Parenting

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  • Childhood behavioural and emotional problems are of growing concern representing increased burdens on families and society and having a poor long-term prognosis.
  • Numerous risk factors associated with the development of childhood behaviour problems have been identified but the key risk factor is poor parenting skills.
  • Behaviourally-based interventions targeting parenting skills have been shown to be effective in improving parenting skills, reducing child behaviour problems, and improving parental mental health.

Dr Margiad Williams

Margiad received her MRes in Psychology and her PhD in Psychology from Bangor University. She is a Research Officer at the Centre for Evidence Based Early Intervention, Bangor University working on parenting interventions for child behaviour problems. She would like to thank Professor Judy Hutchings for her help and guidance whilst writing the Parenting Topic Guide.

  • Introduction

    Behavioural and emotional difficulties in young children are a significant problem. The rates of childhood mental disorders have increased substantially over the last decade with recent worldwide estimates of 13.4% (Polanczyk et al., 2015). The most common disorders in children are behaviour disorders such as Conduct Disorder and Oppositional Defiant Disorder, which are characterised by aggressive, defiant, noncompliant, and oppositional acts (NICE, 2013). Many parents report other behavioural problems such as sleeping and eating challenges, hyperactivity/inattentiveness, and regulatory adjustment. Child behaviour problems are the most common reason for referral to child and adolescent mental health services (NICE, 2013).

    Child behaviour problems are associated with increased economic and social burden on families (Houtrow & Okumura, 2011). Parents report significant restrictions in daily activities, such as visiting friends or family, doing the shopping, and going to new places. Child conduct problems also have economic cost for society through increased service use (Rivenbark et al., 2018).

    Generally, the prognosis for children with early-onset conduct disorder is poor. In the short-term, they are more likely to lack social skills in terms of forming and maintaining friendships (Trentacosta et al., 2010) and these problems are also associated with high levels of unhappiness and low self-esteem (Fanti, 2013). In the long-term, poor outcomes in adolescence and adulthood include school failure, substance misuse, poor mental health, and criminality (Erskine et al., 2016), emphasising the importance of intervening early before problems become entrenched.

    Several risk factors associated with the development of behaviour problems in childhood have been identified (Farrington et al., 2017; NICE, 2013). These include:

    • Child factors – e.g. gender, language delay, and difficult temperament.
    • Parental factors – e.g. maternal depression, harsh/inconsistent parenting, and young maternal age.
    • Family/social factors – e.g. living in poverty and poor housing.
    • School/community factors – e.g. living in a high crime neighbourhood and antisocial peers.

    Social disadvantage and child risk factors can compromise parenting, and the key risk factor for the development of childhood behaviour problems is poor parenting skills (Farrington & Welsh, 2007). Parents have significant influence on their children, especially before children start school. Rearing children is one of the hardest jobs and many parents are not well prepared for it. Limited experience of young children together with other risk factors (as mentioned above) make parenting more challenging. The more risk factors present the more likely that parenting practices are compromised (Gach et al., 2018). Having a child with a difficult temperament from the start is likely to influence how parents behave towards their child. Patterson has suggested that most severe behaviour problems start with a combination of temperamentally difficult toddlers and inexperienced parents. He describes a downward spiral where parents’ ineffective monitoring and discipline inadvertently reinforce their child’s discovery that whining, temper tantrums, and other aggressive or noncompliant behaviours are successful strategies for gaining attention and other reinforcers. This is known as Coercion Theory or the Coercive Family Process (Patterson, 1982).

    There are also protective factors operating in a child’s life that can help to counter the adverse influence of risk factors. These include effective child self- and emotional regulation skills, positive parenting practices such as warmth and acceptance, and stimulating environments (Andershed & Andershed, 2015). Positive parenting practices are particularly important since they are modifiable. Interventions that develop these skills are associated with improvements in behaviour problems over time that are independent of other risk factors (Gardner et al., 2010), demonstrating that it is parenting, rather than disadvantaging factors per se, that predicts behavioural problems in children.

  • What we know already

    The majority of evidence-based parenting interventions are underpinned by behavioural theory, particularly social learning theory (Bandura, 1977). The basic concept is to replace parents’ maladaptive parenting behaviour with more effective behaviour management strategies that can be used to teach and reinforce appropriate behaviour, giving parents additional skills to deal with the challenges presented by their child. The key strategies taught include:

    1. Relationship building and investment in the child through play and joint activities. Helping parents learn to follow their child’s lead during play and strengthening the, often poor, relationship with the child helping establish the parent as a reinforcer.
    2. Rewarding appropriate behaviour. Parents are taught to praise wanted/desirable behaviour as opposed to criticising unwanted behaviour. They learn to recognise when their child is behaving positively and to praise or reward the behaviour so that it becomes more frequent.
    3. Giving clear instructions that tell children what to do rather than focusing on problem behaviour. For example, telling a child to stop running around does not tell him or her what to do, whereas telling him or her to walk gives a clear instruction which increases compliance.
    4. Ignoring minor problems. This normally works best for attention-seeking behaviours such as whining and shouting.
    5. Non-aversive consequences to manage problem behaviours. These include methods such as time-out that involves removing the child from enjoyable things for a brief time so that they can calm down or planned consequences whereby the child learns that their actions have consequences (e.g. losing pocket money or computer time).

    Typically, parenting intervention are delivered over a period of ten to 12 weeks in weekly, two-hour sessions. They can be delivered in different formats including group, individual, and self-directed, and in different settings e.g. clinics, homes, and the community. However, there are a number of effective components which are common to many parenting programmes (Kaminski et al., 2008). These include:

    • Active rehearsal of new skills using videotape feedback, role-play, and/or rehearsal.
    • Teaching principles rather than prescribed techniques. When parents learn behavioural principles, they acquire the tools to decide what works best for them and to respond positively and appropriately when new situations arise.
    • The practice of new skills at home. Some programmes use homework tasks designed to promote skill development in the home whilst others are delivered in the family home.

    Parenting interventions can be delivered to different populations depending on the specific aim i.e. general improvement of parenting skills or targeting severe behaviour problems. For example:

    • Universal – targeted at a population with no specified risk factors.
    • Selected – targeting subgroups with elevated risk factors (e.g. single parents, teenage parents) but whose children show no significant child behaviour problems.
    • Indicated – aimed at subgroups with elevated risk factors and where children are displaying elevated levels of behaviour problems.
    • Treatment – aimed at those meeting diagnostic criteria for child behaviour problems e.g. Conduct Disorder or Oppositional Defiant Disorder.

    More than 40 years of research into parenting interventions has provided strong evidence that they are effective for children with both high and lower levels of behaviour problems (NICE, 2013). Many evaluations report significant improvements in parenting skills, child behaviour and parental mental health (for reviews see Barlow & Coren, 2018; NICE, 2013; Furlong et al., 2012). Programmes have also been shown to be effective in reducing behaviour problems in other childhood disorders e.g. Autism Spectrum Disorders (Postorino et al., 2017), Depression and/or Anxiety (Yap et al., 2016), developmental disability (Skotarczak & Lee, 2015). There is also evidence of their cost-effectiveness (Duncan et al., 2017; NICE, 2013). Larger effects have been found for indicated and treatment programmes compared to universal and selected programmes (Hendriks et al., 2018).

    Some examples of effective parenting programmes include:

    • Incredible Years Series (Webster-Stratton & Reid, 2017).
    • Parent-Child Interaction Therapy (Zisser-Nathanson, Herschell, & Eyberg, 2017).
    • Parent Management Training-Oregon (Forgatch & Gewirtz, 2017).
    • Triple-P Positive Parenting Programme (Sanders & Turner, 2017).

    Even though the evidence suggests that parenting programmes are effective, there are continuing challenges in getting parents to attend and complete programmes. Research studies are plagued by high attrition rates with up to two-thirds of parents who are offered a parent programme not enrolling (Baker et al., 2011) and 40%-60% dropping out partway through the programme (Axford et al., 2012). Many factors have been identified including child/family factors such as mental health issues and income, factors affecting access such as transportation and child care, and perceptual barriers such as feelings of stigma (Whittaker & Cowley, 2012). Several programmes recommend providing services to reduce access barriers e.g. providing transport and childcare to those who need. Another important factor in retaining parents in parent programmes is the skill level of facilitators. Developing strong, trusting relationships with parents and being able to motivate them to continue when things get tough is of utmost importance when delivering parent programmes (Whittaker & Cowley, 2012). The quality of intervention delivery can be more important than the content itself (Kilburn et al., 2017). When all of these factors are dealt with, parenting programmes can work for everyone regardless of personal factors (Gardner et al., 2017).

  • Areas of uncertainty

    Low and middle-income countries

    The mental health of children in low- and middle-income countries (LMIC) is of global concern and international bodies such as the World Health Organisation (WHO) have identified it as a priority (WHO, 2013). Risk factors for the development of behaviour problems for children in LMIC are similar to those for children in high-income countries (HIC) (Murray et al., 2018). The evidence suggests that parenting interventions are effective for child behaviour problems, however the majority of studies are conducted in HIC raising questions about generalisability (Burkey et al., 2018). Burkey et al. (2018) identified a number of key gaps based on the representativeness of study samples, descriptions of training and supervision practices, cultural and contextual adaptations of interventions, and the lack of long-term follow-up data. There is some evidence of HIC-developed parenting interventions being used in LMIC with positive outcomes (Gardner et al., 2016), however more rigorous evidence for the use of parenting interventions in LMIC is needed.

    Fathers

    Fathers are consistently underrepresented in parenting interventions (Panter-Brick et al., 2014). This is of concern particularly when there is limited evidence that father involvement in parenting interventions leads to better outcomes for children and mothers (Lundahl et al., 2008). Very few studies have examined the reasons why father engagement is so low (Tully et al., 2017). More research is needed to increase father engagement in parenting interventions and to explore the effectiveness of programmes aimed at fathers.

    Technology

    Group-based and individually delivered parenting interventions are not always suitable/accessible for all families. The web provides an opportunity to introduce behaviourally-based parenting principles using similar strategies for content and delivery as traditional parenting interventions e.g. modelling skills using video clips, encouraging rehearsal through practical assignments. Aadvantages of web-based programmes include convenience, since parents can access programmes at home, relatively low cost of dissemination, the ability to reach more individuals, and a destigmatising way of accessing information (Baumel & Faber, 2017).

    Recent reviews have found positive effects for technology-based interventions in terms of parent and child behaviour (Corralejo & Rodriguez, 2018; Fairburn & Patel, 2017; MacDonell & Prinz, 2017). However, very few studies include child outcomes and ethnically and culturally diverse samples. Considering the large number of technology-based interventions available, it is surprising that there are so few head-to-head comparisons of programmes (Fairburn & Patel, 2017). The cost-effectiveness of these programmes is also unclear (Corralejo & Rodriguez, 2018).

  • What's in the pipeline?

    Even though we know that parenting interventions are effective and are recommended by the National institute for Health and Care Excellence, the sheer number and diversity of programmes available make it very difficult to choose the right one. Programmes can differ in terms of the mode of delivery (individual, group, online), length, content, and setting. Researchers are now considering how to maximise the effects of parenting interventions by examining different combinations of components using novel research designs. For example, the Multiphase Optimisation Strategy (MOST; Collins, 2018) involves identifying an intervention that provides the highest expected level of effectiveness obtainable within key constraints imposed by the need for efficiency (i.e., the extent to which the intervention avoids wasting time and money), economy (i.e., the extent to which the intervention offers good value), and scalability (i.e. the extent to which the intervention can be implemented in the intended setting exactly as evaluated). This design allows researchers to compare different components to see which work better such as long vs. short programmes, clinic vs. home delivery, individual vs. group, therapist support vs. no support etc. There are also microtrials that can be used to test discrete parenting techniques (e.g. praise) in terms of effectiveness (Leijten et al., 2015). These kinds of trials will allow us to know which components are most effective, for whom/under what circumstances, and allow for the tailoring of interventions for the specific needs of individual families.

  • Useful resources and websites

    NICE Guidelines: Antisocial behaviour and conduct disorders in children and young people. 2013. https://www.nice.org.uk/guidance/cg158

    National Academy Parenting Research. https://www.kcl.ac.uk/ioppn/depts/cap/research/napr/index.aspx

    Jacobs, B. Parenting the Child with Issues. MindEd, 2016
    https://mindedforfamilies.org.uk/Content/parenting_the_child_with_issues/#/id/59e5c70d779fae116f09fac7

    Kelvin, R. Anger and Aggression. MindEd, 2016
    https://mindedforfamilies.org.uk/Content/common_problems_anger_and_aggression/#/id/5a8c0bf22467748f64fe6f98

    Conduct problems

    Erskine, H. E., Norman, R. E., Ferrari, A. J., Chan, G. C. K., Copeland, W. E., Whiteford, H. A., & Scott, J. G. (2016). Long-term outcomes of Attention-Deficit/Hyperactivity Disorder and Conduct Disorder: A systematic review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 55, 841-850. doi:10.1016/j.jaac.2016.06.016

    Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56, 345-365. doi:10.1111/jcpp.12381

    Rivenbark, J. G., Odgers, C. L., Caspi, A., Harrington, H., Hogan, S., Houts, R. M., Poulton, R., & Moffitt, T. E. (2018). The high societal costs of childhood conduct problems: evidence from administrative records up to age 38 in a longitudinal birth cohort. Journal of Child Psychology and Psychiatry, 59, 703-710. doi:10.1111/jcpp.12850

    Parenting as a risk factor

    Farrington, D. P., Gaffney, H., & Ttofi, M. M. (2017). Systematic reviews of explanatory risk factors for violence, offending, and delinquency. Aggression and Violent Behavior, 33, 24-36. doi:10.1016/j.avb.2016.11.004

    Farrington, D., & Welsh, B. C. (2007). Saving children from a life of crime: Early risk factors and effective interventions. New York, NY: Oxford University Press.

    Gach, E. J., Ip, K. I., Sameroff, A. J., & Olson, S. L. (2018). Early cumulative risk predicts externalising behaviour at age 10: The mediating role of adverse parenting. Journal of Family Psychology, 32, 92-102. doi:10.1037/fam0000360

    Patterson, G. R. (1982). Coercive family process (Vol. 3). Eugene, OR: Castalia Publishing Company.

    Effectiveness of parent training

    Barlow, J., & Coren, E. (2018). The effectiveness of parenting programs: A review of Campbell reviews. Research on Social Work Practice, 28, 99-102. doi:10.1177/1049731517725184

    Duncan, K. M., MacGillivray, S., & Renfrew, M. J. (2017). Costs and savings pf parenting interventions: results of a systematic review. Child: Care, Health and Development, 43, 797-811. doi:10.1111/cch.12473

    Forgatch, M. S., & Gewirtz, A. H. (2017). The Evolution of the Oregon Model of Parent Management Training: An intervention for antisocial behaviour in children and adolescents. In: J. R. Weisz & A. E. Kazdin (Eds.), Evidence-Based Psychotherapies for Children and Adolescents (pp. 85-102). New York, NY: Guildford Press.

    Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S.M., & Donnelly, M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Cochrane review). Cochrane Database for Systematic Reviews, 2, 1-362. doi:10.1002/14651858.CD008225.pub2

    Hendriks, A. M., Bartels, M., Colins, O. F., & Finkenauer, C. (2018). Childhood aggression: A synthesis of reviews and meta-analyses to reveal patterns and opportunities for prevention and intervention strategies. Neuroscience & Biobehavioral Reviews, 91, 278-291. doi:10.1016/j.neubiorev.2018.03.021

    Kaminski, J. W., Valle, L. A., Filene, J. H. & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36, 567-589. doi:101007/s10802-007-9201-9

    Postorino, V., Sharp, W. G., McCracken, C. E. Bearss, K., Burrell, T. L. Evans, A. N., & Scahill, L. (2017). A systematic review and meta-analysis of parent training for disruptive behaviour in children with Autism Spectrum Disorder. Clinical Child and Family Psychology Review, 20, 391-402. doi:10.1007/s10567-017-0237-2

    Sanders, M. R., & Turner, K. M. T. (2017). The International Dissemination of the Triple P-Positive Parenting Program. In: J. R. Weisz & A. E. Kazdin (Eds.), Evidence-Based Psychotherapies for Children and Adolescents (pp. 429-446). New York, NY: Guildford Press.

    Skotarczak, L., & Lee, G. K. (2015). Effects of parent management training programs on disruptive behaviour for children with a developmental disability: A meta-analysis. Research in Developmental Disabilities, 38, 272-287. doi:10.1016/j.ridd.2014.12.004

    Webster-Stratton, C., & Reid, J. M. (2017). The Incredible Years Parents, Teachers, and Children Training Series: A Multifaceted Treatment Approach for Young Children with Conduct Disorders. In: J. R. Weisz & A. E. Kazdin (Eds.), Evidence-Based Psychotherapies for Children and Adolescents (pp. 122-141). New York, NY: Guildford Press.

    Yap, M. B. H., Morgan, A. J., Cairns, K., Jorm, A. F., Hetrick, S. E., & Merry, S. (2016). Parents in prevention: A meta-analysis of randomized controlled trials of parenting interventions to prevent internalizing problems in children from birth to age 18. Clinical Psychology Review, 50, 138-158. doi:10.1016/j.cpr.2016.10.003

    Zisser-Nathenson, A., Herschell, A. D., & Eyberg, S. M. (2017). Parent-Child Interaction Therapy and the Treatment of Disruptive Behaviour Disorders. In: J. R. Weisz & A. E. Kazdin (Eds.), Evidence-Based Psychotherapies for Children and Adolescents (pp. 103-121). New York, NY: Guildford Press.

    Additional sources

    Andershed, A., & Andershed, H. (2015). Risk and protective factors among preschool children: Integrating research and practice. Journal of Evidence-Informed Social Work, 12, 412-424. doi:10.1080/15433714.2013.866062

    Axford, N., Lehtonen, M., Kaoukji, D., Tobin, K., & Berry, V. (2012). Engaging parents in parenting programs: Lessons from research and practice. Children and Youth Services Review, 34, 2061-2071. doi:10.1016/j.childyouth.202.06.011

    Baker, C.N., Arnold, D.H., & Meagher, S. (2011). Enrollment and attendance in a parent training prevention program for conduct problems. Prevention Science, 12, 126-138. doi:10.1007/s11121-010-0187-0

    Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall Inc.

    Baumel, A., & Faber, K. (2017). Evaluating Triple P online: A digital parent training program for child behaviour problems. Cognitive and Behavioral Practice. Advance online version. doi:10.1016/j.cbpra.2017.10.001

    Burkey, M. D., Hosein, M., Morton, I., Purgato, M., Adi, A., Kurzrok, M., Kohrt, B. A., & Tol, W. A. (2018). Psychosocial interventions for disruptive behaviour problems in children in low- and middle-income countries: a systematic review and meta-analysis. Journal of Child Psychology and Psychiatry. Advance online version. doi:10.1111/jcpp.12894

    Collins, L. M. (2018). Optimization of Behavioral, Biobehavioral, and Biomedical Interventions: The Multiphase Optimization Strategy (MOST). New York, NY: Springer.

    Corralejo, S. M., & Rodriguez, M. M. D. (2018). Technology in parenting programs: A systematic review of existing interventions. Journal of Child and Family Studies. Advance online version. doi:10.1007/s10826-018-1117-1

    Fairburn, C. G., & Patel, V. (2017). The impact of digital technology on psychological treatments and their dissemination. Behaviour Research and Therapy, 88, 19-25. doi:10.1016/j.brat.2016.08.012

    Fanti, K. A. (2013). Individual, social, and behavioural factors associated with co-occurring conduct problems and callous-unemotional traits. Journal of Abnormal Child Psychology, 41, 811-824. doi:10.1007/s10802-013-9726-z

    Gardner, F., Hutchings, J., Bywater, T., & Whitaker, C. J. (2010). Who benefits and how does it work? Moderators and mediators of outcome in an effectiveness trial of a parenting intervention. Journal of Clinical Child and Adolescent Psychology, 39, 568-580. doi:10.1080/15374416.2010.486315

    Gardner, F., Leijten, P., Mann, J., Landau, S., Harris, V., Beecham, J., Bonin, E-M., Hutchings, J., & Scott, S. (2017). Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective. Public Health Research, 5(10). doi:10.3310/phr05xxx

    Gardner, F., Montgomery, P., & Knerr, W. (2016). Transporting evidence-based parenting programs for child problem behaviour (age 3-10) between countries: Systematic review and meta-analysis. Journal of Clinical Child and Adolescent Psychology, 45, 749-762. doi:10.1080/15374416.2015.1015134

    Houtrow, A. J. & Okumura, M. J. (2011). Pediatric mental health problems and associated burden on families. Vulnerable Child Youth Studies, 6, 222-233. doi:10.1080/17450128.2011.580144

    Kilburn, J.E., Shapiro, C.J., & Hardin, J.W. (2017). Linking implementation of evidence-based parenting programs to outcomes in early intervention. Research in Developmental Disabilities, 70, 50-58. doi:10.1016/j.ridd.2017.09.001

    Leijten, P., Dishion, T. J., Thomaes, S., Raaijmakers, M. A. J., de Castro, B. O., & Matthys, W. (2015). Bringing parenting interventions back to the future: How randomized microtrials may benefit parenting intervention efficacy. Clinical Psychology: Science and Practice, 22, 47-57. doi:10.1111/cpsp.12087

    Lundahl, B. W., Tollefson, D., Risser, H., & Lovejoy, M. C. (2008). A meta-analysis of father involvement in parent training. Research on Social Work Practice, 18, 97-106. doi:10.1177/1049731507309828

    MacDonell, K. W., & Prinz, R. J. (2017). A review of technology-based youth and family-focused interventions. Clinical Child and Family Psychology Review, 20, 185-200. doi:10.1007/s10567-016-0218-x

    Murray, J., Shenderovich, Y., Gardenr, F., Mikton, C., Derzon, J. H., Liu, J., & Eisner, M. (2018). Risk factors for antisocial behaviour in low- and middle-income countries: A systematic review of longitudinal studies. Crime and Justice, 47, 255-364. doi:10.1086/696590

    Panter-Brick, C., Burgess, A., Eggerman, M., McAllister, F., Pruett, K., & Leckman, J. F. (2014). Practitioner Review: Engaging fathers – recommendations for a game change in parenting interventions based on a systematic review of the global evidence. Journal of Child Psychology and Psychiatry, 55, 1187-1212. doi:10.1111/jcpp.12280

    Trentacosta, C. J., & Fine, S. E. (2010). Emotion knowledge, social competence, and behaviour problems in childhood and adolescence: A meta-analytic review. Social Development, 19, 1-29. doi:10.1111/j.1467-9507.2009.00543.x

    Tully, L. A., Piotrowska, P. J., Collins, D. A. J., Mairet, K. S., Black, N., Kimonis, E. R., Hawes, D. J., Moul, C., Lenroot, R. K., Frick, P. J., Anderson, V., & Dadds, M. R. (2017). Optimising child outcomes from parenting interventions: fathers’ experiences, preferences and barriers to participation. BMC Public Health, 17, 550. doi:10.1186/s12889-017-4426-1

    Whittaker, K.A., & Cowley, S. (2012). An effective programme is not enough: A review of factors associated with poor attendance and engagement with parenting programmes. Children & Society, 26, 138-149. doi:10.1111/j.1099-0860.2010.00333.x

    World Health Organisation [WHO] (2013). Mental Health Action Plan 2013-2020. Geneva, Switzerland: WHO Document Production Services.

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