Buchanan-Pascall et al - 2018 - systematic review of parent group interventions

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Child Psychiatry Hum Dev (2018) 49:244–267
DOI 10.1007/s10578-017-0745-9
ORIGINAL ARTICLE
Systematic Review and Meta-analysis of Parent Group
Interventions for Primary School Children Aged 4–12 Years
with Externalizing and/or Internalizing Problems
Sarah Buchanan‑Pascall1 · Kylie M. Gray1,2,4 · Michael Gordon1,3 · Glenn A. Melvin1,2 Published online: 11 July 2017
© Springer Science+Business Media, LLC 2017
Abstract This systematic review and meta-analysis evaluates the efficacy of parent training group interventions to
treat child externalizing and/or internalizing problems. A
search identified 21 randomized controlled trials of parent
group interventions aimed at ameliorating child externalizing and/or internalizing problems in children aged 4–12
years. Random effects meta-analyses yielded significant
pooled treatment effect size (g) estimates for child externalizing (g = −0.38) and internalizing problems (g = −0.18).
Child anxiety symptoms or internalizing problems evident
in children with externalizing behavior problems did not
change significantly following intervention. Study quality was a statistically significant moderator of treatment
response for child externalizing problems, however hours
of planned parent group treatment and treatment recipient
were not. Findings support the use of parent group interventions as an effective treatment for reducing externalizing
problems in children aged 4–12 years. Whilst statistically
significant, programs had a limited impact on internalizing
symptoms, indicating a need for further investigation.
* Kylie M. Gray
[email protected]
1
Centre for Developmental Psychiatry & Psychology,
Department of Psychiatry, School of Clinical Sciences
at Monash Health, Monash University, Melbourne, Australia
2
Centre for Educational Development, Appraisal
and Research, University of Warwick, Coventry, UK
3
Early in Life Mental Health Service, Monash Health,
Melbourne, Australia
4
Centre for Developmental Psychiatry & Psychology, 1/270
Ferntree Gully Road, Notting Hill, VIC 3168, Australia
13
Vol:.(1234567890)
Keywords Parent training · Group therapy · Early
intervention · Externalizing disorders · Internalizing
disorders
Introduction
Internationally, the prevalence of child mental health problems is high. Research suggests that up to one in five children worldwide experience mental health problems [1, 2].
Children’s mental health problems have high social, personal and economic costs [3], in both the short and long
term [4]. Child mental health problems often continue
into adolescence and then adulthood, adding further costs
related to areas such as school dropout, substance abuse,
poor vocational outcomes, family violence and suicide,
along with sick leave, unemployment and crime [5, 6].
The financial cost arising from mental health problems in
young people places significant burden on health services,
social, and education systems [7, 8]. For instance, Scott
et al. [9] estimated the mean individual total cost of publicly resourced services for those aged 28 who continued to
experience behavioral problems associated with early onset
Conduct Disorder to be £70 019 (£114 475.51 inflated to
2017, ten times higher than for those with no behavioral
problems). Given such costs, it is vital that evidence-based,
early intervention treatments are adopted with the aim of
ameliorating these problems before they incur greater burden to the child, family and society.
Broadly speaking, mental health problems in childhood
can be categorized into two broad types: externalizing
(behavioral) and internalizing (emotional) problems. Externalizing problems are characterized by an under-controlled
behavioral pattern, a tendency to act out and respond in
a way that disturbs or is harmful to others [10]. Some of
Child Psychiatry Hum Dev (2018) 49:244–267
the most common mental health disorders considered to
be externalizing problems are attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD)
and conduct disorder (CD) [11]. Internalizing problems,
on the other hand, is a broad term that refers to a range
of difficulties characterized by personal emotional distress and described as over-controlled or inhibited behaviors [12]. Internalizing problems in childhood may manifest as, for example, anxiety or depressive disorder [13].
Together, internalizing and externalizing disorders are
among the most common difficulties of early childhood,
affecting approximately 15% of those aged 8–15 years [14].
Community-based studies have confirmed this high prevalence, along with a strong stability of internalizing symptoms across early to mid-childhood [15]. Without effective
intervention, these children are at great risk of experiencing
deterioration in their presenting difficulties as they move
towards and through the adolescent years and into adulthood [16, 17].
Interventions for Child Externalizing Problems
There is evidence that psychological treatments are effective in reducing externalizing problems in children and
adolescents with clinical conduct problems [18]. Metaanalyses [19–21] and reviews [22, 23] have provided evidence to suggest that parent training interventions are effective at reducing children’s externalizing behavior problems.
Lundahl et al. [19] conducted a meta-analysis of 63 peerreviewed studies that evaluated the ability of parent training programs (including group, individual, self-directed
delivery) to modify disruptive child behaviors and parental
behavior and perceptions. Effects immediately following
treatment for behavioral and non-behavioral programs were
small to moderate. However, studies included in the review
were limited to years spanning 1974–2003 and the authors
conducted an analysis of child (externalizing) behavior
outcomes only. Kaminski et al. [20] meta-analytic review
of the components associated with effective parenting programs indicated larger effects on children’s externalizing
behaviors for programs that included training in behavioral
strategies such as time-out and parental consistency, as well
as training in positive interactions (e.g., positive reinforcement for appropriate behavior) and in vivo practice with the
parent’s own child. However, the programs included in this
review varied widely in their mode of delivery (e.g., individual, group, self-directed) and the review was restricted
to treatment of children aged 0–7 years and studies published from 1990 to 2002.
Research has also focused on a wide range of early intervention programs and have produced evidence indicating that group-based parenting interventions, many based
on social learning theory, offer an effective treatment for
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externalizing behavior problems in children [24–26]. One
group-based parenting program, Group Triple P [27], is
based on theory that suggests that coercive patterns of parent–child interaction lead to child problem behaviour [28].
Previous studies have indicated that Group Triple P results
in significant reductions in negative child behaviors (e.g.,
aggression, tantrums, and oppositionality) [27]. Recently,
Furlong et al. [29] systematic review of randomized controlled trials (RCTs) or quasi-randomized controlled trials
of behavioral and cognitive-behavioral group-based parenting interventions for parents of children aged 3–12 years
with conduct problems found both types of interventions
were effective and cost-effective for improving child conduct problems, parental mental health and parenting skills
in the short-term. However, limitations of the review were
the lack of long-term assessment of outcomes, limited data
on child emotional problems, and the fact that 9 of the 13
included studies evaluated the effectiveness of the Incredible Years intervention [30]; meaning results are most applicable to studies of interventions that share components
similar to the Incredible Years program.
Interventions for Child Internalizing Problems
While there has been extensive past research into parent
training for early intervention of children with externalizing problems, the same cannot be said for children with
internalizing problems [22]. Children with serious internalizing disorders such as anxiety represent some of the
most severely impaired group of students in schools and
those most in need of comprehensive services. Despite this,
few studies have tested parent-only interventions for childhood anxiety and among these existing studies [31–33] the
emphasis has been on training parents as lay therapists to
implement cognitive behavioral therapy (CBT) with the
child. One recent exception is a therapist-led, parent-based
treatment intervention for childhood anxiety called the supportive parenting for anxious childhood emotions program
(SPACE) [34]. The SPACE program is a parent-only intervention that moves away from teaching parents specific
sets of skills and aims to target the fundamental dynamics underlying the interaction between parents and anxious
children. However, the SPACE program is yet to be adapted
or trialed in a group setting.
More promising is recent evidence that supports the
theorized cross-impact effects of group-based parent interventions on child outcomes. That it, there is theoretical
and empirical evidence to suggest that disruptive behaviors and internalizing symptoms have similar developmental antecedents (i.e., exposure to negative parenting practices) and may respond to like interventions [35, 36]. For
instance, Webster-Stratton and Herman [37] found that
the Incredible Years (IY) Parent Training (PT) program
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reduced internalizing symptoms in children in addition to
its well-established effects on child conduct problems. In
a recently conducted randomized control trial, Niec et al.
[38] investigated the relative efficacy of a novel group
format of parent–child interaction therapy (PCIT) versus individual PCIT with parents of 3–6-year-old children
with oppositional defiant or conduct disorder. Study results
demonstrated that in addition to experiencing a significant
reduction of conduct problems, children in both group and
individual PCIT experienced a significant reduction of
internalizing symptoms from intake to post-treatment and
from intake to follow-up. While such results are encouraging, a paucity of research trials that focus on implementation of parent training programs that specifically target
internalizing problems in early primary school aged children or that evaluate child internalizing outcomes resulting
from group-based parent programs with primary school
aged children remains a major shortcoming in the knowledge base.
Current Review
This review seeks to address several gaps in knowledge
of evidence-based parent group interventions. First, it
includes the breadth of group-based parent interventions,
such as studies in which parent group training is delivered
as a stand-alone group treatment, parallel group intervention (i.e., with concurrent child group treatment) or part
of a multi-systemic intervention. Second, it includes studies delivered in ‘real world’ settings (i.e., school settings)
rather than being restricted to clinic or research settings
only. Third, while clinical work directed at parents has been
advocated as a potential enhancer of treatment outcomes
for internalizing problems such as anxiety in children and
adolescents, there have been inconsistent findings in the
research literature regarding whether parent involvement
in treatment significantly improves child anxiety outcomes
[39]. Therefore, group-based parent treatments aimed at
ameliorating child internalizing problems will be encompassed within this review. Finally, in the last decade a number of more recently developed parent group programs have
been trialled that have not been included in prior systematic
reviews. This paper aims to encompass and review such
programs.
Given group-based parent training programs may arguably enhance efficiency and provide parents with increased
peer support and reassurance, this systematic review and
meta-analysis of the current literature examined the efficacy of identified parent group interventions to reduce
externalizing and internalizing problems in children aged
4–12 years. This review had the overarching aim of evaluating the efficacy of parent group interventions to treat
externalizing and/or internalizing problems in children.
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Child Psychiatry Hum Dev (2018) 49:244–267
Specifically, this review also aimed to: (1) describe and
summarize characteristics of the included studies; (2)
examine whether there is a cross-impact treatment effect on
internalizing problems evident in children with externalizing behavior problems whose parents participated in group
programs; and (3) explore if treatment efficacy varies as a
function of treatment recipient (i.e., parent group versus
parent group +/− teacher and/or child intervention components), study quality (i.e., summary risk assessment), and
planned number of hours of parent group intervention.
Method
Identification of Trials
A systematic review and meta-analysis was conducted in
keeping with the preferred reporting items for systematic
reviews and meta-analyses (PRISMA) [40]. A literature
search was conducted for all peer reviewed studies from 01
January 2005 to 21 October 2016, with the aim of locating
trials of parent group interventions for children aged 4–12
years with externalizing and/or internalizing problems.
Earlier studies (i.e., those published prior to 2005) were
excluded to ensure that the results of our analysis were
representative of trials of contemporaneous parent group
programs as well as more recently developed programs
not encapsulated in prior reviews. An electronic search of
the databases PsycINFO, Medline and CINAHL was performed using key words for child externalizing (behaviour,
conduct, externalizing, oppositional, aggressive, impulsivity, hyperactive, or antisocial) and internalizing (emotional,
internalizing, anxiety or depression) problems, combined
with keywords for group-based parent training (parent,
group, training, intervention, education, outcome, program, or treatment). Searches were limited to peer reviewed
papers and children aged 0–12 years. In addition, reference
lists of articles located by this search were hand searched
for additional papers to be included in the review.
Studies met selection criteria for this systematic
review if they (a) included a therapist-led, manualized
parent group intervention aimed at improving externalizing and/or internalizing problems for children aged
4–12, (b) evaluated the parent group intervention in comparison with a control (active or inactive), (c) included a
standardized measure of child externalizing and/or internalizing outcomes, (d) included quantitative analysis of
outcomes, (e) were published in a peer-reviewed journal, and (f) excluded children with primary or co-morbid diagnoses of intellectual disability, communication
disorder, or autism spectrum disorder. Studies reporting
on findings from the same trial were included in the systematic review, provided they reported on different child
Child Psychiatry Hum Dev (2018) 49:244–267
externalizing and/or internalizing outcome measures and
otherwise met criteria for inclusion in the review. The
review authors took care to ensure that the participant
characteristics from articles reporting outcomes from the
same trial were not ‘double counted’ (i.e., when reporting on the total number of participants included in the
review).
To accurately reflect the breadth of contemporaneous
methods of delivery of parent group training, studies in
which parent group training was delivered as a standalone group treatment, parallel group intervention (i.e.,
with concurrent child group treatment) or part of a multisystemic intervention were considered for inclusion. Due
to the high levels of co-morbidity between oppositional
and conduct problems and attention deficit hyperactivity
disorder (ADHD), samples including children with comorbid ADHD or ADHD alone were included in the systematic review provided a primary concern for the child
participants was externalizing behavior problems such
as aggression, conduct problems or oppositional behavior and the parent group intervention component was
designed to teach parents skills to manage externalizing
behavior separate from skills learned to manage specific
ADHD symptoms. However, samples including children
with primary or co-morbid diagnoses of intellectual disabilities, communication disorders, or autism spectrum
disorder were excluded, as children with these conditions require specialized and often modified approaches
to intervention. Studies in which child- or family-focused
interventions were the primary focus were not included in
this review. Studies were also excluded if it was evident
that they were not experimental in nature or examined
a question other than the efficacy of parent group training in improving child externalizing and/or internalizing problems. Studies were not excluded on the basis of
theoretical orientation of the parent group intervention of
interest.
One author (SB-P) independently reviewed all abstracts
located in the electronic database searches and conducted
an initial elimination of studies based on selection criteria. Eligibility assessment was performed on all remaining studies in a non-blinded standardized manner by three
authors (SB-P, KMG and GAM). One author (SB-P) then
independently extracted data from the included studies into a format for systematic review based on existing
guidelines [41, 42]. Study authors were contacted to obtain
further information about data or details not reported for
the included papers. The other authors then reviewed this
extracted information for accuracy and completeness. Risk
of bias was assessed for each study by three authors (SB-P,
KMG and GAM) using The Cochrane Collaboration’s tool
[41]. One author (MG) conducted all meta-analyses undertaken in this review.
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Ratings of Study Quality
Evaluating potential risks of bias in a body of research evidence is an important yet complicated task. The PRISMA
statement recommends that systematic reviews and metaanalyses include assessments of risk of bias within and
across studies [40]. Based on PRISMA recommendations,
all included studies in this review were assessed using a
standardized risk of assessment tool. The current review
authors assessed study quality using two approaches. First,
in accordance with guidelines from the Cochrane Handbook for Systematic Reviews of Interventions [41], the
quality of each RCT was rated in eight criterion categories: random sequence generation, allocation concealment,
blinding of participants and personnel, blinding of outcome
assessment, attrition bias, reporting bias, and any other bias
deemed important. Bias can occur in any of these areas and
can affect the interpretation of the study’s results. Based on
guidelines, each of the eight criterion categories within an
individual study was judged as ‘high’ (plausible bias that
seriously weakens confidence in results), ‘low’ (plausible
bias unlikely to seriously alter the results), or ‘unclear’ risk
of bias (plausible bias that raises some doubt about the
results) by the reviewing authors.
For the second assessment of study quality, the three
criterion categories related to blinding of participants, personnel and outcome assessors (i.e., performance and detection bias) were excluded and a summary risk assessment
for each study was based on ratings across the remaining
five criterion categories (random sequence generation; allocation concealment; incomplete outcome data; selective
reporting; and, any other bias). The rationale for excluding
performance and detection bias criterion categories from
this second assessment of study quality is that almost invariably parents and study personnel (i.e., therapists) in parent
group intervention studies are not completely blinded; they
are usually aware whether or not they or their child have
received a particular intervention or intervention arm in a
trial. Further, parent report of child externalizing and internalizing problems is the most common outcome source
and often the most appropriate and feasible way to obtain
assessment of key outcomes. The summary risk assessment
for each study based on these remaining five criterion was
rated as follows: ‘low risk’ of bias (‘low risk’ of bias for all
five criterion); ‘unclear risk’ of bias (‘unclear risk’ of bias
for one or more criterion); and, ‘high risk’ of bias (‘high
risk’ of bias for one or more criterion).
Meta‑analyses
Data from parent- and clinician-reported measures of
child externalizing and internalizing problems were
used in meta-analyses using a random effects model.
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Under the random effects model, the true effect size is
assumed to vary from study to study and the summary
effect is the estimate of the mean of the distribution of
effect sizes. Data were analyzed using a random effects
model as it was expected that the studies included in this
meta-analysis would differ on their study characteristics,
resulting in varying true effect sizes [43]. Separate metaanalyses were conducted to examine the effects of parent
group interventions on child externalizing and internalizing outcome measures, child anxiety, and cross-impact
treatment effect of parent group interventions on internalizing symptomatology evident in children with externalizing problems. All randomized controlled trials that
met inclusion criteria and provided sufficient data with
post and control variables to calculate an effect size were
included. Where more than one active treatment arm
was reported, the numbers, means and standard deviations were converted to a single treatment outcome using
the formula reported by Cochrane [41]. Where standard
errors were reported, standard deviations were calculated
using the formula reported by Cochrane [41]. Standardized mean differences were calculated with a random
effects model using Hedges’ g. Hedges’ g was used, as
it corrects for biases due to small sample sizes, which is
not assumed under Cohen’s d. Hedges’ g < 0.5 indicate a
small effect size, g = 0.5–0.8 indicate a moderate effect
size and g > 0.8 indicate a large effect size [44].
Heterogeneity was assessed using visual inspection of
the forest plots and the I2 index. The I2 index was computed to provide a measure of the degree of heterogeneity, where I2 is interpreted as the percentage of variability among effect sizes that exists between studies
relative to the total variability among effect sizes [45].
The I2 index can be interpreted as follows: 0% indicates
homogeneity; 25% indicates small heterogeneity; 50% is
medium; and 75% is large [45]. The level of significance
was set for p < 0.1 for the heterogeneity of the studies.
Publication bias was assessed using a funnel plot.
Meta-regression was conducted on those meta-analyses that were significant (p < 0.05). The I2 residual was
computed to provide a percentage of residual heterogeneity that is attributable to between-study heterogeneity. Independent variables of (1) hours of planned parent
group treatment as a continuous measure, (2) treatment
recipient (parent only versus parent +/− teacher and/
or child intervention components) as a categorical variable, and (3) study quality (summary risk assessment of
‘unclear risk’, ‘low risk’ or ‘high risk’) as a categorical
variable were entered in the regression as single variables. Statistical analyses were conducted using Stata 12
[46].
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Child Psychiatry Hum Dev (2018) 49:244–267
Results
Study Selection
As seen in Fig. 1, a total of 3992 articles were identified
through the initial database searches, 746 of which were
duplicates. An additional four potential studies were identified by hand searching the reference lists of included studies. When duplicates were removed and a review of the
titles and abstracts of the remaining 3250 abstracts completed, 3153 papers were excluded because they did not
meet the criteria. Of the remaining 97 articles, a further
74 papers were excluded (see Fig. 1 for reasons). Overall,
a total of 23 articles involving parent group interventions
from 21 RCTs were identified for inclusion in the review.
These articles were published between March 2006 and
April 2016. Articles by Duncombe et al. [47] and Havighurst et al. [48] reported findings from the same trial. Both
articles were included in the current review as they measured child externalizing problems using different outcome
measures. Articles by Chacko et al. [49] and Rajwan et al.
[50] also reported findings from the same trial using different outcome measures and were therefore both included in
the review.
Study Characteristics
Characteristics of each study are included in Table 1 and
summarised below.
Study Design and Treatment Focus
As seen in Table 1, 19 of the 23 (82.6%) studies included
in this review were RCTs and the remaining four studies
(17.4%) were cluster RCTs. In regard to treatment focus,
20 studies (87.0%) evaluated outcomes of intervention programs aimed primarily at addressing child externalizing
problems [47–53, 55–58, 60–66, 68, 69]. The remaining
three studies [54, 59, 67] evaluated outcomes of interventions aimed exclusively at parents of children with internalizing problems.
Number of Treatment Sessions
The number of group treatment sessions completed by parent participants ranged from 3 to 28 sessions across studies.
Session length ranged from 60 min (1-h) to 150 min (2.5-h)
across studies.
Booster Sessions
Of the 23 studies included in this review, four (17.4%) of
studies described use of booster sessions post treatment
Included
Eligibility
Screening
Identification
Child Psychiatry Hum Dev (2018) 49:244–267
249
Records identified through
database searching
(n = 3992)
Additional records identified through
hand searches of reference lists of
located papers or via contact with field
authors (n = 4)
Records screened after
duplicates removed
(n =3250)
Full-text articles assessed
for eligibility
(n = 97)
Studies included in
review
(n = 23)
Records excluded as did not meet
criteria (n =3153)
Articles excluded (n = 74) because:
Outside specified age range
(n = 23)
No therapist-led parent group
intervention (n = 18)
Not an RCT (n = 14)
Did not target child
emotional/behavioral problems
(n = 8)
Non-English language and no
translation located (n = 4)
Sample included children with
known diagnoses of Pervasive
Developmental Disorders, ID or
Communication Disorders (n = 3 )
Moderator analyses of data only
(n = 2)
No measure of child
emotional/behavioral problems
(n = 1)
Study protocol only (n = 1)
Fig. 1 PRISMA flow chart describing identification and selection of studies for inclusion in the systematic review adapted from Moher et al.
[40]
[54, 57, 59, 67]. Havighurst et al. [57] incorporated two
parent booster sessions offered at two-monthly intervals
post intervention. Waters et al. [67] offered booster sessions to parent and child participants in both active treatment conditions 8 weeks after the final sessions. De Groot
et al. [54] conducted one booster session with children
approximately 3–4 weeks following completion of the child
program. Finally, Holmes et al. [59] offered two booster
sessions to parents and children at 1 and 3 months after
completion of the initial program.
Settings
Studies were based on trials conducted in a variety of settings, including: university clinics [49, 50, 52, 54, 58, 59,
67–69], social service organizations [55], primary school
or kindergarten settings [47, 48, 53, 56, 64, 65], community
settings [57], community or school sites [61, 63], outpatient
child mental health clinic settings [51, 60, 66], and insufficiently described settings [62].
Seven (30.4%) studies were based on trials conducted
in Australia [47, 48, 54, 57, 59, 67, 69], five (21.7%) studies were based on trials conducted in the USA [49, 50, 58,
61, 68], and four (17.4%) were based on trials conducted
in the United Kingdom [62–65]. The remaining trials were
conducted in Belgium [52], Hong Kong [55], Ireland [56],
Norway [60], the Netherlands [66], Romania [53], and
Sweden [51].
Participants
The included studies involved a total of 2197 eligible participants. The total sample size per study varied greatly,
ranging from 18 to 320 across studies. Trial samples
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Group CBT program
Individual CBT program
Tuning in to kids (TIK)
Triple P—Positive Parenting Program (Triple P)
Anger Coping Training
(ACT)
Parents Plus Children’s
Program (PPCP)
TIK
TIK
5. de Groot et al. [54]
6. Duncombe et al. [47]b
8. Hand et al. [56]
9. Havighurst et al. [47]
10. Havighurst et al. [56]
7. Fung & Tsang [55]
RCT
Cluster
RCT
RCT
TIK (n = 31)
WL (n = 23)
TIK (n = 91)
WL (n = 113)
PPCP (n = 44)
No treatment CG (n = 31)
Cluster RCT TIK (n = 91)
Triple P (n = 116)
WL (n = 113)
RCT
ACT program (n = 12)
Control group (n = 6)
RCT
Group CBT (n = 15)
Individual (n = 14)
Standard program (n = 47)
Enhanced program
(n = 45)
Wait-list (n = 38)
RCT
4. David et al. [53]
Traditional BPT (n = 40)
STEPP (n = 40)
WL (n = 40)
RCT
Traditional behavioral parent training
STEPP (Strategies to
Enhance Positive Parenting) program
Standard Cognitive Behavioral Parenting Program
(Standard)
Rational Positive Parenting
Program (Enhanced)
3. Chacko et al. [49]a
RCT
Parent Management Training (PMT)
Conditions
2. Braet et al. [52]
Design
PT (n = 37)
WL (n = 24)
PMT (n = 34)
WL (n = 30)
Parent group program(s)
1. Axberg and Broberg [51] Incredible Years BASIC PT RCT
Study
Table 1 Summary of study characteristics
Pre, post, 3 mo FU
Pre, post, 12 mo FU
Pre, post, 12 mo FU
Measure times
Parents of children (aged
4–9 years) screened for
conduct problems
Parents of children (aged
8–10 years) screened for
aggressive behaviors
Parents of children (aged
6–11 years) self-selected
to participate
Primary caregivers of
children (aged 4–9 years)
screened for conduct
problems
Parents of children (aged
4–5 years) who presented
with externalizing behavior difficulties
Parents of children with a
principal diagnosis of an
anxiety disorder
8, 2.5-hr weekly sessions.
(B)
8, 2-hr parent group sessions.
(B)
6, 2-hr weekly sessions. (B)
Baseline
6 mo FU
Pre, Post
6 mo FU
Standard : 10, 90-min sessions. (B)
Enhanced: 10, 90-min sessions, incorporating an
emotion-regulations strategies module. (B)
Group CBT: 12-session
(60–90 min) manualized program including 6
parent-focussed sessions.
(E)
TIK: 8, 2-hr weekly parent
group sessions. (B)
PPP: as above. (B)
10 sessions, 1.5 h per session. (B)
Traditional BPT: 9, 2.5-hr
weekly sessions. (B)
STEPP: 9, 2.5 h weekly sessions. (B)
6–8 parents, weekly 2-h sessions, 12–14 weeks. (B)
8–10 parents, 11 (2-hr)
sessions, spread over 24
weeks. (B)
Parent group program
description and treatment
aim
Pre, post
6 mo FU
Pre, post
3 mo FU
Baseline
6 mo FU
Pre, post, 3 mo FU
6 mo FU
Pre, mid, post
Parents of children (aged
4–12 years) with external- 1 mo FU
izing behavior problems
Parents of children (aged
4–8 years) with ODD
Parents of children (aged
4–7 years) exhibiting
problematic or externalizing behavior
Single mothers of children
with ADHD
Participants
250
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Triple P (n = 73)
Waitlist and services as
usual (n = 73)
Traditional BPT (n = 40)
STEPP (n = 40)
RCT
No Worries! Program
Basic IY Parenting Program
IY Parenting Program
Group Triple P
Traditional Behavioral Par- RCT
ent Training
STEPP Program
1-2-3 Magic Parenting
Program
IY Parenting Program
12. Holmes et al. [59]
13. Larsson et al. [60]
14. Lau et al. [61]
15. Little et al. [62]
16. Rajwan et al. [50]
17. Sayal et al. [63]
18. Scott, O’Connor et al.
[64]
IY Parenting Program
(n = 32)
Delayed treatment (n = 22)
PT (n = 51)
PT + CT (n = 55)
WL condition (n = 30)
Cluster RCT Parent only arm (n = 67)
Parent + Teacher arm
(n = 60)
Control arm (n = 72)
RCT
IY Program plus six-week
literacy program (n = 88)
Usual community services
(control group; n = 86)
RCT
RCT
Cluster RCT PT (n = 31) PT + TT
(n = 24)
CT (n = 30) CT + TT
(n = 23)
PT + CT + TT (n = 25)
WL (n = 26)
RCT
WL (n = 22)
Treatment group (n = 20)
Incredible Years (IY)
Series
Conditions
11. Herman et al. [58]
Design
Parent group program(s)
Study
Table 1 (continued)
Pre
Parents of children (aged
5–6 years) in the screened 12 mo FU
population who scored
above the cut-off level
for ODD symptoms or
conduct problems
Baseline
3 mo and 6 mo after baseline
4, 2.5-hr parent sessions plus
four individual telephone
consultations (15–30 min
duration each). (B)
Baseline
6 mo FU
Parents of children (aged
4–8 years) at risk of
ADHD
5–10 parents, 14 (2-hr) sessions. (B)
Pre, post
6 mo FU
18, 2-hr sessions were
offered, interleaving a
12-week parenting program
with a 6-week literacy
program. (B)
Traditional BPT: 9, 2.5-hr
weekly sessions. (B)
STEPP: 9, 2-5hr weekly sessions. (B)
1–7 parents, 3 (2-hr) weekly
sessions. (B)
10–12 parents, 12–14 weeks,
2-hr sessions. (B)
Baseline, post
12 mo FU
Baseline
Post
7 weekly (1.5-hr) sessions.
(E)
Pre, post, 3 mo FU
Parents of children (aged
7–12 years) with a primary clinical diagnosis
of GAD
Parents of children (aged
4–8 years) with subthreshold or definitive
diagnosis of ODD and/
or CD
Chinese American parents
and their children (aged
5–12 years) referred for
PT due to concerns about
parental discipline or
child behavior problems
Parents of children (aged
4–9 years) whose symptoms indicated a potential
social-emotional or
behavioral disorder
Single mothers of children
with ADHD
10–12 parents, 22–24 weekly
(2-hr) sessions. (B)
Pre, post
12 mo FU
Parents of children (aged
4–8 years) with ODD
Parent group program
description and treatment
aim
Measure times
Participants
Child Psychiatry Hum Dev (2018) 49:244–267
251
13
13
Behavioral parent training
(BPT)
‘‘Take ACTION’’ Program RCT
Incredible Years (IY) treatment condition
Pathways Triple P (PTP)
20. van den Hoofdakker
et al. [66]
21. Waters et al. [67]
22. Webster-Stratton et al.
[68]
23. Wiggins et al. [69]
PTP intervention (n = 30)
WL (n = 30)
IY treatment condiction
(n = 49)
WL (n = 50)
PO condition (n = 25)
P + C condition (n = 24)
WL (n = 11)
BPT + uncontrolled Routine Clinical Care (RCC)
(n = 47)
Uncontrolled RCC alone
(n = 47)
IY Program plus six-week
literacy program (n = 61)
Control (Helpline; n = 51)
Conditions
28 weeks of intervention,
including parent group program and literacy program,
delivered to 4–8 parents
for 2.5 h one morning per
week. (B)
12, 120-min sessions. Six
children’s parents could
participate in each group.
(B)
Pre
12 mo FU
Parents of children (aged
5–6 years) in the screened
population who scored
above the cut-off level
for ODD symptoms or
conduct problems
Parents of children (aged
4–12 years) with ADHD
who had been referred
to an outpatient mental
health clinic by their
general practitioners
Parents of children (aged
4–8 years) with specific
phobia, social phobia,
generalized anxiety
disorder and/or separation
anxiety disorder
Parents of children (aged
4–6 years) with ADHD
(hyperactive or inattention)
Parents of children (aged
4–10 years) with parent–child relationship
disturbance and parentreported child emotional
or behavioral problems
10 parents, 9 weekly (2-hr)
sessions. (B)
Pre, post, 3 mo FU
Pre, Post
Parents of children in the
PO and P + C conditions received 10 weekly
sessions of group-based
cognitive-behavioral treatment (GCBT). (E)
IY treatment condition: 6
parents, 20 weekly (2-hr)
sessions. (B)
Pre, post, 6 mo FU, 12 mo
FU
Pre, post, 6 mo FU
Parent group program
description and treatment
aim
Measure times
Participants
Duncombe et al. [47] and Havighurst et al. [48] studies based on the same trial
b
Chacko et al. [49] and Rajwan et al. [50] studies based on the same trial
a
B behavioral problems, CG control group, CT child therapy, E emotional problems, FU follow-Up, mo months, P + C parent + child, PD professional development, PO parent only, PT parent
training, RCT randomized control trial, TT teacher training, WL waitlist control
RCT
RCT
RCT
RCT
IY Parenting Program
19. Scott, Sylva et al. [65]
Design
Parent group program(s)
Study
Table 1 (continued)
252
Child Psychiatry Hum Dev (2018) 49:244–267
Child Psychiatry Hum Dev (2018) 49:244–267
included a majority of male child participants with exception of four studies [53, 59, 64, 67]. Data pertaining to sex
of child participants was not stated in Hand et al. [56]. The
majority of parent participants were female however parent
gender was not stated in five studies [59, 62–64, 66].
The majority of studies (16/23 or 69.6%) included
samples of children with diagnoses of or sub-threshold
symptoms of externalizing or internalizing disorders. Specifically, nine (39.1%) studies focused on evaluation of
interventions with parents of children with diagnoses of
ADHD [49, 50, 66, 68], ODD [51, 58], or anxiety disorders [54, 59, 67]. Seven (30.4%) studies evaluated interventions with parents of children with specific difficulties
such as oppositional or conduct problems [47, 48, 60, 64,
65], aggressive behaviors [55], or sub threshold symptoms
of ADHD [63]. Four studies (17.4%) evaluated interventions with parents of children with general externalizing
behavior concerns [52, 53, 57, 61] and two studies (8.7%)
included samples of children at risk of social-emotional or
behavioral disorders [62, 69]. One study (4.4%) included
children whose parents self-selected to participate in parent
training [56].
Economic status of participants varied across studies. For instance, samples ranged from being, on average,
markedly disadvantaged [64, 65] to majority of participants
reporting they had no significant financial problems [69].
Four studies (17.4%) involved participants from predominantly low income families [52, 55, 61, 62], three studies
(13.0%) had samples that were predominantly from a low
to middle socioeconomic demographic [47, 48, 57], one
study [68] had a sample of parents with predominantly
middle socioeconomic status, and two studies had samples
of parents with predominantly middle to high socioeconomic status [53, 59]. Economic status of participants was
not explicitly stated for 10 (43%) studies [49–51, 54, 56,
58, 60, 63, 66, 67].
Selection Criteria
Inclusion criteria relating to child characteristics included
specified age range for child [47–53, 58, 60, 62, 63, 66,
69]; elevated child scores on parent/teacher-rated behavioral and/or emotional problem measures [47–50, 52, 53, 55,
62–65, 69]; parent-reported child misconduct or child met
sub threshold or definitive diagnosis of DSM-IV criteria
for ODD or CD [51, 58, 60]; child met DSM-IV criteria
for ADHD [49, 50, 66, 68] or an anxiety disorder [54, 67];
child met DSM-IV criteria for primary diagnosis of GAD
with clinical severity rating (CSR) of at least 4 (on a 0–8
scale) [53] and, minimum reading level of 7 years [53].
Inclusion criteria across studies for parent characteristics consisted of parent and/or clinician identified need for
parent training [61]; both parents (if present) willing and/
253
or able to participate in the group program [65, 66]; parent–child relationship disturbance in borderline to clinically
significant range [69]; parent ability to understand English
[65] or Swedish [51] language; and single mother as primary caregiver [49, 50]. Four studies [56, 57, 63, 68] did
not specify parental inclusion criteria.
Children were excluded if they had intellectual disability/developmental delay [58–60, 64–66]; IQ less than 80
[49, 50]; organic brain damage [67] communication disorder [57]; pervasive developmental disorder [47–50, 57, 59,
60, 67]; debilitating physical impairment [58, 60]; sensory
deprivation [60]; history or evidence of psychosis [49, 50,
58, 67]. One study [67] excluded children with a co-morbid
externalizing disorder, as the CBT-based group treatment
was focused on children with anxiety disorders. A further
study [53] excluded children referred for internalizing disorders as the primary problem, as the focus of treatment
was for child externalizing behavior problems.
Children were also excluded if they were taking medication to treat ADHD [57, 68] or were already in receipt
of psychological, pharmacological or medical treatment
[53, 54, 58–60, 67]; had significant medical problems [54];
had severe learning difficulties [54, 59]; met diagnostic
criteria for a clinically significant non-anxiety diagnosis
([54]; treatment focused on treatment of child anxiety); had
behavioural problems more impairing than anxiety ([59];
study focused on treatment of child anxiety); and had substance abuse, self harm or suicidal ideation [59]. Two studies did not specify child exclusion criteria [51, 63].
Other exclusion criteria across studies included criteria
not specifically stated [51, 52, 55, 58, 61–63, 65, 66, 68,
69]; no exclusionary criteria applied [56]; insufficient parent English skills to complete assessment or understand
content of intervention [57, 64]; parent presenting with
psychotic disorders, current substance abuse or intellectual
disability [53]; parent declined invitation to participate [47,
48]; and, schools withdrew from study following screening
[47, 48].
Interventions
In regard to parent group programs evaluated, seven
(30.4%) studies evaluated versions of the Incredible Years
program [51, 58, 60, 61, 64, 65, 68], two studies evaluated versions of the Triple P Program—Positive Parenting
Program [62, 69], and two studies evaluated the Tuning
into Kids (TIK) program [48, 57]. Duncombe et al. [47]
evaluated both the Triple P Parenting—Positive Parenting Program and TIK programs. Other programs evaluated
included Parent Management Training [52], behavioral
parent training [66], Anger Coping Training (ACT) parent–child parallel group program [55], Parents Plus Children’s Program (PPCP) [56], and the Take Action Program
13
254
[67], Behavioral Parent Training (BPT) versus Strategies
to Enhance Positive Parenting (STEPP) [49, 50], No Worries! Program (cognitively-focused program) [59], Standard
Group based Cognitive-Behavioral Parent Program versus
Enhanced Cognitive-Behavioral Parent Programs [53], Do
as I do program for parents (group CBT) [54] and, 1-2-3
Magic parenting program [63].
Outcome Measures
Child externalizing and internalizing problems were
measured using a variety of outcome measures. All of the
included studies used parent report measures. Teacherreported measures were used in ten (43.5%) studies [47,
48, 51–53, 55, 57, 59, 64, 68]. Investigator-based parent
interview was used in five (21.7%) of studies [54, 59, 64,
65, 67]. Child assessed measures were used in three studies
[47, 54, 59]. Refer to Table 1 for details of timing of outcome assessment for individual studies.
Treatment Fidelity
Of 23 studies included within this review, 20 (87.0%) studies reported efforts or measures taken to ensure treatment
fidelity [47–51, 53, 54, 57–69]. Nineteen studies (82.6%)
reported satisfactory or high treatment fidelity. One study
[62] reported poor treatment fidelity.
Child Psychiatry Hum Dev (2018) 49:244–267
Child Externalizing Problems
Twenty studies (87.0%) reported on child externalizing
problem outcomes using parent report [47–53, 55–57,
60–69]. Clinician-rated diagnostic interviews with parents
were used to measure child externalizing problems in two
studies [64, 65].
Of the 20 studies that measured child externalizing
problems, 16 (80.0%) of the included studies reported statistically significant findings that favored the parent group
intervention over control (or alternative treatment) for child
externalizing problems [47–51, 53, 55–57, 60, 61, 63, 65,
66, 68, 69]. Four of the studies [52, 62, 64, 67] reported
no statistically significant difference between groups. Three
studies [54, 58, 59] did not measure child externalizing
problems.
Effect size values reported with Cohen’s d for difference
in outcomes between intervention groups versus control
on parent-reported measures [70–74] of child externalizing problems ranged from negligible to large (d = 0–1.26).
Effect size values reported with partial eta squared for
difference in outcomes between intervention groups versus control on parent-reported measures [70, 71, 74] of
child externalizing problems ranged from medium to large
(partial η2 = 0.04–0.24). Effect size values reported with
Cohen’s d for difference in outcomes between intervention
groups versus control on clinician-reported measures [75]
of child externalizing problems showed medium treatment
effect (d = 0.44–0.52).
Study Outcomes
Child Internalizing Problems
The results of the 23 included papers are listed in Table 2.
Results are based on post/follow-up treatment outcomes for
parent- and clinician-reported measures of child externalizing and internalizing problems. Statistically significant
differences (p values) in outcome between intervention
group(s) versus control have been indicated where available
throughout. Effect sizes for differences in outcome between
intervention group(s) versus control are also reported
where available. Effect sizes were presented using partial
eta squared (partial η2; [44]) in four studies [59, 67–69]
and Cohen’s d [44] in 13 studies [47–49, 51–53, 56–58,
60, 61, 65, 66]. Effect sizes were not reported in six studies
[50, 54, 55, 62–64]. According to Cohen [44], guidelines
for magnitude of partial eta squared are that 0.02, 0.13 and
0.26 indicate small, medium and large effect sizes respectively, whereas guidelines for magnitude of Cohen’s d are
that 0.2, 0.5 and 0.8 indicate small, medium and large effect
sizes respectively. The following component of this section
of the review provides a narrative summary of the effects
of the parent group interventions on the two key child outcome variables of interest.
Fourteen studies (60.9%) reported on child internalizing
problem outcomes [51, 52, 54, 56, 58–62, 65–69]. All fourteen studies used parent-rated measures. Four studies [54,
59, 65, 67] used clinician-rated diagnostic interviews with
parents to measure severity of child anxiety symptoms.
Of the fourteen studies that measured child internalizing
problems, five (35.7%) studies included statistically significant findings that favored the parent group intervention
over control (or alternative treatment) for child internalizing problems [58–60, 66, 67]. Nine of the fourteen studies
(64.3%) reported outcomes showing no statistically significant difference between groups [51, 52, 54, 56, 61, 62, 65,
68, 69]. Little et al. [61] reported that emotional disorders
for some children whose parents participated in the TripleP groups increased in severity compared with those in the
control group receiving services as usual. Nine studies did
not measure child internalizing outcomes [47–50, 53, 55,
57, 63, 64].
Effect size values reported with Cohen’s d for difference
in outcomes between intervention groups versus control
on parent-reported measures [70, 72] of child internalizing
13
BPT and STEPP combined > waitlist
DBD oppositional defiant disorder (P) (p < 0.01,
d = 0.44)**
BPT and STEPP combined = waitlist
DBD inattentive (P) (ns, d = 0)
DBD hyperactive/impulsive (P) (ns, d = 0.11)
STEPP > traditional BPT
DBD oppositional defiant disorder (P) (p < 0.01,
d = 0.75)**
STEPP = traditional BPT
DBD inattentive (P) (ns, d = −0.16)
DBD hyperactive/impulsive (P) (ns, d = −0.16)
Standard program > WL
CBCL externalizing behavior (P) (p < 0.001,
d = 0.80)***
Enhanced program > WL
CBCL externalizing behavior (P) (p < 0.001,
d = 0.76)***
Outcome not measured
3. Chacko et al. [49]b
N = 120
6. Duncombe et al. [47]c
N = 320
5. de Groot et al. [54]
N = 29
4. David et al. [53]
N = 130
TIK or PPP > WL
ECBI behavior intensity (P) 6-month FU
(p = 0.000, d (TIK) = 0.40, d (PPP) = 0.40)***
PT > WL
ECBI behavior intensity (P) (p = 0.001,
d = 1.17)**
ECBI behavior problems (P) (p = 0.003,
d = 1.26)**
PMT = WL
CBCL total problem behavior (P) (ns, d = 0.66)
CBCL externalizing behavior (P) (ns, d = 0.91)
CBCL aggressive behavior (P) (ns, d = 0.81)
CBCL delinquent behavior (P) (ns, d = 0.63)
1. Axberg and Broberg [51]
N = 61
2. Braet et al. [52]
N = 64
Child externalizing o­ utcomesa
Study
Table 2 Summary of child outcomes and quality of evidence
High (outcome assessment partially blinded; not
all of the study’s pre-specified outcome measures
were reported; reported loss to follow up imbalanced across groups: PMT −4/34 (12%) loss and
WL −11/30 (37%) loss; study did not specify
reasons for attritions or exclusions; randomization
claimed but not described and unclear if allocation was concealed)
Unclear (outcome assessment partially blinded;
unclear randomization method and allocation
concealment unclear; study did not specify reasons for attritions)
Unclear (outcome assessment partially blinded;
unclear randomization method and allocation
concealment unclear; adequate attrition analysis)
PMT = WL
CBCL internalizing behavior (P) (ns, d = 0.23)
Outcome not measured
GCBT = ICBT
ADIS-IV-C/P clinical severity of anxiety (CL)
(ns)
SDQ emotional symptoms (P) (ns)
Outcome not measured
High (outcome assessment partially blinded;
unclear randomization method; allocation not
concealed as parents aware of allocation when
received pre-measures via post)
Unclear (outcome assessment not blinded; randomization method described but unclear if allocation concealed)
Unclear (outcome assessment partially blinded;
unclear randomization method and allocation
concealment unclear; unequal sample sizes)
PT = WL
SDQ emotional symptoms (P) (p = 0.993,
d = 0.004)
Outcome not measured
Quality of evidence—bias risk
Child internalizing o­ utcomesa
Child Psychiatry Hum Dev (2018) 49:244–267
255
13
13
PPCP > CG
SDQ total difficulties (P) (p < 0.01, d = 0.32)**
SDQ hyperactivity problems (P) (p < 0.01,
d = 0.31)**
SDQ conduct problems (P) (p > 0.05, d = 0.41)
PPCP = CG
SDQ peer problems (P) (p > 0.05)
TIK > WL
ECBI oppositional defiant disorder (P) 6-month
FU (p = 0.011, d = 0.37)*
ECBI conduct disorder (P) 6-month FU
(p = 0.012, d = 0.37)*
TIK = WL
ECBI hyperactivity disorder (P) 6-month FU
(p = 0.066, d = 0.29)
TIK > WL (treatment as usual)
ECBI behavior intensity (P) (p = 0.009,
d = 1.20)**
TIK = WL (treatment as usual)
ECBI behavior problems (P) (ns, d = 1.05)
Outcome not measured
8. Hand et al. [56]
N = 75
12. Holmes et al. [59]
N = 42
11. Herman et al. [58]d
N = 159
10. Havighurst et al. [57]
N = 54
Outcome not measured
ACT > CG
CBCL aggressive behavior (P) (p < 0.01)**
7. Fung & Tsang [55]
N = 18
9. Havighurst et al. [48]
N = 204
Child externalizing o­ utcomesa
Study
Table 2 (continued)
Unclear (outcome assessment partially blinded;
randomization technique adequate but unclear if
allocation concealed)
High (outcome assessment partially blinded;
unclear randomization method and unconcealed
allocation; results of two experimental groups
collapsed into one overall group (n = 12) and
compared with control group (n = 6), leading to
potential source of bias in results)
High (outcome assessment not blinded; randomization claimed but method unclear; at 6-month
follow-up, there was approximately 55% missing
data for participating families from the intervention group - nil reasons provided regarding attrition at post-intervention or follow-up for either
group; nil intention-to-treat analysis performed)
Unclear (outcome assessment not blinded; randomization technique adequate but unclear if
allocation concealed)
Quality of evidence—bias risk
Unclear (outcome assessment not blinded; ranTwo-Group ANCOVA analysis
domization technique adequate but unclear if
PT + TT + CT > control
allocation concealed)
CBCL internalizing behavior (P) (p = 0.006,
d = 0.64)*
PT = control
CBCL internalizing behavior (P) (p = 0.06,
d = 0.42)
PT + TT = control
CBCL internalizing behavior (P) (p = 0.08,
d = 0.44)
Treatment program > WLC group
Low (outcome assessment partially blinded;
ADIS-IV-C/P severity of anxiety (CL) (p < 0.001,
adequate description of randomization method;
partial η2 = 0.43)***
attrition analyses adequate and attrition balanced
across groups)
Treatment program = WLC group
SCAS-P total anxiety score (P) (ns)
SCAS-P GAD subscale score (P) (p = 0.053)
CBCL internalizing behavior (P) (ns)
Outcome not measured
Outcome not measured
PPCP = CG
SDQ emotional symptoms (P) (p > 0.05)
Outcome not measured
Child internalizing o­ utcomesa
256
Child Psychiatry Hum Dev (2018) 49:244–267
PT > WL condition
ECBI behavior intensity (P) (p = 0.003,
d = 0.65)**
CBCL attention problems (P) (p = 0.012,
d = 0.53)*
CBCL aggressive behavior (P) (p = 0.007,
d = 0.58)**
PT = WL condition
ECBI behavior problems (P) (ns, d = 0.47)
PT + CT > WL condition
CBCL aggressive behavior (P) (p = 0.004,
d = 0.75)**
PT + CT = WL condition
ECBI behavior intensity (P) (ns, d = 0.42)
ECBI behavior problems (P) (ns, d = 0.55)
CBCL attention problems (P) (ns, d = 0.59)
IY parenting program > delayed treatment
CBCL externalizing behavior (P) (p < 0.05,
d = −0.40)*
Triple P = waitlist (receiving services as usual)
SDQ conduct problems (P) (p = 0.65)
SDQ hyperactivity (P) (p = 0.54)
SDQ total difficulties (P) (p = 0.83)
ECBI behavior intensity (P) (p = 0.40)
ECBI behavior problems (P) (p = 0.10)
STEPP > traditional BPT (sum of families who
met criteria for reliably improved but not recovered, reliably improved but came in functional,
and reliably improved and recovered)
ECBI behavior intensity (P) (p = 0.004)**
ECBI behavior problems (P) (p = 0.036)*
STEPP = traditional BPT: (reliable change and
recovery)
ECBI behavior intensity (P) (ns)
ECBI behavior problems (P) (ns)
13. Larsson et al. [60]d
N = 136
15. Little et al. [62]
N = 146
16. Rajwan et al. [50]
N = 120
14. Lau et al. [61]
N = 54
Child externalizing o­ utcomesa
Study
Table 2 (continued)
Outcome not measured
Unclear (outcome assessment partially blinded;
unclear randomization method and allocation
concealment unclear; study did not specify reasons for attritions)
High (outcome assessment not blinded; adequate
randomization method described; investigators
enrolling participants could possibly foresee
assignments and thus introduce selection bias)
High [unclear if outcome assessment blinded;
randomization method adequately described but
unclear if allocation concealed; poor fidelity of
implementation; poor attendance rate of parents
(average of 40% across groups)]
IY parenting program > delayed treatment
CBCL internalizing behavior (P) (p < 0.05,
d = −0.51)*
Triple P = Waitlist (receiving services as usual)
SDQ emotional symptoms (P) (p = 0.83)
Unclear (outcome assessment partially blinded;
randomization stated but insufficiently described;
unclear if allocation concealed)
Quality of evidence—bias risk
PT > WL condition
CBCL internalizing behavior (P) (p = 0.012,
d = 0.57)*
PT + CT = WL condition
CBCL internalizing behavior (P) (ns, d = 0.60)
Child internalizing o­ utcomesa
Child Psychiatry Hum Dev (2018) 49:244–267
257
13
Child externalizing o­ utcomesa
Parent + teacher arm > control arm
CPRS-R hyperactivity (P) (p = 0.05)*
Parent + teacher arm = control arm
CPRS-R oppositional (P) (p = 0.78)
CPRS-R inattention (P) (p = 0.64)
CPRS-R ADHD symptoms (P) (p = 0.31)
Parent-only arm = control arm
CPRS-R hyperactivity (P) (p = 0.24)
CPRS-R oppositional (P) (p = 0.17)
CPRS-R inattention (P) (p = 0.27)
CPRS-R ADHD symptoms (P) (p = 0.57)
18. Scott, O’Connor et al. [64]
IY parenting program = CG
N = 174
PACS conduct problems (CL) 12-month FU (ns)
SDQ conduct problems (P) 12-month FU (ns)
19. Scott, Sylva et al. [65]
IY parenting program > CG
N = 112
PACS ADHD symptoms (CL) 12-month FU
(p = 0.002, d = 0.44)**
PACS antisocial behavior (CL) 12-month FU
(p < 0.001, d = 0.52)***
ECBI oppositional defiant disorder (P) 12-month
FU (p = 0.011)*
20. Van den Hoofdakker et al. [66] BPT + RCC > RCC alone
N = 94
CBCL externalizing behavior (P) (p = 0.021, d
(BPT + RCC) = 0.56)*
BPT + RCC = RCC alone
CPRS-R: ADHD symptoms (P) (p = 0.161, d
(BPT + RCC) = 0.51)
P + C = PO
21. Waters et al. [67]
N = 60
CBCL externalizing behavior (P) (ns)
17. Sayal et al. [63]e
N = 199
Study
Table 2 (continued)
High (outcome assessment not blinded; adequate
randomization method described, baseline and
6-month outcome data collected for less than 50%
of parents)
Low (outcome assessment partially blinded;
adequate randomization method described and
allocation appears to have been concealed)
Low (outcome assessment partially blinded; randomization method adequately described; allocation appears to have been concealed)
Unclear (outcome assessment not blinded; randomization stated but insufficient information
about method; unclear if allocation concealed)
High (outcome assessment partially blinded; randomization stated but not described; allocation not
concealed)
Outcome not measured
IY Parenting Program = Control
PACS emotional symptoms (CL) 12-month FU
(p = 0.60, d = 0.10)
BPT + RCC > RCC alone
CBCL internalizing behavior (P) (p = 0.042, d
(BPT + RCC) = 0.33)*
P + C or PO > WL
ADIS-IV-C/P severity of anxiety (CL) (p < 0.05,
partial η2 = 0.08)*
P + C = PO
CBCL internalizing behavior (P) (ns)
SCAS-P total anxiety score (P) (ns)
Quality of evidence—bias risk
Outcome not measured
Child internalizing o­ utcomesa
258
Child Psychiatry Hum Dev (2018) 49:244–267
13
Intervention > WL
CBCL externalizing behavior (P) (p ≤ 0.05, partial
η2 = 0.06)*
CBCL aggressive behavior (P) (p ≤ 0.05, partial
η2 = 0.04)*
CBCL attention problems (P) (p ≤ 0.05, partial
η2 = 0.04)*
CPRS-R oppositional (P) (p ≤ 0.001, partial
η2 = 0.11)***
CPRS-R inattention (P) (p ≤ 0.01, partial
η2 = 0.07)**
CPRS-R hyperactivity (P) (p ≤ 0.01, partial
η2 = 0.13)**
ECBI behavior intensity (P) (p ≤ 0.001, partial
η2 = 0.22)***
ECBI behavior problems (P) (p ≤ 0.001, partial
η2 = 0.24)***
PTP > WL
CBCL externalizing behavior (P) (p = 0.005,
partial η2 = 0.128)*
22. Webster-Stratton et al. [68]d
N = 99
PTP > WL
CBCL internalizing behavior (P) (p = 0.025,
partial η2 = 0.084)*
Intervention = WL
CBCL internalizing behavior (P) (ns, partial
η2 = 0.02)
Child internalizing o­ utcomesa
High (outcome assessment not blinded; investigator enrolling participants could possibly foresee
assignments and thus introduce selection bias;
insufficient reporting of attrition/exclusions)
Unclear (outcome assessment partially blinded;
randomization stated but not described; unclear if
allocation concealed)
Quality of evidence—bias risk
Data from Chacko et al. [49] and Rajwan et al. [50] based on the same trial
Parent data based on maternal report
Outcomes reported in this paper were based on treatment effect on mean from baseline. Outcome here is based on p value for change difference between active treatments versus control arm.
e
d
Data from Duncombe et al. [47] and Havighurst et al. [48] based on the same trial
c
b
= Denotes non statistically significant difference in outcome between intervention versus control. Effect sizes reported using Cohen’s d with the exception of Holmes et al. [59], Waters et al.
[67], Webster-Stratton et al. [68] and Wiggins et al. [69] that reported partial eta squared (partial η2). According to Cohen [44], guidelines for magnitude of partial eta squared are that 0.02, 0.13
and 0.26 indicate small, medium and large effect sizes respectively, whereas guidelines for magnitude of Cohen’s d are that 0.2, 0.5 and 0.8 indicate small, medium and large effect sizes respectively
> Denotes statistically significant difference in outcome between intervention versus control, where *p < 0.05 **p < 0.01 ***p ≤ 0.001 and ns not significant
Child externalizing and internalizing outcomes are reported as follows:
a
ACT anger coping training, ADHD attention deficit hyperactivity disorder, ADIS-IV-C/P anxiety disorders interview schedule for the fourth edition of the diagnostic and statistical manual of
mental disorders (DSM-IV): child/parent versions, BPT behavior parent training, CBCL child behavior checklist, CG control group, CL clinician report; CPRS-R Conners’ parent rating scalerevised, CT child therapy, DBD disruptive behavior disorders, ECBI Eyberg child behavior inventory, FU follow-up, mo months, GAD generalized anxiety disorder, IY incredible years, (P) parent report, PACS parent account of child symptoms, partial η2 partial eta squared, P + C parent + child, PMT parent management training, PO parent only, PPCP parents plus children’s program,
PPP Triple P-Positive Parenting Program, PT Parent Training, PTP pathways triple P, RCC routine clinical care, SCAS-P Spence Children’s Anxiety Scale-Parent Version, SDQ strengths and
difficulties questionnaire, TIK tuning in to kids, TT teacher training, WL waitlist control
23. Wiggins et al. [69]
N = 60
Child externalizing o­ utcomesa
Study
Table 2 (continued)
Child Psychiatry Hum Dev (2018) 49:244–267
259
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260
Child Psychiatry Hum Dev (2018) 49:244–267
problems ranged from small practical significance to
medium treatment effect (d = 0.004–0.64). Effect size values reported with partial eta squared for difference in outcomes between intervention groups versus control on parent-reported measures [70] of child internalizing problems
ranged from small to medium (partial η2 = 0.02–0.084). The
effect size value reported with Cohen’s d for difference in
outcomes between intervention groups versus control on a
clinician-reported measure [75] of child internalizing problems showed low practical significance (d = 0.10). Effect
size values reported with partial eta squared for difference
in outcomes between intervention groups versus control
on a clinician-reported measure [76] of child internalizing
problems were medium to large (partial η2 = 0.08–0.43).
Study Quality
A summary risk assessment of each included study is
located in Table 2 and the overall quality of the included
studies is summarized in Fig. 2. Many studies were unclear
about important quality criteria, including allocation concealment, random sequence generation and blinding.
Other aspects of studies which contributed to bias risk and
therefore possibly on study outcomes and interpretation,
included not reporting results of all pre-specified outcome
measures, reported loss to follow-up imbalanced across
groups, failure to specify reasons for attrition or exclusions,
and poor fidelity of implementation of treatment. We also
examined the included studies for conflict of interest, which
was implicated in the following ways: three studies where
the study author also delivered the intervention [54, 63,
67]; six studies where the program developer was involved
in the evaluation [47, 48, 57, 58, 68, 69], in particular
Fig. 2 Assessment of risk of
bias within studies using The
Cochrane Collaboration’s tool
for assessing risk of bias [41]
for randomized trials
studies involving the incredible years, Triple P and tuning
into kids; and, three studies where the program developer
was involved in a supervisory or consultative role [58, 60,
62]. Based on our earlier described approach to determining summary risk assessment for each study, the majority
(20/23 or 87.0%) of studies included in the current systematic review were deemed to have ‘unclear’ [12/23 or 52.2%]
or ‘high risk’ [9/23 or 39.1%] of bias. The two studies [59,
64] that were deemed to have overall ‘low risk’ of bias
involved an RCT of a behavioral parent training program
(the incredible years programme) designed to address child
behavior combined with a literacy programme [64] and an
RCT [59] comparing a group-based cognitively-focussed
treatment program for parents of children with generalised
anxiety disorder (GAD). Refer to Table 2 for specific outcomes of these trials.
Meta‑analysis
Of the 23 studies meeting inclusion criteria, 20 reported
externalizing outcomes and 14 reported internalizing outcomes with 11 studies reporting both internalizing and
externalizing outcomes. De Groot et al. [54] was a comparison of two active treatments without a control arm and was
excluded from the meta-analysis. Sayal et al. [63] included
change data however the authors could not be contacted for
the post data and therefore this study was excluded from
the meta-analysis. Chacko et al. [49] and Rajwan et al. [50]
reported different outcome measures on the same treatment cohort. As such, Rajwan et al. [50] was excluded from
the meta-analysis as it reported on child outcome variables using reliable change data and reported fewer child
externalizing outcome data. Havinghurst et al. [48] and
Assessment of risk of bias within studies
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Blinding of participants (performance bias)
Blinding of personnel (performance bias)
Blinding of outcome assessment (detection
bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other bias
High Risk
13
Unclear Risk
Low Risk
Child Psychiatry Hum Dev (2018) 49:244–267
Duncombe et al. [47] also used the same treatment cohort
reporting different outcome measures. Havighurst et al.
[48] was excluded from the meta-analysis due to having a
smaller sample size. Waters et al. [67] was included in the
meta-analyses involving internalizing data, but could not be
included in the meta-analysis of externalizing outcomes as
no post intervention of follow-up data was reported for the
waitlist-control group.
Sixteen studies [47, 49, 51–53, 55–57, 60–62, 64–66,
68, 69] were included in the meta-analysis of the effect of
parent group treatment on externalizing symptoms. Five
of these studies [47, 49, 53, 55, 60] utilised more than one
intervention group. The active interventions in these studies were combined on the advice of a biostatistician to create a single pair-wise comparison with the control group.
Externalizing outcome measures included parent rated
child behavior checklist (CBCL) [70] broadband externalizing scale, Eyberg child behavior inventory (ECBI)
[71], strengths and difficulties questionnaire (SDQ) [72]
conduct problems scale, and the disruptive behavior disorders (DBD) rating scale [73]. A random-effects metaanalysis (see Fig. 3) revealed a statistically significant
and small treatment effect for parent group treatment over
control for child externalizing problems (g = −0.38, 95%
CI −0.56, −0.19, z = 3.97, p < 0.001). Visual inspection
of the funnel plot (see Fig. 4) suggested no evidence for
publication bias. However, the level of study heterogeneity (I2 = 61.80%, p = 0.001) was substantial. Independent
variables of (1) study quality, (2) hours of planned parent
261
group treatment and (3) treatment recipient were separately
entered into a meta-regression for the child externalizing
problems. Neither hours of planned parent group treatment
(I2 residual = 63.67%, p = 0.53) nor treatment recipient (I2
residual = 59.32%, p = 0.28) were a significant moderator of
treatment response. However, study quality was a significant moderator in studies with a summary risk assessment
of ‘Low risk’ compared to studies with a summary risk
assessment of ‘unclear risk’ or ‘high risk’ of bias (coefficient = 0.72, p = 0.02). This would suggest that the average
standardized mean difference for studies with a summary
risk assessment of ‘low risk’ of bias compared with studies
with a summary risk assessment of ‘unclear risk’ or ‘high
risk’ of bias is 0.72 larger.
Thirteen studies [51, 52, 56, 58–62, 65–69] were
included in the meta-analysis of the effect of parent
group treatment on internalizing symptoms. Three of
these studies [58, 60, 67] utilised more than one intervention group. The active interventions in these studies
were combined on the advice of a biostatistician to create a single pair-wise comparison with the control group.
Internalizing outcome measures included the CBCL
broadband internalizing scale [70], SDQ emotional
symptoms scale [72], parent account of child symptoms
(PACS) [75], and anxiety disorders interview schedule
for the fourth edition of the diagnostic and statistical
manual of mental disorders (DSM-IV): child/parent versions (ADIS-IV-C/P) [76]. A random-effects meta-analysis (see Fig. 5) revealed a statistically significant albeit
Fig. 3 Forest plot of studies
included in the meta-analysis
for effect of parent group intervention on child externalizing
problems
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262
Child Psychiatry Hum Dev (2018) 49:244–267
Fig. 4 Funnel plot of included
studies in the meta-analysis for
effect of parent group intervention on child externalizing
problems (N = 16)
Fig. 5 Forest plot of studies
included in the meta-analysis
for effect of parent group intervention on child internalizing
problems
small treatment effect for parent group treatment over
control for child internalizing problems (g = −0.18, 95%
CI −0.36, −0.01, z = 2.03, p = 0.04). The level of study
heterogeneity (I2 = 41.9%, p = 0.056) was moderate. Visual inspection of the funnel plot (see Fig. 6) suggested no
evidence for publication bias. Independent variables of
(1) study quality, (2) hours of planned parent group treatment and (3) treatment recipient were separately entered
into a meta-regression for the child externalizing problems. Neither hours of planned parent group treatment
13
(I2 residual = 46.72%, p = 0.97), treatment recipient (I2
residual = 39.53%, p = 0.28), nor study quality (I2 residual = 46.85%, p = 0.68) were significant moderators of
treatment response.
A meta-analysis of the two studies which compared an
active parent group treatment for child anxiety with control [59, 67] was not significant (g = −0.40, 95% CI −1.50,
0.71, z = 0.71, p = 0.48). Finally, a meta-analysis of the 11
studies [51, 52, 56, 58, 60–62, 65, 66, 68, 69] that evaluated parent group interventions with samples of children
Child Psychiatry Hum Dev (2018) 49:244–267
263
Fig. 6 Funnel plot of included
studies in the meta-analysis for
effect of parent group intervention on child internalizing
problems (N = 13)
with externalizing problems found no change in internalizing problems (g = −0.16, 95% CI −0.34, 0.01, z = 1.87,
p = 0.06).
Discussion
This systematic review and meta-analysis examined parent
group training interventions aimed at the treatment of externalizing and internalizing problems for children aged 4–12
years. Whereas previous reviews have focused on one child
outcome variable, such as conduct problems [21] or disruptive behaviors [19], the current review included samples
with externalizing and/or internalizing problems commonly
seen in clinical practice (e.g., conduct problems, oppositional behavior, inattention and hyperactivity, depression,
anxiety). The majority of studies included in the review
consisted of samples of children with diagnoses of or subthreshold symptoms of externalizing (i.e., ADHD, ODD,
CD) or internalizing (i.e., anxiety) disorders. The review
revealed fewer studies of indicated prevention for children
with externalizing and/or internalizing problems at risk of
developing severe behavior disorders. Of the included studies that reported on child externalizing problems, 80.0%
studies reported significant findings that favored the parent
group intervention over control (or alternative treatment).
Of the included studies that reported on child internalizing
problems, 35.7% studies reported significant findings that
favored the parent group intervention over control (or alternative treatment).
Results from the current meta-analysis demonstrated
that parent group intervention programs are effective for
the amelioration of child externalizing problems, with a
significant and small treatment effect size but with substantial heterogeneity. This heterogeneity was evidenced by the
broad range (i.e., negligible to large) of effect size values
reported for difference in outcomes between intervention
groups versus control on parent- and/or clinician-reported
measures of child externalizing problems. Study quality
moderated the treatment effect sizes for child externalizing
problems, but hours of planned parent group treatment and
treatment recipient did not. Findings from the moderator
analysis may inform mental health service providers and
clinicians who are seeking cost effective parent group interventions. That is, the addition of teacher or child intervention components to parent group interventions or increase
in treatment hours may not necessarily translate to greater
improvements in child externalizing behavior problems.
However, further research is needed to determine the optimal treatment recipients and dose for this population.
The second meta-analysis conducted in this review
showed a statistically significant reduction in child internalizing problems, however the effect size was more modest
and the level of study heterogeneity was moderate. None
of the intervention-based variables explored explained the
variability in treatment effect size for child internalizing
problems. Although a meta-analysis conducted to explore
the efficacy of parent group interventions aimed at reducing child anxiety was non-significant, this analysis only
relied upon two studies. The meta-analysis of 11 studies
that evaluated parent group interventions with samples of
children with externalizing behavior problems resulted in
non-statistically significant improvement in internalizing
problems. Given that the majority of studies included in the
13
264
review were parent group interventions focused on reduction of child externalizing or disruptive behavior problems,
this finding is not necessarily unexpected. However, this
demonstration of the absence of a cross-impact treatment
effect suggests the need for specific targeting of internalizing symptoms within programs for externalizing disorders,
if this comorbid symptom cluster is to be prioritized.
Results of the current review are broadly consistent with
findings of earlier reviews that included studies published
prior to 2005 [19–21, 24, 29], providing further evidence
of the efficacy of parent training interventions for treatment of child externalizing behavior problems. The current
review’s effect size for child externalizing problems is in
line with findings by Kaminski et al. [20] but smaller than
the medium effect sizes found in some earlier reviews [19,
21, 24, 29], perhaps accounted for by differences in review
design. For instance, in contrast to the current review, other
reviews [19–21, 24] included both group and individually
delivered parent training, while Dretzke et al. [21] only
reviewed studies of interventions aimed at treatment of
children with conduct problems.
In regards to child internalizing problems, the current review’s effect size is concordant with the effect size
for emotional problems reported by Furlong et al. [29]
but smaller than the effect size for internalizing problems
reported by Kaminski et al. [20]. However, Kaminski et al.
[20] included both group and individual treatments and
samples of children aged 0–7 years whereas the current
review included samples of children aged 4–12 years. The
current review’s finding that the addition of child and/or
teacher intervention components failed to moderate treatment outcomes for child externalizing problems is consistent with Lundahl et al. [19]. Finally, treatment effect on
child externalizing outcomes was not moderated by treatment hours in the current review, consistent with previous
research [26, 77].
While this review specifically set out to review the published literature pertaining to parent group interventions,
current results should take into account the broader psychosocial treatment literature, inclusive of individual parent
training programs. For instance, current review results for
parent group treatment effect on child externalizing problems are smaller than some previously reported treatment
effect outcomes for individual parent training programs
to modify child externalizing behaviors [19] and child
social, emotional and behavioral outcomes [24]. The current review’s effect size for internalizing problems is also
smaller than results of some individual parent training
programs aimed at modifying child anxiety disorders [78,
79]. However, there is mixed evidence regarding the relative efficacy of individual parent training versus group parent training for children with externalizing problems. Some
studies have reported superior outcomes for individual
13
Child Psychiatry Hum Dev (2018) 49:244–267
parent training [19, 24], other studies have reported superior outcomes for group parent training [80], and others
have reported no difference [38, 81, 82].
There are advantages of both individual and group-based
parent interventions. For example, individual parent training programs include the ability to tailor treatment to fit the
needs of the individual child, the opportunity to adjust to
each parent’s mastery level, and the possibility that a parent might be more willing to disclose sensitive information
in an individual session [83]. However, group approaches
can also provide parents with social support, normalize
individual parent’s experiences, and offer extra solutions as
individual members suggest specific techniques [84]. Conducting parent training in groups rather than individually
can also be more cost-effective [80]. Selection of treatment
modality should also take into account parent preferences
[85].
This systematic review and meta-analysis should be
interpreted in the context of its limitations. As documented in Fig. 1, four studies were excluded from the current review on the basis that review authors were unable
to locate full-text english-language translations. In each
of these instances, although the abstracts for these studies were written in english, inadequate information was
provided in the abstracts to determine whether the studies
met selection criteria, thus introducing the possibility of a
language bias [86, 87]. As this review only included published studies, there is also a risk that a bias towards trials
with positive outcomes occurred [88]. Due to the limited
number of studies included in the meta-analyses, moderator analyses should be interpreted with caution and require
replication, while other potential moderating variables
should also be explored. Future reviews would benefit from
reporting on data from all available informants, including
teacher-rated measures and child self-report measures.
Summary
This review provides an important update for the field on
contemporary research outcomes on the efficacy of parent
group interventions and provides support for their ability
to reduce externalizing behaviors in children. While study
methodology may have contributed to the variability in
treatment effect sizes for child externalizing problems, further research is needed to determine the optimal treatment
recipients and dose and explore other potential moderators of treatment response. Whilst statistically significant,
the effect of parent group treatment on child internalizing
problems was modest, however the majority of studies
evaluated interventions focused on treatment of child externalizing problems. There was no evidence to support treatment effect on anxiety symptomatology or on cross-impact
Child Psychiatry Hum Dev (2018) 49:244–267
treatment effect on internalizing behaviors for treatments
that aimed to address child externalizing problems. Metaanalysis results thus highlight the need for more specific
targeting of internalizing symptoms within programs for
externalizing disorders, if this comorbid symptom cluster is
to be prioritized. Given the high prevalence of internalizing disorders in childhood and adolescence [89, 90], review
results suggest the need for more research focused on parent group interventions for treatment of child internalizing
disorders, regardless of whether such problems are targeted
in isolation or in conjunction with externalizing problems.
Funding The authors received no financial support for the research,
authorship, and/or publication of this article.
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