinquency prevention for targeted or indicated groups and the main theoretical underpinning for these programmes is behaviour management. The Family Links Nurturing Programme (FLNP) focuses on family relationships as well as behaviour management and is offered on a universal basis. As a result it may be better placed to improve health and educational outcomes. Developed in the UK voluntary sector, FLNP is popular with practitioners, has impressed policy makers throughout the UK, has been found to be effective in before/after and qualitative studies, but lacks a randomised controlled trial (RCT) evidence base.

Methods/Design

A multi-centre, investigator blind, randomised controlled trial of the FLNP with a target sample of 288 south Wales families who have a child aged 2-4 yrs living in or near to Flying Start/Sure Start areas. Changes in parenting, parent child relations and parent and child wellbeing are assessed with validated measures immediately and at 6 months post intervention. Economic components include cost consequences and cost utility analyses based on parental ranking of states of quality of life. Attendance and completion rates and fidelity to the FLNP course delivery are assessed. A nested qualitative study will assess reasons for participation and non-participation and the perceived value of the programme to families. By the end of May 2010, 287 families have been recruited into the trial across four areas of south Wales. Recruitment has not met the planned timescales with barriers including professional anxiety about families entering the control arm of the trial, family concern about video and audio recording, programme facilitator concern about the recording of FLNP sessions for fidelity purposes and delays due to the new UK research governance procedures.

Discussion

Whilst there are strong theoretical arguments to support universal provision of parenting programmes, few universal programmes have been subjected to randomised controlled trials. In this paper we describe a RCT protocol with quantitative and qualitative outcome measures and an economic evaluation designed to provide clear evidence with regard to effectiveness and costs. We describe challenges implementing the protocol and how we are addressing these.

Trial Registration

Current Controlled Trials ISRCTN13919732

Recruitment in an indicated prevention program for externalizing behavior - parental participation decisions

BACKGROUND

Parents are the ones who decide whether or not to participate in parent focused prevention trials. Their decisions may be affected by internal factors (e.g., personality, attitudes, sociodemographic characteristics) or external barriers. Some of these barriers are study-related and others are intervention-related. Internal as well as external barriers are especially important at the screening stage, which aims to identify children and families at risk and for whom the indicated prevention programs are designed. Few studies have reported their screening procedure in detail or analyzed differences between participants and dropouts or predictors of dropout. Rates of participation in prevention programs are also of interest and are an important contributor to the efficacy of a prevention procedure.

METHODS

In this study, we analyzed the process of parent recruitment within an efficacy study of the indicated Prevention Program for Externalizing Problem behavior (PEP). We determined the retention rate at each step of the study, and examined differences between participants and dropouts/decliners. Predictors of dropout at each step were identified using logistic regression.

RESULTS

Retention rates at the different steps during the course of the trial from screening to participation in the training ranged from 63.8% (pre-test) to 81.1% (participation in more than 50% of the training sessions). Parents who dropped out of the study were characterized by having a child with lower symptom intensity by parent rating but higher ratings by teachers in most cases. Low socioeconomic status and related variables were also identified as predictors of dropout in the screening (first step) and for training intensity (last step).

CONCLUSIONS

Special attention should be paid to families at increased risk for non-participation when implementing the prevention program in routine care settings.

TRIAL REGISTRATION

ISRCTN12686222.

Systematic review of preventive interventions for children's mental health: what would work in Australian contexts?

In childhood, mental health problems primarily consist of behaviour and emotional problems. These affect one in every seven children (i.e. 200 000 in Australia). Left untreated, up to 50% of preschool problems continue through the childhood years. Because of their high prevalence, population-based approaches will be needed to reduce their associated burden. The aim of the present study was therefore to identify evidence-based preventive interventions for behavioural and emotional problems of children aged 0-8 years. Randomized controlled trials of preventive interventions for behavioural and emotional problems were located by searching standard clinical databases and systematic reviews. The authors determined which programmes were effective and ineffective, dividing the effective programmes into those with high or low risk of trial bias. Among effective programmes, the most promising for delivery in Australian contexts were identified, selected for their strength of evidence, sample comparability to Australia's population, and programme compatibility with Australia's service system. Around 50 preventive interventions have been evaluated in randomized controlled trials. Most targeted children's behavioural problems, and a few targeted emotional problems. Three US programmes have the best balance of evidence: in infancy, the individual Nurse Home Visitation Programme; at preschool age, the individual Family Check Up; at school age, the Good Behaviour Game class programme. Three parenting programmes in England and Australia are also worthy of highlight: the Incredible Years group format, Triple P individual format, and Parent Education Programme group format. Effective preventive interventions exist primarily for behaviour and, to a lesser extent, emotional problems, and could be disseminated from research to mainstream in Australia, ensuring fidelity to original programmes. Future research should develop programmes targeting emotional problems, and replicate effective programmes for behaviour problems in quality population translation trials. Randomized trial methods in staged roll-outs can determine population cost-benefits for children's mental health without delaying dissemination.

Parenting programmes: a systematic review and synthesis of qualitative research

BACKGROUND

Parenting programmes are at the heart of intervention strategies for parents of children with emotional and behaviour problems. Systematic reviews and meta-analyses of randomized controlled trials have indicated that such programmes can improve many aspects of family life. However, there is currently a dearth of information concerning what it is that makes parenting programmes meaningful and helpful to parents. The aim of this paper was to examine parents' experience and perceptions of parenting programmes using the meta-ethnographic method, in order to sensitize policymakers and practitioners to the key factors that parents perceive to be of value.

METHODS

Systematic searches of a number of electronic databases were undertaken using key search terms. Critical appraisal of included studies was conducted using standardized criteria, and the reports were synthesized using meta-ethnographic methods.

RESULTS

Six reports were purposefully selected and critically appraised independently by two reviewers. Two were excluded. Based on the remaining four papers, five key concepts were identified as important when planning and delivering parenting programmes. A lines-of-argument synthesis was developed which suggests that the acquisition of knowledge, skills and understanding, together with feelings of acceptance and support from other parents in the parenting group, enabled parents to regain control and feel more able to cope. This led to a reduction in feelings of guilt and social isolation, increased empathy with their children and confidence in dealing with their behaviour.

CONCLUSION

This evaluation provides an indication of the components that parents perceive to be necessary in the provision of parenting programmes, independent of the particular type of programme being provided. It may therefore aid policymakers in decisions about which programmes to provide.

Perceived Benefits on Family Health of Small Groups for Families With Children

BACKGROUND

Thus far, international research on small groups has focused on health problems. Research on preventive, resource-, and family-oriented small groups and their impact on family health is scant.

OBJECTIVES

To describe the experiences of families with small children concerning resource-enhancing small support groups, and to identify the benefits to family health described by participating parents at the end of the group processes.

SAMPLE

The study population consisted of parents (n=123) attending 13 small groups. Participants included 63 mothers and 14 fathers (63% response rate).

METHODS

Data were collected through group interviews. Qualitative content analysis of latent content was the method of analysis.

RESULTS

Small groups provided the parents with knowledge about family life and encouraged them to seek information, made them feel refreshed, strengthened their social support networks, enhanced their awareness of their own resources and the different developmental needs at times of change in the family, and increased their confidence concerning their ability to cope.

CONCLUSIONS

Concepts from this study can be used in the future to construct instruments to evaluate the effectiveness of small groups from the perspective of families and family health. The findings add to our professional understanding of resource-oriented family work from the perspective of families.

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.

Randomised controlled trial of a parenting intervention in the voluntary sector for reducing child conduct problems: outcomes and mechanisms of change

BACKGROUND

To test effectiveness of a parenting intervention, delivered in a community-based voluntary-sector organisation, for reducing conduct problems in clinically-referred children.

METHODS

Randomised controlled trial, follow-up at 6, 18 months, assessors blind to treatment status. Participants--76 children referred for conduct problems, aged 2-9, primarily low-income families, randomised to treatment vs. 6-month wait-list group. Retention was 93% at 6 months, 90% at 18 months. Interventions--Webster-Stratton Incredible Years video-based 14-week group programme, teaches cognitive-behavioural principles for managing behaviour, using a collaborative, practical, problem-solving approach. Primary outcomes--child problem behaviour by parent-report (Eyberg) and home-based direct observation; secondary outcomes--observed positive and negative parenting; parent-reported parenting skill, confidence and depression.

RESULTS

Post-treatment improvements were found in child problem behaviour, by parent-report (effect size (ES) .48, p = .05) and direct observation (ES .78, p = .02); child independent play (ES .77, p = .003); observed negative (ES .74, p = .003) and positive (ES .38, p = .04) parenting; parent-reported confidence (ES .40, p = .03) and skill (ES .65, p =.01), using ANCOVA to control for baseline scores. Maternal depression did not change. Consumer satisfaction was high. At 18-month follow-up, although no randomised comparison was possible, changes appeared to maintain, with no significant change toward baseline level on any measure. Change in observed positive parenting appeared to mediate change in child problem behaviour (p < .025).

CONCLUSIONS

Findings suggest that a group-based cognitive-behavioural parenting programme, delivered by well-trained and supervised staff, can be effective in a community voluntary-sector setting, for reducing conduct problems and enhancing parenting skills. Change in parenting skill appears to be a key mechanism for change in child behaviour. Findings have implications for feasibility of translating evidence-based programmes, even for clinically-referred conduct problems, into less specialised community settings, likely to have lower costs and be more accessible for families.

Interventions for adolescent depression in primary care

BACKGROUND

Depression in adolescents is underrecognized and undertreated despite its poor long-term outcomes, including risk for suicide. Primary care settings may be critical venues for the identification of depression, but there is little information about the usefulness of primary care interventions.

OBJECTIVE

We sought to examine the evidence for the treatment of depression in primary care settings, focusing on evidence concerning psychosocial, educational, and/or supportive intervention strategies.

METHODS

Available data on brief psychosocial treatments for adolescent depression in primary settings were reviewed. Given the paucity of direct studies, we also drew on related literature to summarize available evidence whether brief, psychosocial support from a member of the primary care team, with or without medication, might improve depression outcomes.

RESULTS

We identified 37 studies relevant to treating adolescent depression in primary care settings. Only 4 studies directly examined the impact of primary care-delivered psychosocial interventions for adolescent depression, but they suggest that such interventions can be effective. Indirect evidence from other psychosocial/behavioral interventions, including anticipatory guidance and efforts to enhance treatment adherence, and adult depression studies also show benefits of primary care-delivered interventions as well as the impact of provider training to enhance psychosocial skills.

CONCLUSIONS

There is potential for successful treatment of adolescent depression in primary care, in view of evidence that brief, psychosocial support, with or without medication, has been shown to improve a range of outcomes, including adolescent depression itself. Given the great public health problem posed by adolescent depression, the likelihood that most depressed adolescents will not receive specialty services, and new guidelines for managing adolescent depression in primary care, clinicians may usefully consider initiation of supportive interventions in their primary care practices.

Strengths and Difficulties Questionnaire: research and clinical applications

PURPOSE OF REVIEW

To critically discuss recent findings from studies using the Strengths and Difficulties Questionnaire, in relation to different research designs and clinical purposes.

RECENT FINDINGS

A substantive body of research exists on the psychometric properties of the Strengths and Difficulties Questionnaire in different cultures. This body supports the validity and reliability of its versions for the parent, teacher and self-reporting purpose, despite some variation in cut-off scores. The Strengths and Difficulties Questionnaire is increasingly being used as a measure of child psychopathology in other types of research, that is, aetiological, longitudinal and service evaluation studies. Future studies need to address in more detail the Strengths and Difficulties Questionnaire diagnostic algorithms, added value score, impact and burden items and a preschool version.

SUMMARY

The Strengths and Difficulties Questionnaire has been established as the most widely used instrument in child mental health research. It is easy to complete, is user friendly because of its positive attributes items, allows comparisons to be made between different populations and is sensitive to change.