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

BACKGROUND: High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality. OBJECTIVE: This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers. METHODS: A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches. RESULTS: For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t168=23.2; P<.001), family costs (t185=9.2; P<.001), and total costs (t171=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars. CONCLUSIONS: The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal. TRIAL REGISTRATION: ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Online-delivered parenting intervention for young children with disruptive behavior problems: a noninferiority trial focused on child and parent outcomes.

BACKGROUND: This study evaluated whether an evidence-based parenting intervention, when delivered online, could effectively address disruptive behavior problems in young children and yield outcomes comparable to in-person delivery of the same intervention. METHODS: Families (n = 334) of children (3-7 years; 63% White, 22% African American, 15% other races; 63% male) with disruptive behavior problems were randomized to online-delivered intervention (ODI) or staff-delivered intervention (SDI), resulting in baseline and demographic equivalence. Primary outcome measures for child disruptive behavior (independent observation, parent report) and secondary outcome measures of parenting and family impact were assessed at baseline, postintervention, and follow-up. Conducted using intent-to-treat (ITT) as well as per-protocol (PP) methods, noninferiority analyses, which drew on an HLM framework with repeat measures across three timepoints and on REML to provide unbiased estimates of model parameters, tested whether the outcome-difference CI did not exceed the a priori noninferiority margin. RESULTS: For ITT and PP analyses, the ODI was found to be noninferior to the SDI on the primary outcome: independently observed child disruptive behavior and parent-reported child behavior problems. The pattern for secondary outcomes was more varied: (a) noninferiority for observed positive and aversive parenting; (b) noninferiority for observed quality of parent-child relationship at post but not follow-up assessment; (c) noninferiority for parent-reported inappropriate/inconsistent discipline for PP but not ITT analyses; and (d) noninferiority not confirmed for parenting daily hassles and adverse family quality of life, despite large effect sizes for the ODI (Cohen's d .75-1.07). Finally, ODI noninferiority was found for teacher-reported child disruptive behavior. CONCLUSIONS: The tested online-delivered parenting intervention demonstrated clear noninferiority with the corresponding staff-delivered parenting intervention on the primary outcome, child disruptive behavior problems, and reflected substantial though nonuniform noninferiority and meaningful effect sizes for secondary outcomes related to parenting and family. Future research will guide optimization of online interventions.

Development and Validation of Fidelity Monitoring and Enhancement in an Evidence-Based Parenting Program.

This article adds to current research by examining treatment fidelity of an evidence-based parenting program (namely Triple P) as part of a large clinical trial which included a range of procedures for promoting fidelity including both expert and peer supervision. Procedures for monitoring and promoting fidelity are described, and two major aspects of fidelity, namely content adherence and process fidelity, were evaluated. All treatment sessions for 166 families participating in the Standard Triple P-Positive Parenting Program were video-recorded and then sampled for evaluation without advanced knowledge by delivery practitioners. Independent coders at an external site assessed content adherence and rated delivery process. Fidelity promotion included high-quality training of practitioners on a standardized protocol, ongoing clinical supervision by peers and supervisors, and fidelity feedback sessions. Average content fidelity was consistently high (i.e., over 80%). Process fidelity scores were similarly high across sessions. A brief survey indicated practitioners found that the fidelity and implementation model was useful and contributed to increasing self-efficacy over the course of the initiative.

Applying Self-Regulation Principles in the Delivery of Parenting Interventions.

An individual's capacity to self-regulate their cognitions, emotions and actions is an important life skill and emergent developmental competency for both children and parents. Individuals with better self-regulation achieve more positive life course outcomes and are less likely to develop significant mental health, social, and relationship problems. Parenting support programs that promote positive, nurturing parent-child relationships provide a unique multigenerational context to promote the self-regulatory capacity of both parents and children. Such programs provide a meaningful context and many opportunities for parents to enhance their self-regulation capacities, including skills such as goal setting, self-monitoring, self-evaluation, self-efficacy, personal agency, and thought and emotion regulation that, in turn, enable independent problem solving and responsive parenting. Parenting programs based on social learning theory, cognitive behavioral principles, and developmental theory typically include structured session activities and homework tasks that can be optimized to promote parental self-regulation. These include enhancing executive functions such as anticipating, planning ahead, following a plan, and problem solving, so that parents acquire greater cognitive flexibility, better impulse control, and are better able to generalize and apply learned parenting principles and skills beyond their immediate concerns to a broader range of child problems and challenging parenting and family situations. We illustrate how positive parenting principles and strategies can promote enhanced self-regulation, and discuss implications for research and practice.

Primary Health Care: Potential Home for Family-Focused Preventive Interventions.

Family-focused prevention programs have been shown to effectively reduce a range of negative behavioral health outcomes but have had limited reach. Three key barriers must be overcome to expand the reach of family-focused prevention programs and thereby achieve a significant public health impact. These barriers are (1) current social norms and perceptions of parenting programs; (2) concerns about the expertise and legitimacy of sponsoring organizations to offer parenting advice; and (3) a paucity of stable, sustainable funding mechanisms. Primary healthcare settings are well positioned to overcome these barriers. Recent changes within health care make primary care settings an increasingly favorable home for family-focused prevention and suggest possibilities for sustainable funding of family-focused prevention programs. This paper discusses the existing advantages of primary care settings and lays out a plan to move toward realizing the potential public health impact of family-focused prevention through widespread implementation in primary healthcare settings.

Social media and gamification: Engaging vulnerable parents in an online evidence-based parenting program.

The aim of this study was to examine the feasibility (accessibility, engagement and impact) of adding social media and gaming features (e.g., social sharing with anonymity, badges to incentivize skills practice, an accredited facilitator for support) and access via smartphones to an evidenced-based parenting program, Triple P Online. The highly vulnerable population included 155 disadvantaged, high-risk parents (e.g., 76% had a family annual income of less than $15,000; 41% had been incarcerated; 38% were in drug/alcohol treatment; and 24% had had a child removed due to maltreatment). The ethnic groups most commonly identified were African American (24%) and Hispanic (66%). Respondents were primarily mothers (86%) from five community programs in Los Angeles. The study used a single group repeated measures design (pre, post, 6-month follow-up). Data collected included standardized self-report measures, post-intervention focus groups and interviews, website usage reports, and Google Analytics. Significant multivariate ANOVA time effects were found, demonstrating reductions in child behavioral problems, reduced lax/permissive and over-reactive parenting, and decreased parental stress. No effects were found for parental confidence, attributions, or depression and anxiety (which were in the normal range at baseline). Positive effects were maintained or improved at 6-month follow-up. The participants engaged in the online community and valued its flexibility, anonymity, and shared learning. This foundational implementation trial provides support for future rigorous evaluation of social media and gaming features as a medium for increasing parental engagement in evidence-based parenting programs online--a public health approach to protect and improve the development of vulnerable children.

Emulating real-life situations with a play task to observe parenting skills and child behaviors.

Play tasks that use standardized procedures and materials are a practical way to assess parenting skills, child behaviors, and the ways in which parents and children interact. We describe a systematic process for developing the parent-child play task (PCPT) to assess mother-child interactions for a randomized controlled trial of a video-based parenting program. Participants were 307 mothers and their 3- to 6-year-old children who presented oppositional and disruptive behavior challenges. The validity of the PCPT was investigated by testing (a) the extent to which the tasks elicited the specific parent and child behaviors of interest, (b) the consistency of individuals' behavior across the play tasks, and (c) the concurrent associations of the PCPT-observed child behaviors and mother reports of child behavior. The different tasks elicited the mother and child behaviors that they were designed to elicit. Behavior consistency across tasks for individual mothers and children was fair to good, with the exception of 2 task-specific behaviors. Mother's guidance (provision of instructions to foster a skill) during the teaching task and children's interruptions while mother was busy during the questionnaire task were highly task specific. Modest associations were found between observed children's noncompliance and inappropriate behaviors and mother-reported conduct problems and oppositional behaviors. Implications for clinical and research assessments are discussed.

Enhancing Accessibility and Engagement in Evidence-Based Parenting Programs to Reduce Maltreatment: Conversations With Vulnerable Parents.

11 focus groups (N = 160) of high-risk parents in Los Angeles County were asked to assess the value of social media to deliver an evidence-based parenting program, Triple P-Positive Parenting Program, to reduce child maltreatment. For feasibility, (N = 238) parents were surveyed regarding their internet use. Parents responded enthusiastically to the online program, and expressed the importance of a sense of community and learning through the experiences of others. 78% of the young, high-poverty, minority parents used the internet. An online evidence-based parenting program delivered in social media could enhance accessibility and engagement of high-risk parents - a powerful tool to reduce child maltreatment.

Using consumer preference information to increase the reach and impact of media-based parenting interventions in a public health approach to parenting support.

Within a public health approach to improving parenting, the mass media offer a potentially more efficient and affordable format for directly reaching a large number of parents with evidence-based parenting information than do traditional approaches to parenting interventions that require delivery by a practitioner. Little is known, however, about factors associated with parents' interest in and willingness to watch video messages about parenting. Knowledge of consumer preferences could inform the effective design of media interventions to maximize parental engagement in the parenting messages. This study examined parents' preferred formats for receiving parenting information, as well as family sociodemographic and child behavior factors that predict parents' ratings of acceptability of a media-based parenting intervention. An ethnically diverse sample of 162 parents of children ages 3-6 years reported their preferences for various delivery formats for parenting information and provided feedback on a prototype episode of a video-format parenting program based on the Triple P Positive Parenting Program. Parents reported the strongest preference for self-administered delivery formats such as television, online programs, and written materials; the least preferred formats were home visits, therapists, and multiweek parenting groups. Parents' ratings of engagement, watchability, and realism of the prototype parenting episode were quite strong. Parents whose children exhibited clinical levels of problem behaviors rated the episode as more watchable, engaging, and realistic. Mothers also rated the episodes as more engaging and realistic than did fathers. Lower income marginally predicted higher watchability ratings. Minority status and expectations of future problems did not predict acceptability ratings. The results suggest that the episode had broad appeal across groups.