Meta-meta-analysis on the effectiveness of parent-based interventions for the treatment of child externalizing behavior problems

Exploring Allied Health Models of Care for Children with Developmental Health Concerns, Delays, and Disabilities in Rural and Remote Areas: A Systematic Scoping Review

BACKGROUND

Access to appropriate healthcare is essential for children's healthy development. This is lacking in rural and remote areas, impacting health outcomes. Despite efforts to improve access for these communities, to date, no review has systematically mapped the literature on allied health models of care for children with developmental needs. This scoping review seeks to address this knowledge gap.

METHODS

Adhering to the PRISMA-ScR and Joanna Briggs Institute guidelines, a systematic search was conducted. A total of 8 databases (from inception to May 2023) and 106 grey literature sources were searched. Two reviewers independently undertook a two-stage screening process. Data were extracted using customised tools and narratively synthesised utilising the Institute of Medicine's quality domains. This review is registered a priori via Open Science Framework.

RESULTS

Twenty-five citations were identified within the literature. Varied models of care were reported from five mostly Western countries. Models of care identified in these areas were classified as screening services, role substitution, consultative services, or online-based services. Positive impacts on quality of healthcare were reported across all quality domains (apart from safety) with the domain of effectiveness being the most commonly reported.

CONCLUSIONS

Multiple models of care are currently in operation for children with developmental needs in rural and remote areas and appear to improve the quality of care. Due to complexities within, and limitations of, the evidence base, it is unclear if one model of care is superior to another. This review provides a basis for further research to explore why some models may be more effective than others.

Irritability in Youths: A Critical Integrative Review

Irritability, defined as proneness to anger that may impair an individual's functioning, is common in youths. There has been a recent upsurge in relevant research. The authors combine systematic and narrative review approaches to integrate the latest clinical and translational findings and provide suggestions for addressing research gaps. Clinicians and researchers should assess irritability routinely, and specific assessment tools are now available. Informant effects are prominent, are stable, and vary by age and gender. The prevalence of irritability is particularly high among individuals with attention deficit hyperactivity disorder, autism spectrum disorder, and mood and anxiety disorders. Irritability is associated with impairment and suicidality risk independent of co-occurring diagnoses. Developmental trajectories of irritability (which may begin early in life) have been identified and are differentially associated with clinical outcomes. Youth irritability is associated with increased risk of anxiety, depression, behavioral problems, and suicidality later in life. Irritability is moderately heritable, and genetic associations differ based on age and comorbid illnesses. Parent management training is effective for treating psychological problems related to irritability, but its efficacy in treating irritability should be tested rigorously, as should novel mechanism-informed interventions (e.g., those targeting exposure to frustration). Associations between irritability and suicidality and the impact of cultural context are important, underresearched topics. Analyses of large, diverse longitudinal samples that extend into adulthood are needed. Data from both animal and human research indicate that aberrant responses to frustration and threat are central to the pathophysiology of irritability, revealing important translational opportunities.

"Daddy comforts me"-Young Swedish children's perspectives on their family relations before and after their parents' participation in a parenting programme

Despite extensive research assessing parenting support, there is a lack of knowledge about the perspectives of the youngest children. In this study, we explored changes in preschool children's emotional and relational experiences at home before and after their parents participated in a parenting intervention, the Triple P parenting programme. Nine children in total were interviewed, aged 3-6 years, whose parents participated in a group parenting intervention. The interviews were conducted during the first and final group sessions attended by the children's parents. Data were analysed qualitatively, using a longitudinal approach, resulting in a deductive mapping of the children's statements onto four themes, based on the parenting intervention's main objectives. Further, changes in content for each of the four themes were assessed. Before the programme, children described conflicts with siblings, parents' negative emotions, and punitive parenting behaviours. After the programme, sibling conflicts remained, but parents' negative emotions decreased and parent threats and violence ceased. Positive family interactions and quality time increased, along with experiences of tenderness and being comforted. Parents also implemented new strategies such as verbal management and more comforting or soothing behaviours. Clinical implications of the results include promoting positive sibling relationships, emphasising parental self-regulation, encouraging empathy and reconciliation, and highlighting the importance of spending quality time with children. These findings contribute to a better understanding of children's perspectives and provide implications for clinical practice and future research.

Universal Digital Programs for Promoting Mental and Relational Health for Parents of Young Children: A Systematic Review and Meta-Analysis

Digital parenting programs aim to increase program access, improve psychosocial outcomes for parents and children, and support triage to targeted interventions where required. This meta-analysis assessed the efficacy of online parenting programs in improving parenting skills and capabilities, and by consequence, the mental health and well-being of parents and children, and the quality of the parent-child relationship. Studies were included if they were: (1) online, (2) self-delivered, (3) designed for universal general population prevention, (4) evaluated experimental or quasi-experimental designs, and (5) assessed parent and child emotional and/or relational health, from pregnancy to 5 years of age. A systematic search of electronic databases and grey literature identified 22 studies that met inclusion criteria, including 24 independent samples, with 5671 unique parents. Meta-analyses were conducted using random effects models and Cohen's d effects. Small-to-moderate improvements in parent depression, anxiety, self-efficacy, and social support were observed. No effects on parent stress, satisfaction, or parent-child relationship quality were observed. Meta-regression and sub-group analysis were conducted to identify sensitivity or moderation effects. Collectively, findings suggest any benefits of online parenting programs mostly occur at the time of the intervention, for parent mental health and well-being outcomes, and that enduring effects are unlikely. However, given the cost effectiveness and accessibility of online programs, further research into ways of sustaining effects on parenting outcomes is warranted. Furthermore, given the centrality of the parent-child bond to child development across the lifecourse, additional investment in new digitally facilitated approaches focusing on this bond are likewise warranted.PROSPERO registration CRD42021275647.

Parent Training Tailored to Parents With ADHD: Development of the Improving Parenting Skills Adult ADHD (IPSA) Program

OBJECTIVE

To describe the development of the Improving Parenting Skills Adult ADHD (IPSA) parent training (PT) program, designed for parents with ADHD.

METHOD

IPSA was developed using an iterative co-creation approach, involving parents with ADHD from the initial knowledge mobilization phase onwards. The program prototype was evaluated by 16 parents with ADHD, in an open trial of program feasibility.

RESULTS

IPSA was deemed feasible in terms of acceptability and levels of active participation, with no evidence of unintended harm. All but one participant completed the program, attending on average 84% of sessions. Pre-to-post within-group comparisons of targeted skills and outcomes revealed changes in the expected direction regarding, for example, use of introduced parenting skills (Cohen's d = 1.3).

CONCLUSION

The program prototype was found acceptable, accessible, and safe. Findings support the potential value of adapting PT protocols for parents with ADHD and warrant further evaluation of IPSA in a randomized controlled trial.

A pilot randomized control trial on the feasibility, acceptability, and initial effects of a digital-assisted parenting intervention for promoting mental health in Malaysian adolescents

Objective

Online parenting interventions for enhancing child development, specifically mental health is relatively new in Malaysia. This pilot study tests the feasibility, acceptability, and initial effects of a universal digital-assisted parenting intervention (DaPI) in promoting mental health in adolescents by improving parental behaviors and self-efficacy.

Methods

A two-arm pilot randomized controlled trial was conducted. Twenty-four mothers of adolescent aged 10 to 14 years from a non-clinical sample were recruited online and randomly allocated into two groups (intervention [DaPI] and waitlist-control [WLC]). Eight weekly sessions were delivered online via technological devices. Feasibility outcomes were based on the participants' engagement in DaPI and study retention. Primary (parental behaviors and self-efficacy) and secondary (adolescent mental health) outcomes were assessed using an online survey at baseline (T0), post-intervention (T1), and 1-month follow-up (T2). Data were analyzed using descriptive and inferential statistics and an intention-to-treat approach.

Results

The DaPI was well received by the mothers. Retention was high (81.8%) in both groups and intervention adherence was excellent (91.6%). Within-group analyses showed a significant decrease in physical control at T2 and an increase in parental self-efficacy at T1 and T2 among the DaPI mothers. No significant differences were observed in adolescents' mental health at any time point. As for the WLC group, there were no significant differences in all the outcome variables across the three assessment moments. Between groups analyses revealed DaPI mothers had significant differences in proactive parenting at T1, and in positive reinforcement and lax control at T2. There were no significant differences in adolescents' mental health between the groups at any time point.

Discussion

The DaPI is feasible and acceptable in the Malaysian context. Findings show promise regarding the initial effects of the DaPI. However, a larger RCT is needed to determine its effectiveness in promoting mental health of adolescents.

Trial registration

https://www.irct.ir/; identifier: IRCT20211129053207N1.

The Father's Part: A Pilot Evaluation of a Father-Centered Family Intervention Group in Child and Adolescent Psychiatry

Changes in parental roles have renewed the focus on a father's involvement in an offspring's psychological development. However, fathers are still under-represented in family research. There are only a few structured father-centered intervention programs in child and adolescent psychiatry. In a German population sample, a pilot father-centered family intervention program with n = 16 participants, conducted in person (n = 8) and online (n = 8), in a child and adolescent psychiatry inpatient/day clinic setting was evaluated by comparing paternal stress, PSE, and child-rated paternal competence in a pre-post design. Participating fathers showed significant decreases in child-related parenting stress (presence: p = 0.042, online: p = 0.047) and significant increases in PSE (p = 0.006/0.012). Parent-related stress and child-rated paternal competence were unaffected (p = 0.108/0.171; p = 0.167/0.101), while small-to-medium effect size measures pointed in the direction of our hypothesis (d = 0.48/0.36; d = 0.37/0.50). Participant satisfaction was higher in person than online (p = 0.008). As social and biological fathers have important influences on child and adolescent well-being and development, they should be included more frequently in prevention and intervention programs. Fathers seem to benefit from gender-specific intervention programs with regard to stress reduction, as well as experiencing competence- and PSE-increasing effects.

Longitudinal relations among perceived parental warmth, self-esteem and social behaviours from middle childhood to early adolescence in China: Disentangling between- and within-person associations

Although several studies have addressed the relations between perceived parental warmth and social behaviours, few have distinguished their between- and within-person effects or explored their within-person mediating mechanisms. This study examined the transactional relations among perceived parental warmth (i.e. maternal warmth and paternal warmth), children's self-esteem and children's positive/negative social behaviours (i.e. prosocial behaviour and delinquent behaviour) along with the mediating role of self-esteem after disentangling between- and within-person effects. A total of 4315 Chinese elementary children (44.9% girls; Mage  = 9.93 years, SD = 0.73) completed relevant measures on four occasions employing 6-month intervals. Results of random-intercept cross-lagged panel models showed that (a) perceived parental warmth reciprocally and positively predicted prosocial behaviour and self-esteem; (b) perceived paternal warmth reciprocally and negatively predicted delinquent behaviour; (c) self-esteem reciprocally predicted prosocial and delinquent behaviour; (d) perceived maternal warmth reciprocally and positively predicted prosocial behaviour through self-esteem; (e) perceived parental warmth reciprocally and negatively predicted delinquent behaviour through self-esteem; and (f) perceived maternal and paternal warmth differed in their relations with prosocial and delinquent behaviours through self-esteem. These findings illuminated the complicated longitudinal within-person interactions among perceived parental warmth, self-esteem, and social behaviours, the specific mediating mechanism of self-esteem, and the differing results associated with perceived maternal and paternal warmth, all of which yield significant implications for assessments and early interventions aimed to promote positive social behaviour.

Does the apple fall far from the tree? Commentary on Hafeman et al., early indicators of bipolar risk in preschool offspring of parents with bipolar disorder

Comorbid externalizing and internalizing disorders are common in offspring of a parent with bipolar I or II disorder. In some cases, the symptoms are harbingers of future bipolar spectrum disorder. Even when they are not, they are likely to be impairing to the child. Clinicians need to be better informed about how the history leading up to mania/hypomania unfolds, and what comorbid disorders are impairing in and of themselves. More information is needed about the parents' psychopathology, course of illness and response to treatment. Until we have data on how to prevent bipolar disorder, the best course of action is to treat the child's current impairing symptoms and render the parent as asymptomatic as possible.

The efficacy of a self-help parenting program for parents of children with externalizing behavior: a randomized controlled trial

Parenting programs are effective for children with externalizing problems, but not always easily accessible for parents. In order to facilitate accessibility, we developed a self-help parenting program, consisting of a manual and online part. The efficacy of the program in reducing children's externalizing problems was compared to waitlist in a randomized controlled trial. In addition, two versions of the program were exploratively compared, one with and one without biweekly telephonic support. Candidate moderators (child and parent factors) and parental satisfaction were also examined. We randomly assigned 110 families to one of the following three conditions: the support condition, the no support condition, or the waitlist condition. Intervention duration was 15 weeks. Outcomes were collected at baseline (T0), 8 weeks (T1), 15 weeks (T2), and 28 weeks (T3) and included daily telephonic measurements of parent-rated externalizing behavior and the Intensity scale of the parent-rated Eyberg Child Behavior Inventory (ECBI). Main analyses compared outcomes at T2, using longitudinal regressions with T0 as fixed factor. Results showed that children improved significantly more on both outcomes in the intervention condition compared to waitlist, with small to medium effect sizes. Parental satisfaction was high. Neither differences in efficacy nor in parental satisfaction were found between the support and no support condition. No moderators were detected. The newly developed self-help parenting program is effective in reducing children's externalizing behavior problems and may help improve access to evidence-based care.

Virtual Delivery of Parent Coaching Interventions in Early Childhood Mental Health: A Scoping Review

Parent-coaching interventions positively impact child development. Virtual delivery of such interventions is supported by literature reviews and a practice guideline, however, none of these focused on children under age six. A scoping review of virtually-delivered parent-coaching interventions for disruptive behaviour, anxiety, and parent-child relationship concerns in children under age six was conducted between Dec. 15, 2020 and April 22, 2021. Iterative searches of the databases PubMed, CINAHL, and PsycINFO were complemented by reference list searches and clinician expert review (N = 1146). After relevance screening and duplicate removal, collaboratively-developed inclusion criteria were applied to records, followed by data extraction from eligible articles (n = 30). Most literature documented behavioural-based interventions targeting disruptive behaviour which were delivered individually, by therapists, to White, non-Hispanic parents. Evidence supports feasibility and efficacy of virtually-delivered parent-coaching interventions to improve child disruptive behaviour (strong), anxiety (moderate), and parent-child relationship (weak). There is a significant gap in the literature regarding the virtual delivery of attachment-based parent-coaching interventions. In sum, virtual parent coaching can be an efficacious approach for children under age six, particularly for behavioural challenges.

Relative Age Within School Grade, Including Delayed and Accelerated School Start: Associations With Midlife Psychiatric Disorders, Suicide, and Alcohol- and Drug-Related Mortality

Within a school grade, children who are young for grade are at increased risk of psychiatric diagnoses, but the long-term implications remain understudied, and associations with students who delay or accelerate entry underexplored. We used Norwegian birth cohort records (birth years: 1967-1976, n = 626,928) linked to records in midlife. On-time school entry was socially patterned; among those born in December, 23.0% of children in the lowest socioeconomic position (SEP) delayed school entry, compared with 12.2% among the highest SEP. Among those who started school on time, there was no evidence for long-term associations between birth month and psychiatric/behavioral disorders or mortality. Controlling for SEP and other confounders, delayed school entry was associated with increased risk of psychiatric disorders and mortality. Children with delayed school entry were 1.31 times more likely to die by suicide (95% confidence interval: 1.07, 1.61) by midlife, and 1.96 times more likely to die from drug-related death (95% confidence interval: 1.59, 2.40) by midlife than those born late in the year who started school on time. Associations with delayed school entry are likely due to selection, and results thus underscore that long-term health risks can be tracked early in life, including through school entry timing, and are highly socially patterned.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

A brief compassion focused therapy intervention can help self-critical parents and their children: A randomised controlled trial

BACKGROUND

Parents can be highly self-critical of their own parenting, which can negatively impact parenting style and child outcomes.

AIMS

The aim of this randomised controlled trial (RCT) was to examine the efficacy of a brief 2-hour Compassion Focused Therapy intervention (CFT) for parents to determine if it can reduce self-criticism, improve parenting and improve child social, emotional and behavioural outcomes.

MATERIALS & METHODS

In total, 102 parents (87 mothers) were randomised to either a CFT intervention (n = 48) or waitlist control group (n = 54). Participants were measured at pre-, 2-week post-intervention and the CFT group again at 3-month follow-up.

RESULTS

At 2-week post-intervention parents in the CFT group compared to waitlist control had significantly reduced levels of self-criticism, significant reductions in child emotional and peer problems, but no changes in parental style. At 3-month follow-up, these outcomes improved, with self-criticism further decreasing, parental hostility and verbosity decreasing, as well as a range of childhood improvements.

CONCLUSION

The results from this first RCT evaluation of a brief 2-hour CFT intervention for parents show promise for not only improving how parents relate to themselves with self-criticism and self-reassurance, but also for improving parenting styles and child outcomes.

The Father's Part: Influences of Paternal Psychopathology and Parenting Behavior on Child and Adolescent Well-Being

Family influences on child quality of life (QoL) are increasingly understood. Parenting behavior and parent individual psychopathology are among the established predictors of offspring mental health. However, literature often addresses these factors as 'parental', lacking further gender-specific differentiation while predominantly studying maternal aspects. Social and biological fathers are still underrepresented in family research. The aim of this study was to analyze paternal contributions to child well-being. A total of 197 father/mother-dyads gave a standardized self-report on parenting behavior and their own psychopathology at child primary school age (t1; 6-10 y). Ratings were compared mutually and associated with child self-rated QoL at t1 and adolescence (t2; 12-14 y). Fathers and mothers differed in psychopathology and most parenting behavior dimensions (positive parenting, involvement, responsible parenting, poor monitoring, and corporal punishment). Father psychopathology made a relevant predictive contribution to girls' QoL at t2. Boys' t1 QoL was significantly influenced by maternal parenting factors (positivity and corporal punishment). Compared to mothers, fathers are faced with different individual stressors; paternal parenting behavior is different, while fathers' influences are significant, particularly for daughters. Father-addressed pre- and intervention programs in child psychotherapeutic treatment are of high relevance.

Evidence-Based Treatment in Practice: PCIT Research on Addressing Individual Differences and Diversity Through the Lens of 20 Years of Service

Parent-Child Interaction Therapy (PCIT) is an intensive parent support program for caregivers and their children who exhibit difficult-to-manage disruptive behaviors. After more than four decades of research supporting its efficacy for reducing children's disruptive behaviors and improving parent-child relationships, PCIT has become one of the most popular and widely disseminated parenting support programs in the world. The evidence for the efficacy of PCIT can be found in many reviews of randomized clinical trials and other rigorous studies. To add to those reviews, our aim was to provide practical guidance on how PCIT can be part of an evidence-based program for families that depends on practitioner expertise, as well as attention to families' diverse needs. To do this, we describe the evolution of PCIT as practiced in a university-community partnership that has continued for over 20 years, alongside a narrative description of selected and recent findings on PCIT and its use in specific client presentations across four themes. These themes include studies of 1) whether the standard manualized form of PCIT is efficacious across a selection of diverse family situations and child diagnoses, 2) the mechanisms of change that explain why some parents and some children might benefit more or less from PCIT, 3) whether treatment content modifications make PCIT more feasible to implement or acceptable to some families, at the same time as achieving the same or better outcomes, and 4) whether PCIT with structural modifications to the delivery, such as online or intensive delivery, yields similar outcomes as standard PCIT. Finally, we discuss how these directions in research have influenced research and practice, and end with a summary of how the growing attention on parent and child emotion regulation and parents' responses to (and coaching of) their children's emotions has become important to PCIT theory and our practice.

Interventions for ADHD in childhood and adolescence: A systematic umbrella review and meta-meta-analysis

There are several meta-analyses of treatment effects for children and adolescents with attention deficit hyperactivity disorder (ADHD). The conclusions of these meta-analyses vary considerably. Our aim was to synthesize the latest evidence of the effectiveness of psychological, pharmacological treatment options and their combination in a systematic overview and meta-meta-analyses. A systematic literature search until July 2022 to identify meta-analyses investigating effects of treatments for children and adolescents with ADHD and ADHD symptom severity as primary outcome (parent and teacher rated) yielded 16 meta-analyses for quantitative analyses. Meta-meta-analyses of pre-post data showed significant effects for pharmacological treatment options for parent (SMD = 0.67, 95% CI 0.60 to 0.74) and teacher ADHD symptom ratings (SMD = 0.68, 95% CI 0.54 to 0.82) as well as for psychological interventions for parent (SMD = 0.42, 95% CI 0.33 to 0.51) and teacher rated symptoms (SMD = 0.25, 95% CI 0.12 to 0.38). We were unable to calculate effect sizes for combined treatments due to the lack of meta-analyses. Our analyses revealed that there is a lack of research on combined treatments and for therapy options for adolescents. Finally, future research efforts should adhere to scientific standards as this allows comparison of effects across meta-analyses.

Policies are Needed to Increase the Reach and Impact of Evidence-Based Parenting Supports: A Call for a Population-Based Approach to Supporting Parents, Children, and Families

Parents can be essential change-agents in their children's lives. To support parents in their parenting role, a range of programs have been developed and evaluated. In this paper, we provide an overview of the evidence for the effectiveness of parenting interventions for parents and children across a range of outcomes, including child and adolescent mental and physical health, child and adolescent competencies and academic outcomes, parental skills and competencies, parental wellbeing and mental health, and prevention of child maltreatment and family violence. Although there is extensive research showing the effectiveness of evidence-based parenting programs, these are not yet widely available at a population level and many parents are unable to access support. We outline how to achieve increased reach of evidence-based parenting supports, highlighting the policy imperative to adequately support the use of these supports as a way to address high priority mental health, physical health, and social problems.

Parenting app to support socio-emotional and cognitive development in early childhood: iterative codesign learnings from nine low-income and middle-income countries

OBJECTIVE

Many children in low-income and middle-income countries are disadvantaged in achieving early developmental potential in childhood as they lack the necessary support from their surroundings, including from parents and caregivers. Digital technologies, such as smartphone apps, coupled with iterative codesign to engage end-users in the technology-delivered content development stages, can help overcome gaps in early child development (ECD). We describe the iterative codesign and quality improvement process that informs the development of content for the Thrive by Five International Program, localised for nine countries in Asia and Africa.

DESIGN

Between 2021 and 2022, an average of six codesign workshops in each country were conducted in Afghanistan, Indonesia, Kyrgyzstan, Uzbekistan, Cameroon, the Democratic Republic of the Congo, Ethiopia, Kenya and Namibia.ParticipantsA total of 174 parents and caregivers and 58 in-country subject matter experts participated and provided feedback to refine and inform the cultural appropriateness of the Thrive by Five app and its content. Detailed notes from the workshops and written feedback were coded and analysed using established thematic techniques.

RESULTS

Four themes emerged from the codesign workshops: local realities, barriers to positive parenting, child development and lessons learnt about the cultural context. These themes, as well as various subthemes, informed content development and refinement. For example, childrearing activities were requested and developed to promote inclusion of families from diverse backgrounds, encourage best parenting practices, increase engagement of fathers in ECD, address parents' mental well-being, educate children about cultural values and help bereaved children with grief and loss. Also, content that did not align with the laws or culture of any country were removed.

CONCLUSIONS

The iterative codesign process informed the development of a culturally relevant app for parents and caregivers of children in the early years. Further evaluation is required to assess user experience and impact in real world settings.

Wild and Willful Kids: Can We Help Parents? The Effectiveness of a Group Parent Training Program Without a Psychiatric Label

Many children with a classification of attention-deficit/hyperactivity disorder exhibit mild-to-moderate problem behavior. For these children, a stepped diagnosis and stepped care approach has been proposed. Although a psychiatric classification may bring support to families, it may also have negative consequences. Therefore, in this preliminary study, the effect of a group parent training program without child-bound classifications (named Wild & Willful, Druk & Dwars in Dutch) was investigated. In 7 sessions, groups of parents (experimental, n=63; waiting list control, n=38) learned strategies to deal with wild and willful behavior in their children. Outcome variables were assessed by questionnaires. Multilevel analyses showed that, compared with the control group, the intervention group had significantly lower scores on parental stress and communication problems (Cohen d=0.47 and 0.52, respectively), but not on attention and hyperactivity problems, oppositional defiant problems, and responsivity. Zooming in on the course of outcome variables over time in the intervention group, improvements on all variables were seen, with small to moderate effect sizes (Cohen d=0.30 to 0.52). Overall, the group parent training program without the need for a classification for children seemed beneficial. The training is low cost, brings together parents who are facing similar problems in rearing their children, and may help to reduce overdiagnosis of mild and moderate problems, without risking undertreatment of severe difficulties.

Corporal punishment of children in Australia: The evidence-based case for legislative reform

OBJECTIVE

Across all of Australia's states and territories, it is legal for a parent or carer to hit their child. In this paper, we outline the legal context for corporal punishment in Australia and the argument for its reform.

METHODS

We review the laws that allow corporal punishment, the international agreements on children's rights, the evidence on the effects of corporal punishment, and outcomes of legislative reform in countries that have changed their laws to prohibit corporal punishment.

RESULTS

Legislative reform typically precedes attitude changes and reductions in the use of corporal punishment. Countries with the most ideal outcomes have instigated public health campaigns educating the population about law reform while also providing access to alternative non-violent discipline strategies.

CONCLUSIONS

Extensive evidence exists demonstrating the adverse effects of corporal punishment. When countries change legislation, educate the public about these effects, and provide alternative strategies for parents, rates of corporal punishment decrease.

IMPLICATIONS FOR PUBLIC HEALTH

We recommend law reform in Australia to prohibit corporal punishment, a public health campaign to increase awareness of corporal punishment and its effects, provision of access for parents to alternative evidence-based strategies to assist in parenting, and a national parenting survey to monitor outcomes.

Parental Discipline Techniques and Changes in Observed Temper Tantrum Severity in Toddlers

Although temper tantrums are considered a normal part of emotional development in toddlerhood, for some they foreshadow more serious behavioral and emotional problems. Parental discipline techniques may play a role in explaining why this behavior worsens for some children whereas for others it fades away. With this three-wave longitudinal study, we examined bidirectional associations between specific discipline techniques - ignoring, power assertion, and consistency - and intra-individual changes in the severity of tantrum behavior. We observed tantrum behavior in a standardized clean-up task, overcoming the limitation of most earlier work that relied on parent-report for associated changes in parenting and child behavior over time. For 94 children (53 boys; M_age = 30 months, range 20-43 months), mothers filled out the Parenting Dimensions Inventory, and temper tantrum severity (i.e., duration and aggressiveness) was coded three times across one year. Random Intercept Cross-Lagged Panel Models suggested parent-effects rather than child-effects: more maternal power assertion and less consistency predicted increases in tantrum severity over time (ignoring did not), but temper tantrum severity did not predict changes in parenting over time. Results indicate that reducing power assertion and increasing consistency may be especially helpful in reducing temper tantrums in children. Findings add to previous findings indicating that mothers' parenting may be driven less by objective child behavior than by her own perceptions of her child's behavior.

Patterns of parent screen use, child screen time, and child socio-emotional problems at 5 years

Digital media screens have become an essential part of our family life. However, we have insufficient knowledge about parental screen use patterns and how these affect children's socio-emotional development. In total, 867 Canadian parents of 5-year-old children from the TARGet Kids! Cohort (73.1% mothers, mean ± SD age = 38.88 ± 4.45 years) participated in this study from 2014 to the end of 2019. Parents reported parental and child time on television (TV) and handheld devices and completed the Strengths and Difficulties Questionnaire (SDQ). Latent profile analysis identified six latent profiles of parent screen use: low handheld users (P1, reference; n = 323), more TV than handheld (P2; n = 261), equal TV and handheld (P3; n = 177), more handheld than TV (P4; n = 57), high TV and handheld (P5; n = 38), and extremely high TV and handheld (P6; n = 11). Parents that were more likely to belong to P6 were also more likely to be living in single-parent households compared to P1 (estimate = -1.49 ± 0.70), p = .03). High membership probability for P2 (estimate = -0.67 ± 0.32, p = .04) and P4 (estimate = -1.42 ± 0.40, p < 0.001) was associated with lower household income compared to P1. Children of parents with higher P4 (χ²  = 12.32, p < 0.001) or P5 (χ²  = 9.54, p = .002) membership probability had higher total screen time compared to P1. Finally, a higher likelihood to belong to P6 (χ²  = 6.82, p = .009) was associated with a higher SDQ Total Difficulties Score compared to P1. Thus, patterns of parent screen use were associated with child screen use and child socio-emotional problems. The emerging link between parental screen use profiles and child behaviors suggests the need for more research on parent screen time.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

OBJECTIVE

Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.

METHOD

The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.

RESULTS

Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.

CONCLUSION

Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Peripheral Treg Levels and Transforming Growth Factor-β (TGFβ) in Patients with Psoriatic Arthritis: A Systematic Review Meta-Analysis

INTRODUCTION

Studies on the level of regulatory T (T_reg) cells in psoriatic arthritis (PsA) have been controversial, leading to disagreement regarding the role T_reg cells play in the pathogenesis of the disease. To clarify the status of T_reg cells in patients with PsA, we performed a meta-analysis to determine the levels of T_reg cells and serum T_reg-associated cytokines in PsA patients.

METHODS

According to published data from PubMed, Web of Science, Embase, Clinical Trials.gov, MEDLINE, Web of Knowledge, Cochrane Library, and FDA.gov, we determined the T_reg and T_reg cytokine levels in patients with PsA. The effect estimates were pooled using a random-effects model.

RESULTS

This meta-analysis included 12 studies. Compared to healthy controls (HCs), the proportions of T_reg cells had no significant difference in patients with PsA (based on standardized means[SMD] = - 1.038, 95% confidence intervals[CI] =  - 2.165 to 0.089, p = 0.071). On the basis of subgroup analysis, patients with PsA had a lower percentage of CD4⁺ T_reg cells (SMD = - 1.501, 95% CI - 2.799 to - 0.202, p = 0.023) than OKT8⁺ T_reg (SMD = 0.568, 95% CI - 2.127 to 3.263, p = 0.679). Besides, CD4⁺CD25⁺FoxP3⁺ T_reg cells and CD4⁺CD25^highCD127^low T_reg cells were both significantly decreased on the levels of PBMCs in patients with PsA (SMD = - 0.764, 95% CI - 1.404 to - 0.125, p = 0.019; SMD = - 5.184, 95% CI - 6.955 to - 3.412, p < 0.001). CD4⁺CD25⁺FoxP3⁺ T_reg cells were particularly more abundant in the synovial fluid thanin peripheral blood (SMD = 3.288, 95% CI 2.127 to 4.449, p < 0.001). No significant difference was observed in the proportion of CD4⁺CD25⁺ T_reg cells in peripheral blood and CD4⁺CD25⁺FoxP3⁺ T_reg cells in CD4⁺ T cells (SMD = - 2.498, 95% CI - 7.720 to 2.725, p = 0.349; SMD = - 0.719, 95% CI - 2.525 to 1.086, p = 0.435). PsA patients had decreased cytokines such as transforming growth factor-β (TGFβ) (SMD = - 2.199, 95% CI - 3.650 to - 0.749, p = 0.003).

CONCLUSIONS

T_reg definition markers influence the scale of T_reg cells in patients with PsA. Pathogenesis of PsA may be attributed to an insufficient or malfunctioning T_reg population.

Parents' differential susceptibility to a "micro" parenting intervention: Rationale and study protocol for a randomized controlled microtrial

BACKGROUND

Given evidence that parenting can influence children's development, parenting interventions are often the strategy of choice when it comes to treating children's disruptive behavior problems-or preventing problems from developing in the first place. What remains under appreciated, however, is that some parents appear to be more responsive to interventions to foster skilled parenting than others. Notable in this regard is the ever-increasing observational and, perhaps more importantly, experimental evidence indicating that some children prove more susceptible to parenting interventions than others. So, while the experimental evidence clearly indicates that "susceptibility factors" which children carry seem to affect their likelihood of benefiting from a parenting intervention (and other environmental influences), what remains unclear is why the parenting interventions in question prove more effective in changing the behavior of some parents more than others. Could it be as a result of their own parental characteristics?

OBJECTIVE

The Parfective Microtrial in a randomized controlled microtrial, in which we focus not just on parental (and child) responsiveness but also on an underlying physiological mechanism hypothesized to contribute to heightened susceptibility to parenting interventions.

METHODS

Participants are 120 families, with children aged 4-5 years, recruited from the community. Of these, 60 are randomly assigned to the "micro" intervention condition (i.e., immediate positive parenting feedback) and 60 families to the care-as-usual control condition. Assessments in both conditions will be conducted at baseline (pretest), after 2 weeks (posttest), and after 4 weeks (follow-up). Primary outcomes are the hypothesized moderating effects of physiology on the anticipated "micro" intervention effect (i.e., decrease in negative parenting behavior and/or increase in positive parenting behavior). Secondary outcomes are the observed (changes in) child behavior in response to the parenting intervention, such that those parents and children-in the same family-who manifest these physiological attributes will prove most susceptible to the beneficial effects of the intervention.

TRIAL REGISTRATION

This study protocol is registered at ClinicalTrials.gov (NCT05539170).

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

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

Developing a Brief Parent Training Intervention to Prevent Anxiety in Offspring

Offspring of parents with anxiety disorders have an increased risk of developing anxiety themselves. Very few studies have evaluated interventions aiming to prevent anxiety in offspring of anxious parents. This study was a small (N=40) randomized pilot study with three arms evaluating the feasibility of a novel parent support group for anxious parents, the Supporting Anxious Parents Program (SAPP). The primary objective was to evaluate the acceptability of the SAPP. In addition, we also evaluated preliminary effects on child anxiety, parent risk factors, and quality of life, and feasibility of the study design. Excessive parental worry and anxiety and having a child not meeting criteria for an anxiety disorder (6-12 years old), served as inclusion criteria. Thirteen parents were randomly allocated to a group-based intervention, 14 to an individual Internet-based version of the intervention, and 13 to a waitlist control condition. The intervention was developed to target three risk factors involved in the parent-child transmission of anxiety; criticism/low warmth, overprotective behaviors, and modeling of anxiety. The results showed that parents were generally very satisfied with the intervention. We did not find any significant decreases in child anxiety in the intervention conditions. However, for the parents, we found preliminary support for reduced overprotective behaviors, reduced worry, and increased quality of life. The study design was found to be feasible. According to the results, a revision of the intervention is recommended before a full randomized controlled trial could be conducted.

Multiple needs and multiple treatments. What's a clinician to do? Update on the psychosocial treatment of disruptive behaviours in childhood

PURPOSE OF REVIEW

There are a wide range of psychosocial treatment options, delivered in different modalities, for children with disruptive behaviour. However, clinicians face many challenges in ensuring the empirically supported treatments (ESTs) they select will be effective for their patient. This has prompted studies to generate knowledge on how to improve treatment outcomes for children with disruptive behaviour. This review identifies the major challenges in treatment selection as well as emerging research seeking to improve outcomes.

RECENT FINDINGS

This review emphasizes the salience of the research-practice gap associated with establishing ESTs using narrow definitions of clinical problems. Recent research is reviewed considering the complex determinants of disruptive behaviours, including parent and family factors that influence outcomes. The review subsequently outlines recent advances in research and clinical practice guidelines aiming to surmount these challenges. Key advances discussed include examining the most impactful components of ESTs, personalizing interventions by targeting core dysfunction underlying behaviour, and addressing parent factors including mental health and cultural relevance to improve outcomes.

SUMMARY

Thorough assessment of patients' needs, combined with knowledge of treatment response predictors, are recommended to determine the most suitable treatment plan. Recent advances have focused on developing and designing interventions that meet needs in a way that is flexible and tailored.

The Impact of Parent Child Interaction Therapy on Temper Tantrums in Pre-school

Temper tantrum behavior is a child's emotional behavior which is shown by explosive anger and some parents consider this behavior to be bad behavior. Temper tantrums can occur in children aged 3-6 years or more. This literature review aims to determine the impact of PCIT (Parent Child Interaction Therapy) on temper tantrums in preschool. In finding this literature review used four databases (ProQuest, Scopus, Pubmed, and Sains Direct) for the design of the study used cross sectional, True Experimental, Observational and Systematic Reviews published in the last five years. The protocol and evaluation of the literature review used the PRISMA checklist to determine the selection of studies that were found and adapted to the objectives of the literature review. The results of literature review analysis of several parents in group and individual PCIT reported that the application of parent-child-based interventions was proven to be effective and has the potential to bring significant and lasting changes in increasing positive behavior in children with external behavior problems. The frequency of problematic child relationship behavior significantly decreased with increasing age of the child.  In addition, assessing both positive and negative child relationship behavior could assist parents in understanding the relevance of different aspects for the development of parent-child relationships.

Developing a Parenting App to Support Young Children’s Socioemotional and Cognitive Development in Culturally Diverse Low- and Middle-Income Countries: Protocol for a Co-design Study

Background

Digital technologies are widely recognized for their equalizing effect, improving access to affordable health care regardless of gender, ethnicity, socioeconomic status, or geographic region. The Thrive by Five app is designed to promote positive interactions between children and their parents, extended family, and trusted members of the community to support socioemotional and cognitive development in the first 5 years of life and to strengthen connections to culture and community.

Objective

This paper aims to describe the iterative co-design process that underpins the development and refinement of Thrive by Five’s features, functions, and content. Minderoo Foundation commissioned this work as a quality improvement activity to support an engaging user experience and inform the development of culturally appropriate and relevant content for parents and caregivers in each country where the app is implemented.

Methods

The app content, referred to as Collective Actions, comprises “The Why,” that presents scientific principles that underpin socioemotional and cognitive development in early childhood. The scientific information is coupled with childrearing activities for parents, extended family, and members of the community to engage in with the children to support their healthy development and to promote positive connections between parents, families, and communities and these young children. Importantly, the initial content is designed and iteratively refined in collaboration with a subject matter expert group from each country (ie, alpha testing). This content is then configured into the app (either a beta version or localized version) for testing (ie, beta testing) by local parents and caregivers as well as experts who are invited to provide their feedback and suggestions for improvements in app content, features, and functions via a brief web-based survey and a series of co-design workshops. The quantitative survey data will be analyzed using descriptive statistics, whereas the analysis of qualitative data from the workshops will follow established thematic techniques.

Results

To date, the co-design protocol has been completed with subject matter experts, parents, and caregivers from 9 countries, with the first results expected to be published by early 2023. The protocol will be implemented serially in the remaining 21 countries.

Conclusions

Mobile technologies are the primary means of internet connection in many countries worldwide, which underscores the potential for mobile health programs to improve access to valuable, evidence-based, and previously unavailable parenting information. However, for maximum impact, it is critically important to ensure that mobile health programs are designed in collaboration with the target audience to support the alignment of content with parents’ cultural values and traditions and its relevance to their needs and circumstances.

International Registered Report Identifier (IRRID)

DERR1-10.2196/39225

Levels of Peripheral Th17 Cells and Th17-Related Cytokines in Patients with Ankylosing Spondylitis: A Meta-analysis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease. Several proinflammatory cytokines produced by T helper 17 (Th17) cells are involved in the pathogenesis of AS. We performed a meta-analysis to determine the levels of Th17 cells and serum Th17-associated cytokines in patients with AS.

METHODS

We determined the levels of Th17 cells and Th17 cytokines in patients with AS using data extracted from published articles retrieved from the PubMed, Embase, Web of Science, Cochrane Library, MEDLINE, Web of Knowledge, Clinical Trials.gov, and FDA.gov.

DATABASES

The effect estimates were pooled using a random-effects model. The review protocols were registered on PROSPERO (reference: CRD42021255741) and followed the PRISMA guideline.

RESULTS

This meta-analysis included 138 studies. Compared to healthy controls (HCs), patients with AS had a higher proportion of Th17 cells (standardized mean difference [SMD] 2.23, 95% confidence interval [CI] 1.78-2.68; p < 0.001) and levels of proinflammatory cytokines, such as interleukin (IL)-17 (SMD 2.04, 95% CI 1.70-2.38; p < 0.001), IL-21 (SMD 1.77, 95% CI 0.95-2.59; p < 0.001), and IL-23 (SMD 1.11, 95% CI 0.78-1.44; p < 0.001). The subgroup analysis showed higher levels of IL-17⁺ Th17 cells among peripheral blood mononuclear cells (PBMCs) and CD4⁺ T cells in patients with AS compared to HCs (SMD 2.26, 95% CI 1.58-2.94 [p < 0.001] and SMD 1.61, 95% CI 0.55-2.67 [p = 0.003], respectively). Patients with AS had higher levels of CD4⁺IL-17⁺IFN-γ^- Th17 in PBMCs and of CD4⁺CCR6⁺CCR4⁺Th17 in CD4⁺ T cells compared to HCs (SMD 1.85, 95% CI 1.06-2.64 [p < 0.001] and SMD 7.72, 95% CI 6.55-8.89 [p < 0.001], respectively). No significant differences were observed in the proportions of CD4⁺IL-17⁺IFN-γ^- Th17 in CD4⁺ T cells and CD4⁺CCR6⁺CCR4⁺ Th17 in PBMCs (SMD - 0.11, 95% CI - 0.61 to 0.38 [p = 0.650] and SMD 1.32, 95% CI - 0.54 to 3.19 [p = 0.165], respectively). In addition, compared to stable AS, the levels of Th17 cells and IL-17 and IL-23 were significantly higher in active AS (SMD 1.58, 95% CI 0.30-2.85 [p = 0.016], SMD 3.52, 95% CI 0.72-6.33 [p = 0.014], and SMD 5.10, 95% CI 1.83-8.36 [p = 0.002], respectively).

CONCLUSIONS

The levels of Th17 cells and serum IL-17, IL-21, and IL-23 were higher in patients with AS than in HCs and, compared with stable AS, they increased more significantly in active AS. These results suggest that Th17 cells and Th17-related cytokines play major roles in AS pathogenesis and are an important target for treatment.

Role of Psychologists in Pediatric Subspecialties: Integrated Psychological Services Overarching Concepts Across Pediatric Subspecialties

This article addresses, in more general terms, the overarching concepts of the role of integrated psychologists and how their services are incorporated in the medical home with the use of provider consultation, administering assessments in identifying common mental health concerns, providing interventions for treatment adherence and providing short-term therapy within pediatric subspecialties.

Aldehyde dehydrogenase 2 rs671 polymorphism and multiple diseases: protocol for a quantitative umbrella review of meta-analyses

BACKGROUND

The mutant allele (*2) of aldehyde dehydrogenase type 2 (ALDH2) caused by a single nucleotide variant (rs671) inhibits enzymatic activity and is associated with multiple diseases. In recent years, an explosive number of original studies and meta-analyses have been conducted to examine the associations of ALDH2 rs671 polymorphism with diseases. Due to conflicting results, the overall associations of ALDH2 rs671 polymorphism and multiple diseases remain unclear.

METHODS

A quantitative umbrella review will be conducted on meta-analyses of genetic association studies to examine the pleiotropic effects of ALDH2 rs671, mainly including cardio-cerebral vascular disease, diabetes mellitus, cancer, neurodegenerative disease, and alcohol-induced medical disease. A search of relevant literature according to comprehensive search strategies will be performed on studies published before July 1st, 2022 in PubMed, MEDLINE Ovid, Embase, Cochrane Database of Systematic Reviews, and Web of Science. Study selection, data extraction, methodology quality assessment, and strength of evidence assessment will be conducted by two reviewers independently and in duplicate. Included meta-analyses will be grouped by outcomes. Data conflicts and overlap between meta-analyses will be managed through updated standardized and customized methods including the calculation of CCA for study selection reference, application of Doi plots to assess small-study effects and others. Evidence from included meta-analyses will be quantitatively synthesized by overlap-corrected analyses and meta-analysis using primary studies.

DISCUSSION

This umbrella review is expected to generate systematic evidence on the association between ALDH2 rs671 and diseases. Specific approaches were developed to address key challenges in conducting an umbrella review, including assessment tools of methodology and evidence quality of meta-analyses, methods to manage overlap between meta-analyses, a "stop-light" plot to summarize key findings. These approaches provide applicable methods for future umbrella reviews of meta-analyses on genetic association studies.

TRIAL REGISTRATION

CRD42021223812.

A Preliminary Evaluation of the Cultural Appropriateness of the Tuning in to Kids Parenting Program in Germany, Turkey, Iran and China

Background: Parenting interventions based on emotion socialization (ES) theory offer an important theoretically driven approach to improve children's emotional competence and behavioral functioning. Whether such approaches are effective in different cultural contexts, and whether the methods of delivery used are appropriate and acceptable, is an important empirical question. This paper reports on the preliminary evaluation of an ES parenting intervention, Tuning in to Kids (TIK), in Germany, Turkey, Iran, and China. Pilot studies of TIK have been conducted in each country with mothers of 4-6-year-old children. Method: The current study used qualitative methods with thematic analysis to explore the cultural appropriateness of the program in each site. Results: Culture-specific challenges were found across all sites in changing parents' beliefs about the value of encouraging children's emotional expression and supportive emotion discussions. Emotion literacy of parents depended on their access to emotion terms in their language, but also to parents' experiences with emotions in their family of origin and culture-related beliefs about emotions. Adaptations were required to slow the speed of delivery, to address issues of trust with parents in seeking help, and to provide more opportunities to practice the skills and integrate different beliefs about parenting. Conclusion: While this ES parenting intervention has been developed in a Western cultural context, slight adaptations to the delivery methods (rather than change to the content) appeared to contribute to cultural appropriateness. The next step will be to quantitatively evaluate these adaptations of TIK in the different countries using randomized controlled 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.

Attachment- and Emotion-Focused Parenting Interventions for Child and Adolescent Externalizing and Internalizing Behaviors: A Meta-Analysis

Attachment- and emotion-focused parenting interventions (AE) have grown in popularity as an alternative to behavioral parent training (BPT) for children and adolescents. AE go beneath behavior by helping parents understand and respond to their child’s underlying attachment and emotional needs. Past reviews have examined their effects on attachment security and caregiver sensitivity, though less is known regarding their effects on child mental health symptoms. Reported here is the first systematic review and meta-analysis of individual and group AE on externalizing behavior (EXT) and internalizing behavior (INT) for children aged 0–18 years. A search of four databases prior to July 2021 elicited 43 studies that met eligibility criteria. Meta-analysis revealed that AE were superior to waitlist controls for EXT (SMD = − 0.17) and INT (SMD = − 0.34). Effects were sustained at follow-up periods of 6 months and greater, and AE considered to target child mental health were significantly more effective than those that did not in reducing EXT and INT. Two studies retrieved directly compared AE to BPT, which showed no evidence of a difference for follow-up measures of EXT. No studies compared AE to BPT on INT. AE demonstrated no evidence of superiority compared to controls for parent mental health. Findings support the potential for AE to reduce EXT and INT in children and adolescents; however, future research should consider the relative effectiveness of AE.

The long-term cost of childhood conduct problems: Finnish Nationwide 1981 Birth Cohort Study

BACKGROUND

Commonly recognized childhood conduct problems often lead to costly problems in adulthood. This study aimed to evaluate the long-term cumulative cost of childhood conduct problems until the age of 30. The costs included inpatient care, nervous system medicine purchases, and criminal offences.

METHODS

The study used population-based nationwide 1981 birth cohort data. Families and teachers assessed the conduct problems of the eight-year-olds based on Rutter questionnaires. We grouped 5,011 children into low-level of conduct problems (52%), intermediate-level of conduct problems (37%), and high-level of conduct problems (11%) groups, based on combined conduct symptoms scores. The analysis included the cohort data with the Care Register for Health Care, the Drug Prescription Register, and the Finnish Police Register. The cost valuation of service use applied national unit costs in 2016 prices. We used Wilcoxon rank-sum test to test the differences between groups and gender.

RESULTS

During 1989-2011, average cumulative costs of the high-level (€44,348, p < .001) and the intermediate-level (€19,405, p < .001) of conduct problems groups were higher than the low-level of conduct problems group's (€10,547) costs. In all three groups, the boys' costs were higher than girls' costs.

CONCLUSIONS

The costs associated with conduct problems in childhood are substantial, showing a clear need for cost-effective interventions. Implementation decisions of interventions benefit from long-term cost-effectiveness modelling studies. Costing studies, like this, provide cost and cost offset information for modelling studies.

A Smartphone App for Parental Management of Adolescent Conduct Problems: Randomized Clinical Trial of iKinnect

OBJECTIVE

This study evaluates iKinnect, a linked caregiver-teen mobile app system designed to address serious adolescent conduct problems through a focus on key targets of evidence-based treatments for juvenile offending, such as parent expectation setting, monitoring, consistency, and positive reinforcement. Additional gamification and autonomy-supporting features are designed to maximize youth engagement. Digital therapeutics such as mobile apps have great potential to expand access to effective interventions, particularly for youth who engage in serious conduct problems and substance abuse, since most never receive an evidence-based treatment and few apps exist for these concerns.

METHODS

This randomized clinical trial used a short-term (12 week) longitudinal design with four time points. Recruited was a U.S. national sample of teens (n = 72, age 13-17, 59.7% male, 68.1% White) receiving services for a serious conduct problem and their primary caregiver. The efficacy of iKinnect, used by parent and teen dyads, was measured against an active control condition, Life360, an app that provided mutual GPS-based location tracking to dyads.

RESULTS

Across 12 weeks of app use, youth who used iKinnect showed significantly greater reductions in alcohol use, marijuana use, school delinquency, status offenses, and general delinquency than did controls. Parents who used iKinnect Reported greater improvements in structure/rule clarity and discipline consistency relative to control parents. Teen and parent iKinnect app use and acceptability ratings were high.

CONCLUSIONS

Real-world use of iKinnect in future applications can, like other emerging digital health technologies, help to expand the reach of evidence-based interventions to children, youth, and families.Registered at clinicaltrials.gov (NCT03065517).

Changes in Prosocial Behaviors Among Children With Behavioral Problems Following Incredible Years Parenting Program

Parenting programs often train parents in improving their parenting practices and parent-child relationship to reduce behavioral problems in children. However, the children's prosocial behaviors are less examined as an intervention outcome in these programs. This study aimed to evaluate the effectiveness of the Incredible Years parenting program (IYPP) for Malaysian parents of school-going children and its sustainability in improving the children's prosocial behaviors. This randomized controlled study involved pre- and post-intervention assessments at 2 and 14 weeks. Mothers of children aged 6-12 years (n = 70) recruited through the pediatrics and the child and adolescent psychiatric clinics were randomly assigned to the parenting program or a waitlist control condition. The mothers rated their children's prosocial behaviors using a self-administered questionnaire. The program ran two to three hours weekly for 14 weeks. Several modifications were made to the program to accommodate public health control during the pandemic. Children in the intervention group showed a notable but non-significant increase in prosocial skills. However, subsequent score decline at follow-up may suggest a lack of evidence that the program is potentially effective in improving prosocial behaviors among school children who are at risk of or already having behavioral problems.

Translation and validation of the evidence-based practice attitude scale (EBPAS-15) to Brazilian Portuguese: Examining providers' perspective about evidence-based parent intervention

BACKGROUND

Few existing evidence-based parent interventions (EBPIs) for prevention and treatment of child and youth mental health disorders are implemented in low-middle-income countries. This study aimed to translate and confirm the factor structure of the Evidence-Based Practice Attitude Scale (EBPAS-15) survey in Brazilian Portuguese with the goal of examining providers' perspective about EBPIs.

METHODS

We translated and back translated the EBPAS-15 from English to Brazilian Portuguese. Participants were recruited via snowball sampling and data were collected using an online survey from July of 2018 through January of 2020. A confirmatory factor analysis was conducted to determine if the scale retained its original structure. Open-ended questions about providers' perspectives of their own clinical practice were coded using the Theoretical Domains Framework (TDF). Analyses included data from 362 clinicians (318 women, 41 men) from 20 of the 27 states of Brazil. Participants on average were 26.7 years old, held specialist degrees in the field of psychology, actively worked as therapists, and practiced in private clinics.

RESULTS

The translation of the EBPAS to Brazilian Portuguese retained the same four-factor structure as the English version except for dropping one item from the Divergence domain. When asked about the challenges in their practices, providers generally referred to parents as clients with little skills to discipline their children and lacking knowledge about child development.

DISCUSSION

The Brazilian version of the EBPAS-15 is promising, but future research should consider using quantitative data alongside qualitative information to better understand providers' attitudes about evidence-based interventions to inform implementation efforts.

TRIAL REGISTRATION

N/A.

Intergenerational Transmission of Effects of Women's Stressors During Pregnancy: Child Psychopathology and the Protective Role of Parenting

Objective

Experiences of stress and adversity, such as intimate partner violence, confer risk for psychiatric problems across the life span. The effects of these risks are disproportionately borne by women and their offspring-particularly those from communities of color. The prenatal period is an especially vulnerable period of fetal development, during which time women's experiences of stress can have long-lasting implications for offspring mental health. Importantly, there is a lack of focus on women's capacity for resilience and potential postnatal protective factors that might mitigate these intergenerational risks and inform intervention efforts. The present study examined intergenerational associations between women's prenatal stressors and child executive functioning and externalizing problems, testing maternal parenting quality and child sex as moderators, using a large, prospective, sociodemographically diverse cohort.

Methods

We used data from 1,034 mother-child dyads (64% Black, 30% White) from the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) pregnancy cohort within the ECHO PATHWAYS consortium. Women's prenatal stressors included stressful life events (pSLE) and intimate partner violence (pIPV). Measures of child psychopathology at age 4-6 included executive functioning and externalizing problems. Parenting behaviors were assessed by trained observers, averaged across two sessions of mother-child interactions. Linear regression models were used to estimate associations between women's prenatal stressors and child psychopathology, adjusting for confounders and assessing moderation effects by maternal parenting quality and child sex.

Results

Women's exposures to pSLE and pIPV were independently associated with child executive functioning problems and externalizing problems in fully-adjusted models. Maternal parenting quality moderated associations between pSLE and both outcomes, such that higher parenting quality was protective for the associations between women's pSLE and child executive functioning and externalizing problems. No moderation by child sex was found.

Discussion

Findings from this large, sociodemographically diverse cohort suggest women's exposures to interpersonal violence and major stressful events-common for women during pregnancy-may prenatally program her child's executive functioning and externalizing problems. Women's capacity to provide high quality parenting can buffer this intergenerational risk. Implications for universal and targeted prevention and early intervention efforts to support women's and children's wellbeing are discussed.

Successful implementation of parenting support at preschool: An evaluation of Triple P in Sweden

Although emotional and behavioural problems among young children are common and, if unaddressed, can lead to multi-facetted problems later in life, there is little research investigating the implementation of parenting programs that target these problems. In this study, the RE-AIM framework was used to evaluate the implementation of the Triple P parenting program in a preschool setting at a medium-sized municipality in Sweden. Reach increased over time, showing an overall increase in participating fathers and parents with lower education. Effectiveness outcomes showed an improvement in emotional and behavioural problems in children and less mental health-related symptoms and higher self-efficacy in parents. Adoption rate was 93.3%. To ensure staff “buy-in”, designated coordinators made changes in recruitment procedures, and provided supervision and training to all Triple P practitioners. Implementation adaptations were made, such as minor revisions of parenting strategies and other program content, as well as providing child care during seminars and groups, and setting up weekend-groups. Maintenance assessed through 12 month follow-up data suggested that several child and parent outcomes were maintained over time. Uppsala municipality continues to offer Triple P to parents. The reach, effectiveness, adoption, implementation and maintenance of the program were all satisfactory and demonstrated the suitability of delivering evidence-based parenting support using preschools as an arena.

Externalizing Behavior Problems Among Hui Ethnicity Left-Behind Children in Rural China: A Cross-Sectional Study

OBJECTIVE

This study aimed to investigate the prevalence of externalizing behavior problems (EBPs) and its influencing factors among Hui left-behind children (LBC) in rural China.

METHODS

A cross-sectional study was conducted among school students from the southern rural areas in Ningxia, China (2012-2013). The general self-made questionnaire, Egma Minnen av Bardndosna Uppforstran, Eysenck Personality Questionnaire (for Children), Piers-Harris Children's Self-Concept Scale, and Achenbach's Child Behavior Checklist (for parents) were used to investigate the related information. Binary logistic regressions were conducted.

RESULTS

The prevalence of EBPs in boys Hui LBC was significantly higher than that of non-LBC (12.37% vs. 6.84%, χ2=4.09, and p=0.04). Multivariate logistic regression analysis showed that low self-awareness of behavior (odds ratio [OR]=29.78), introversion (OR=21.67) and intermediate personality (OR=15.83), poor academic performance (OR=11.65) and both parent migrating (OR=2.73) were the risk factors for the EBPs of Hui LBC, while middle and high father refusal and denial (OR=0.11, OR=0.09) were their protective factors.

CONCLUSION

Our findings suggest that both parent migrating is a potential risk factor for EBPs among Hui LBC. Hui boys LBC should be paid more attention when formulating relevant policies.

Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis

BACKGROUND

High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality.

OBJECTIVE

This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers.

METHODS

A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches.

RESULTS

For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t₁₆₈=23.2; P<.001), family costs (t₁₈₅=9.2; P<.001), and total costs (t₁₇₁=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars.

CONCLUSIONS

The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Effectiveness of Child-Focused Interventions for Externalizing Behavior: a Rapid Evidence Review

Parent behavior management training (BMT) is well established as an effective, evidence-based treatment for children with externalizing behavior. Despite the wealth of data supporting BMT, many community providers use a variety of child-focused and non-directive interventions to target behavior problems. There is lack of clarity as to whether the evidence supporting child-focused externalizing treatments is sufficiently compelling to support offering these treatments rather than or in addition to BMT. This rapid evidence review compares the effectiveness of BMT with several common child-focused interventions for externalizing behavior including cognitive behavioral (CBT), social skill (SS), and play/dynamic (PT) approaches. PubMed, PsychINFO, and Web of Science were searched for English-language articles from year 2000 onwards for each intervention type. Inclusion criteria were child age (12 and under), presence of a child-focused behavioral treatment condition, and externalizing behavior as an outcome variable. A total of 30 studies met inclusion criteria and were coded (13 CBT, 10 SS, 7 PT). Results supported social skills interventions with accompanying BMT as effective in improving externalizing problems, with generally moderate effect sizes. Individual social skills interventions were promising but needing further evaluation compared to treatment as usual. CBT treatments with and without accompanying BMT showed moderate effects over waitlist but produced less consistently significant effects compared to more robust controls. Play therapy approaches showed inconsistent effects and require further evaluation. This review supports social skills plus BMT treatments as a child-focused intervention with probable efficacy for child externalizing problems. Implications for policy and community practice are discussed.

Public mental health: required actions to address implementation failure in the context of COVID-19

Mental disorders account for at least 18% of global disease burden, and the associated annual global costs are projected to be US$6 trillion by 2030. Evidence-based, cost-effective public mental health (PMH) interventions exist to prevent mental disorders from arising, prevent associated impacts of mental disorders (including through treatment), and promote mental wellbeing and resilience. However, only a small proportion of people with mental disorders receive minimally adequate treatment. Compared with treatment, there is even less coverage of interventions to prevent the associated impacts of mental disorders, prevent mental disorders from arising, or promote mental wellbeing and resilience. This implementation failure breaches the right to health, has increased during the COVID-19 pandemic, and results in preventable suffering, broad impacts, and associated economic costs. In this Health Policy paper, we outline specific actions to improve the coverage of PMH interventions, including PMH needs assessments, collaborative advocacy and leadership, PMH practice to inform policy and implementation, training and improvement of population literacy, settings-based and integrated approaches, use of digital technology, maximising existing resources, focus on high-return interventions, human rights approaches, legislation, and implementation research. Increased interest in PMH in populations and governments since the onset of the COVID-19 pandemic supports these actions. Improved implementation of PMH interventions can result in broad health, social, and economic impacts, even in the short-term, which support the achievement of a range of policy objectives, sustainable economic development, and recovery.

Impact of a New Parent Behavioral-Schema Training on Children with ADHD: A Pragmatic Control Trial

OBJECTIVES

To examine whether adding schema therapy strategies to the conventional parent behavioral program prevents symptom relapse in children with attention deficit hyperactivity disorder (ADHD).

METHOD

The intervention was designed as an adaptive pragmatic control trial. The parent behavioral training and schema-enhanced parent behavior therapy (SPBT) protocols were delivered to the control group (40 parents of 23 children) and experimental group (97 parents of 54 children), respectively. Participants were assessed at baseline, mid-treatment, and termination. Parents and teachers indicated the severity of ADHD and comorbid symptoms through their responses to standardized questionnaires designed for this purpose.

RESULTS

A nested growth curve analysis demonstrated that participants in the schema-enhanced intervention group had a lower risk of symptom relapse than the control group.

CONCLUSION

Participation in the SPBT program significantly reduced relapse rates by the end of the intervention. Future research may determine the long-term effects of the treatment.

Effects of Positive Psychology Interventions on the Well-Being of Young Children: A Systematic Literature Review

Over the last 20 years, the effectiveness of positive psychology interventions for the development of the well-being of children and adolescents and the moderation of high levels of anxiety and depression in this population has been largely demonstrated. Emphasis has been placed on the promotion of well-being and prevention of mental health problems in the school context in order to foster, through positive psychology, the cognitive and socio-emotional development of primary and secondary students, e.g., by strengthening positive relationships, positive emotions, character strengths, optimism, and hope. However, little is known about the impact of these interventions on young children. This systematic review aims at examining the effects of positive psychology interventions on the well-being of early childhood children (<6 years old), both in the preschool education context with educators or teachers and also in the family context with parents. Several electronic databases were searched, and the findings systematically reviewed and reported by the PRISMA guidelines. Very few studies met the inclusion criteria (n = 3), highlighting the need for further research in this area. Indeed, all of the selected studies demonstrated the importance of positive psychology interventions with young children to promote positive aspects of development, such as gratitude, positive emotions, life satisfaction, accomplishment, positive relationship, or self-esteem. Limitations in the field are discussed.