NIHR Signal Online parental training may help to improve behaviour in children

Published on 1 August 2017

Online parental training led to reasonable improvements in behaviour problems in children and young people, compared to no training. The findings of this review suggest that additional support and contact – such as “check-in” calls and on-line forums – can help to increase participation. Online training had similar outcomes to face-to-face training.

The review identified 14 studies of online training and tested ten different ways of training parents. One large programme “Triple P” featured in two studies and a toolkit for adolescents featured in four. The digital assistance on offer to parents ranged from online self-directed sessions or podcasts (2-5 hours total time) to more interactive computer training packages with eleven 45 minutes weekly support sessions by phone.  All showed improvements in children’s behaviour compared to no treatment. Taken together the results are similar to those found with similar face to face delivery methods.

Delivering parental training online may also be more efficient and enable commissioners and providers to deliver training to greater numbers of people. However, consideration should be given to how the support offered can ensure that participants get the most out of online training.

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Why was this study needed?

Around 5% of children aged five to 16 are diagnosed with conduct disorder, and behavioural problems are the most common reason for referring children to mental health services. Behavioural problems affect the child and those around them, including relationships with their family, friends and schoolmates in the short and long term. Into adolescence and adulthood, conduct disorders can lead to substance abuse, poor education and job prospects, involvement in crime and mental health problems.

Training parents and carers has been effective in improving parents’ skills to cope with these behavioural problems. Attending training sessions in person can be difficult for parents if they have to make childcare arrangements and book time off work. Face-to-face sessions can also be expensive for the local NHS to run and availability may be limited. This review looked at whether this training could be provided online instead.

What did this study do?

This systematic review included 14 studies (2,427 people), one from the UK. Ten studies were aimed at children under nine years old, the remaining four studies mostly included children aged 11 to 15. On average, seven sessions were delivered over nine weeks. The training programmes drew on behavioural approaches to give parents the skills to reduce conflict and increase obedience.

Ten programmes were identified. Interactive elements were included in six of the programmes – including multiple choice questions, direct feedback and online discussion forums. Four programmes were not interactive, consisting of videos and audio podcasts.

The studies were generally at low risk of bias and small, but as there was such variety, only a few studies were available for each comparison which reduces the reliability of the findings.

What did it find?

  • Parental training led to a moderate improvement in children under nine’s behaviour compared to no treatment (effect size 0.47 to 0.80, four studies).
  • For adolescents, parental training led to small improvements in behaviour compared to no treatment (effect size 0.17 to 0.20, two studies).
  • There was no clear difference in outcomes when comparing online training with a face-to-face therapist-led programme or interactive versus non-interactive programs. However, people were more likely to complete therapist-led programmes and two studies suggested that enhancing online training with telephone calls or other “check-ins” may help to improve participation and increase the effectiveness of training programmes.
  • A large proportion (almost four out of five) people completed the programmes – 79% (standard deviation 18.8%). Making the programme available via smartphones and creating a community feel amongst participants seemed to encourage participation.
  • It is unclear whether targeting families in low socioeconomic circumstances of  children without a clear diagnosis led to  improved outcomes.

What does current guidance say on this issue?

NICE guidelines updated in 2017 looked at group training for parents and individual training separately. It recommended a group intervention for those with children aged three to 11 with or at high risk of developing oppositional defiant disorder, conduct disorder, or contact with the criminal justice system due to antisocial behaviour. Individual training can be offered to those who are not able to participate in a group training programme or to parents and children together.

The training should follow a manual and be based on social learning, enabling parents to rehearse scenarios and receive feedback to improve their parenting skills.

For children aged over 11, group therapy is recommended or multiple interventions including joint sessions with their parents.

What are the implications?

Face-to-face skills training for parents of children and young people with behavioural problems can be expensive to commission. This systematic review suggests that similar results can be achieved by delivering this training online, which would potentially save resources.

Local commissioners may want to consider testing the “Triple P” programme further in the UK or evaluating the most successful elements of other programmes, such as the “parenting wisely” toolkits and to consider how these could be optimised for online delivery. Enhancing the programmes with telephone “check-ins” seems likely to support participants.

Citation and Funding

Baumel A, Pawar A, Mathur N, et al. Technology-Assisted Parent Training Programs for Children and Adolescents With Disruptive Behaviors: A Systematic Review. J Clin Psychiatry. 2017. [Epub ahead of print].

No direct funding was provided for this research.

Bibliography

NICE. Antisocial behaviour and conduct disorders in children and young people: recognition and management. CG158. London: National Institute for Health and Care Excellence; 2013.

NHS Choices. New guidelines on child antisocial behaviour: behind the headlines. London: Department of Health; 2013.

RCPSYCH. Behavioural problems and conduct disorder: information for parents, carers and anyone who works with young people. London: Royal College of Psychiatrists; 2017.

Why was this study needed?

Around 5% of children aged five to 16 are diagnosed with conduct disorder, and behavioural problems are the most common reason for referring children to mental health services. Behavioural problems affect the child and those around them, including relationships with their family, friends and schoolmates in the short and long term. Into adolescence and adulthood, conduct disorders can lead to substance abuse, poor education and job prospects, involvement in crime and mental health problems.

Training parents and carers has been effective in improving parents’ skills to cope with these behavioural problems. Attending training sessions in person can be difficult for parents if they have to make childcare arrangements and book time off work. Face-to-face sessions can also be expensive for the local NHS to run and availability may be limited. This review looked at whether this training could be provided online instead.

What did this study do?

This systematic review included 14 studies (2,427 people), one from the UK. Ten studies were aimed at children under nine years old, the remaining four studies mostly included children aged 11 to 15. On average, seven sessions were delivered over nine weeks. The training programmes drew on behavioural approaches to give parents the skills to reduce conflict and increase obedience.

Ten programmes were identified. Interactive elements were included in six of the programmes – including multiple choice questions, direct feedback and online discussion forums. Four programmes were not interactive, consisting of videos and audio podcasts.

The studies were generally at low risk of bias and small, but as there was such variety, only a few studies were available for each comparison which reduces the reliability of the findings.

What did it find?

  • Parental training led to a moderate improvement in children under nine’s behaviour compared to no treatment (effect size 0.47 to 0.80, four studies).
  • For adolescents, parental training led to small improvements in behaviour compared to no treatment (effect size 0.17 to 0.20, two studies).
  • There was no clear difference in outcomes when comparing online training with a face-to-face therapist-led programme or interactive versus non-interactive programs. However, people were more likely to complete therapist-led programmes and two studies suggested that enhancing online training with telephone calls or other “check-ins” may help to improve participation and increase the effectiveness of training programmes.
  • A large proportion (almost four out of five) people completed the programmes – 79% (standard deviation 18.8%). Making the programme available via smartphones and creating a community feel amongst participants seemed to encourage participation.
  • It is unclear whether targeting families in low socioeconomic circumstances of  children without a clear diagnosis led to  improved outcomes.

What does current guidance say on this issue?

NICE guidelines updated in 2017 looked at group training for parents and individual training separately. It recommended a group intervention for those with children aged three to 11 with or at high risk of developing oppositional defiant disorder, conduct disorder, or contact with the criminal justice system due to antisocial behaviour. Individual training can be offered to those who are not able to participate in a group training programme or to parents and children together.

The training should follow a manual and be based on social learning, enabling parents to rehearse scenarios and receive feedback to improve their parenting skills.

For children aged over 11, group therapy is recommended or multiple interventions including joint sessions with their parents.

What are the implications?

Face-to-face skills training for parents of children and young people with behavioural problems can be expensive to commission. This systematic review suggests that similar results can be achieved by delivering this training online, which would potentially save resources.

Local commissioners may want to consider testing the “Triple P” programme further in the UK or evaluating the most successful elements of other programmes, such as the “parenting wisely” toolkits and to consider how these could be optimised for online delivery. Enhancing the programmes with telephone “check-ins” seems likely to support participants.

Citation and Funding

Baumel A, Pawar A, Mathur N, et al. Technology-Assisted Parent Training Programs for Children and Adolescents With Disruptive Behaviors: A Systematic Review. J Clin Psychiatry. 2017. [Epub ahead of print].

No direct funding was provided for this research.

Bibliography

NICE. Antisocial behaviour and conduct disorders in children and young people: recognition and management. CG158. London: National Institute for Health and Care Excellence; 2013.

NHS Choices. New guidelines on child antisocial behaviour: behind the headlines. London: Department of Health; 2013.

RCPSYCH. Behavioural problems and conduct disorder: information for parents, carers and anyone who works with young people. London: Royal College of Psychiatrists; 2017.

Technology-Assisted Parent Training Programs for Children and Adolescents With Disruptive Behaviors: A Systematic Review

Published on 12 May 2017

Baumel, A.,Pawar, A.,Mathur, N.,Kane, J. M.,Correll, C. U.

J Clin Psychiatry , 2017

OBJECTIVE: To systematically review digitally assisted parent training programs (DPTs) targeting the treatment of children and adolescents with disruptive behaviors. DATA SOURCES: A search was conducted using PubMed, PsycINFO, and EMBASE databases for peer-reviewed studies published between January 1, 2000, and March 1, 2016. Reference lists of included and review articles were searched manually for additional references. STUDY SELECTION: Broad search terms in varying combinations for parent, training, technologies, and disruptive behavior problems were used. We included English-language articles reporting on the effectiveness of DPTs targeting child or adolescent disruptive behaviors (eg, conduct disorder, oppositional defiant disorder). DPTs designed to use digital media or software programs not to be primarily used within a therapy setting (eg, group, face-to-face) were included. DATA EXTRACTION: Study design, recruitment and sample characteristics, theoretical background, digital program features, user's engagement, and measures of child behavior were extracted. RESULTS: Fourteen intervention studies (n = 2,427, 58% male, 1,500 in DPT conditions, 12 randomized trials) examining 10 programs met inclusion criteria. Interventions included self-directed noninteractive (eg, podcasts; 3 studies) and interactive (eg, online software; 4 studies) DPTs, remotely administered DPTs combined with professional phone-based coaching (2 studies), and a smartphone enhancement of standard treatment. Interventions were delivered over a mean +/- SD period of 8.7 +/- 4.2 weeks, most (11/14; 78.6%) were remotely administered, and all recruitment procedures included an outreach for parents outside of mental health-care settings. For programs with > 5 sessions, the mean +/- SD completion rate of available sessions was 68.6% +/- 13.1%. In comparison to no treatment control, self-directed programs yielded significant improvements in child behavior for children (age < 9 years, Cohen d = 0.47-0.80, 4 studies) and adolescents (d = 0.17, 0.20, 2 studies). Overall, reduced professional support combined with DPT was not inferior to full-contact conditions and showed small improvement in comparison to usual care (d = 0.34). Preliminary indicators also suggested that technology enhancements may increase engagement and outcomes of standard treatment. CONCLUSIONS: The current review indicates the efficacy of DPT across a range of therapy formats applied in real-world settings demonstrating the potential for increased accessibility of evidence-based treatment for youth with disruptive behaviors. Additional studies are needed to extend these findings and to determine moderating effects of different designs.

Expert commentary

This systematic review looks at the effectiveness of parenting programmes either exclusively delivered through the internet, or using that as an enhancement. The findings look positive, but the only programme studied with good numbers is “Triple P” and while this is encouraging, it now needs to be independently replicated by a team other than the programme developer.

Given the huge prevalence of conduct problems (the commonest disorder in child and adolescent mental health) there will never be enough face-to-face provision of parenting programmes, so an online offer must surely be part of service provision.

Stephen Scott, Professor of Child Health & Behaviour; Director, National Academy for Parenting Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London; Head, National Conduct Problems & National Adoption & Fostering Services, Maudsley Hospital, London