Informing the personalisation of interventions for parents of children with conduct problems: a qualitative study

Rapid white matter changes in children with conduct problems during a parenting intervention

Studies report that the microstructural integrity of the uncinate fasciculus (UF; connecting the anterior temporal lobe to the orbitofrontal cortex) is abnormal in adults with psychopathy and children with conduct problems (CP), especially those with high callous-unemotional (CU) traits. However, it is unknown if these abnormalities are 'fixed' or 'reversible'. Therefore, we tested the hypothesis that a reduction in CP symptoms, following a parenting intervention, would be associated with altered microstructural integrity in the UF. Using diffusion tensor imaging tractography we studied microstructural differences (mean diffusivity (MD) and radial diffusivity (RD)) in the UF of 43 typically developing (TD) and 67 boys with CP before and after a 14-week parenting intervention. We also assessed whether clinical response in CP symptoms or CU traits explained changes in microstructure following the intervention. Prior to intervention, measures of MD and RD in the UF were increased in CP compared to TD boys. Following intervention, we found that the CP group had a significant reduction in RD and MD. Further, these microstructural changes were driven by the group of children whose CU traits improved (but not CP symptoms as hypothesized). No significant microstructural changes were observed in the TD group. Our findings suggest, for the first time, that microstructural abnormalities in the brains of children with CP may be reversible following parenting intervention.

Personalised interventions for subgroups of children with conduct problems

BACKGROUND

Conduct problems are a range of disruptive behaviours in childhood that are associated with long-term adverse outcomes in adolescence and adulthood, including antisocial behaviour, substance misuse, and poor academic achievement. Children with conduct problems can vary according to age of onset, comorbidities, and environmental factors, and it has been suggested that certain groups of children may have different treatment outcomes. Therefore, it is important to assess the extent to which personalised interventions for different groups of children with conduct problems may affect outcomes. To our knowledge, this is the first review to systematically identify and appraise the effectiveness of personalised interventions, adapted, or developed, for prespecified subgroups of children with conduct problems.

OBJECTIVES

To assess whether personalised interventions, adapted or developed for subgroups of children with conduct problems are effective in improving outcomes.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was 1 February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), in any setting, in children (aged two to 12 years) with conduct problems and within a prespecified subgroup, comparing a personalised intervention with a non-personalised intervention, waitlist control, or treatment as usual. Personalised interventions included adaptations to standard practice, such as parent-training programmes; other recommended interventions for children with conduct problems; or interventions developed specifically to target subgroups of children with conduct problems. We excluded non-personalised and non-psychological interventions (e.g. pharmacological or dietary intervention). Prespecified subgroups of children with conduct problems, however defined, were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. child conduct problems or disruptive behaviour and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. personalised treatment outcomes relevant to each subgroup, 4. parenting skills and knowledge, 5. family functioning, engagement and decreased dropout, and 6. educational outcomes. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We identified 13 RCTs (858 participants). Seven studies were conducted in the USA, five in Australia, and one in Germany. Eleven studies reported their source of funding, with five studies receiving grants from the National Institute of Mental Health. In total, 15 different funders supported the studies included in the review. We separated subgroups of children with conduct problems into three broad categories: children with co-occurring conditions (e.g. emotional difficulties), parent characteristics (e.g. conflict between parents), or familial/environmental circumstances (e.g. rural families). All studies delivered a personalised intervention that was adapted or developed for a prespecified subgroup of children with conduct problems. We rated all trials at unclear or high risk of bias in most domains. Below, we report the results of improvement in child conduct problems and disruptive behaviour, personalised treatment outcomes, and parenting skills and knowledge for our main comparison: personalised versus non-personalised interventions. Improvement in child conduct problems and disruptive behaviour Compared with a non-personalised intervention, a personalised intervention may result in a slight improvement in child conduct problems or disruptive behaviour measured using the Eyberg Child Behavior Inventory (ECBI) Problem subscale in the short term (mean difference (MD) -3.04, 95% confidence interval (CI) -6.06 to -0.02; 6 studies, 278 participants; P = 0.05), but may have little to no effect on improving child conduct problems or disruptive behaviour measured by the ECBI Intensity subscale (MD -6.25, 95% CI -16.66 to 4.15; 6 studies, 278 participants; P = 0.24), or the Externalising subscale of the Child Behaviour Checklist (CBCL) (MD -2.19, 95% CI -6.97 to 2.59; 3 studies, 189 participants, P = 0.37) in the short term. We graded the certainty of evidence as very low for all three outcomes, meaning any estimate of effect is very uncertain.  Personalised treatment outcomes, relevant to each subgroup Although six studies reported personalised treatment outcomes, relevant to each subgroup, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive. Parenting skills and knowledge Although seven studies reported parenting skills and knowledge, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive.  Adverse events None of the trials reported monitoring adverse events. Summary of results In summary, there is limited evidence that personalised intervention improves child conduct problems, personalised treatment outcomes, relevant to each subgroup, or parenting skills and knowledge compared with a non-personalised intervention.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of personalised interventions for subgroups of children with conduct problems. The certainty of evidence for all outcomes was very low, meaning that we have very little confidence in the estimated effects and the true effects may be different to our findings, which will limit the relevance of our findings to clinical decisions. To overcome the limitations of the evidence, large-scale RCTs are needed to determine whether personalised interventions, adapted or developed, for subgroups of children with conduct problems are effective in improving outcomes. Consensus on the most appropriate measures to use in these studies is needed in order to facilitate cross-study comparisons. Persistent conduct problems predict a range of adverse long-term outcomes, so future research should investigate the medium- and long-term effects of personalised treatments. Studies are needed in low- and middle-income countries as well as studies recruiting children aged between nine and 12 years, as they were under-represented in the studies.

Do Parents Perceive Practitioners to Have a Specific Role in Change? A Longitudinal Study Following Participation in an Evidence-Based Program

Little attention has been given to the role of practitioners in evidence-based parenting programs and to the evaluation that parents make of their importance in the process of change. This study aims to explore the role that parents assign to the facilitators of the Incredible Years (IY) program in enabling long-term life changes, as well as the association between parents’ evaluation of the practitioners’ skills and specific changes perceived after the intervention. In this longitudinal study, we applied 1 survey to 80 community parents who had participated in an IY group 2 years before, and we retrieved archival data to assess changes in parents’ ratings of sense of competence and in children’s behaviors immediately after the end of the intervention. Two years after the intervention, parents perceived significant improvements, especially in their parenting and their children’s behaviors, and they recognized that their IY practitioners had played a significant role in these life changes. Parents who attributed a greater role to the practitioners’ skills reported a greater number of improvements in parental sense of competence and in children’s behaviors. The practitioners’ skills relating more broadly to these specific changes are the practitioners’ sensitivity and flexibility towards parents’ needs and the practitioners’ ability to clearly share knowledge with parents. The practitioner’s assigned role when implementing an evidence-based parenting program seems to go far beyond the mere conveyance of the program’s specific contents and methods and deserves to be researched further.

"Sometimes I think my frustration is the real issue": A qualitative study of parents' experiences of transformation after a parenting programme

Introduction

Parenting programmes help to alleviate conduct problems in children, but ensuring that all parents feel supported to attend, complete and learn from these programmes has proven difficult. Parents can feel overwhelmed and struggle to change their parenting. This article aims to inform the future refinement of parenting programmes by examining parents’ narratives of how programmes motivated them to change and enabled them to put changes into practice.

Method and results

Forty-two parents, most of whom had attended Incredible Years group sessions, were interviewed about their views and experiences of parenting programmes that focused on positive parenting practices. Analysis of interview transcripts drew on thematic approaches. Parents perceived that parenting programmes helped them to better understand their child and themselves and to let go of anxieties surrounding their child’s behaviour. Better understanding included greater awareness of emotions and of behaviours their child could and could not control. Parents believed this awareness helped them to change the ways that they interacted with their child, which, in turn, helped them and their child to feel calmer. With greater understanding and calmness parents believed they became more able to see for themselves the changes that they could make in their parenting and everyday lives, and to feel more confident in putting these into practice.

Discussion

By supporting parents to reflect on their own and their child’s situation, parents perceived that programmes enabled them to improve interactions with their children without getting stuck in self-blame or feeling overwhelmed. Parents of children whose behaviour remained challenging believed that programmes led to beneficial changes in the way they felt about their child’s behaviours. Enhanced support for reflection by parents could potentially help more families to benefit from parenting programmes.