Effectiveness of an Internet-Based and Telephone-Assisted Training for Parents of 4-Year-Old Children With Disruptive Behavior: Implementation Research.

BACKGROUND: There is a lack of effectiveness studies when digital parent training programs are implemented in real-world practice. The efficacy of the internet-based and telephone-assisted Finnish Strongest Families Smart Website (SFSW) parent training intervention on the disruptive behavior of 4-year-old children was studied in a randomized controlled trial setting in Southwest Finland between 2011 and 2013. After that, the intervention was implemented nationwide in child health clinics from 2015 onwards. OBJECTIVE: The main aim of this study was to compare the treatment characteristics and effectiveness of the SFSW parent training intervention between the families who received the intervention when it was implemented as a normal practice in child health clinics and the families who received the same intervention during the randomized controlled trial. METHODS: The implementation group comprised 600 families who were recruited in the SFSW intervention between January 2015 and May 2017 in real-world implementation. The RCT intervention group comprised 232 families who were recruited between October 2011 and November 2013. The same demographic and child and parent measures were collected from both study groups and were compared using linear mixed-effect models for repeated measurements. The child psychopathology and functioning level were measured using the Child Behavior Checklist (CBCL) version 1.5-5 for preschool children, the Inventory of Callous-Unemotional Traits (ICU), and a modified version of the Barkley Home Situations Questionnaire. Parenting skills were measured using the 31-item Parenting Scale and the shorter 21-item Depression, Anxiety and Stress Scale (DASS-21). The estimated child and parent outcomes were adjusted for CBCL externalizing scores at baseline, maternal education, duration of the behavior problems, and paternal age. The baseline measurements of each outcome were used as covariates. RESULTS: The implementation group was more likely to complete the intervention than the RCT intervention group (514/600, 85.7% vs 176/232, 75.9%, respectively; P<.001). There were no significant differences between the implementation and RCT intervention groups with regard to child measures, including CBCL externalizing score (-0.2, 95% CI -1.3 to 1.6; P=.83), total score (-0.7, 95% CI -3.0 to 4.5; P=.70), internalizing score (-0.3, 95% CI -1.0 to 1.6; P=.64), and ICU total score (-0.4, 95% Cl -1.9 to 1.2; P=.64). No significant difference was detected in the Parenting Scale total score (0.0, 95% Cl -0.1 to 0.1; P=.50), while DASS-21 total score differed nearly significantly (2.5, 95% Cl 0.0-5.1; P=.05), indicating better improvement in the implementation group. CONCLUSIONS: The internet-based and telephone-assisted SFSW parent training intervention was effectively implemented in real-world settings. These findings have implications for addressing the unmet needs of children with disruptive behavior problems. Our initiative could also provide a quick socially distanced solution for the considerable mental health impact of the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT01750996; https://clinicaltrials.gov/ct2/show/NCT01750996. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/1471-2458-13-985.

Web-Based Parent Training Intervention With Telephone Coaching for Disruptive Behavior in 4-Year-Old Children in Real-World Practice: Implementation Study.

BACKGROUND: Parent training is the most effective approach to the psychosocial treatment of disruptive behavioral problems in childhood. However, no studies exist on how well Web-based training programs work when they make the transition from the research setting to implementation in primary health care. OBJECTIVE: The study aimed to examine how the randomized controlled trial (RCT) and implementation study groups of the Strongest Families Smart Website (SFSW) intervention differed in child psychopathology, family demographics and treatment-related factors, such as therapeutic alliance and parents' satisfaction rates. The intervention was conducted in the pediatric primary health care in Finland. METHODS: The study focused on 232 parents who had taken part in the SFSW intervention, which formed part of a 2-arm RCT study, and 882 families that would participate in the subsequent SFSW implementation study group. Both groups comprised parents whose children displayed high levels of parent-reported disruptive behavioral problems when they were screened in child health clinics at 4 years of age. Parents in both groups were provided with the SFSW intervention, which consisted of a Web-based training program with 11 weekly themes and associated telephone sessions. RESULTS: Demographic factors or duration of behavioral problems did not differ statistically or clinically between the RCT and implementation groups. Overall, 42.0% (362/862) of children in the implementation group and 35.4% (80/226) in the RCT intervention group had suffered from behavioral difficulties more than 1 year before the screening phase (χ12=3.2; P=.07). The mean duration of telephone coaching calls was very similar in the implementation and RCT intervention groups, that is, 38 and 37 min per call, respectively (t279.5=0.26; P=.79). The total time spent on the website of the program was 451 min in the implementation group and 431 min in the RCT intervention group (t318.8=1.38; P=.17). In the RCT intervention group, 52 of the 232 participants (22.4%) discontinued the program before the tenth week, whereas in the implementation group, 109 of the 882 participants (12.4%; odds ratio 2.05, 95% CI 1.4-3.0; P<.001) discontinued. Parents in both the implementation (77.1% to 98.5%, 498/742 to 731/742, respectively) and the RCT (64.8% to 98.2%, N=105/162- to 159/162, respectively) groups reported qualitatively similar and high level of posttreatment satisfaction rates in improved parenting skills, expectations, and stress relief. Parents in both groups reported a high level of satisfaction in skills and professionalism of the telephone coaches. CONCLUSIONS: The implementation of population-based screening of Web-based parent training intervention with telephone coaching resulted in good feasibility, fidelity, accessibility, and similar satisfaction level post treatment when compared with intervention in RCT research setting. The discontinuation of treatment in the implementation group was exceptionally low.

Internet-Assisted Parent Training Intervention for Disruptive Behavior in 4-Year-Old Children: A Randomized Clinical Trial.

IMPORTANCE: There is a large gap worldwide in the provision of evidence-based early treatment of children with disruptive behavioral problems. OBJECTIVE: To determine whether an Internet-assisted intervention using whole-population screening that targets the most symptomatic 4-year-old children is effective at 6 and 12 months after the start of treatment. DESIGN, SETTING, AND PARTICIPANTS: This 2-parallel-group randomized clinical trial was performed from October 1, 2011, through November 30, 2013, at a primary health care clinic in Southwest Finland. Data analysis was performed from August 6, 2015, to December 11, 2015. Of a screened population of 4656 children, 730 met the screening criteria indicating a high level of disruptive behavioral problems. A total of 464 parents of 4-year-old children were randomized into the Strongest Families Smart Website (SFSW) intervention group (n = 232) or an education control (EC) group (n = 232). INTERVENTIONS: The SFSW intervention, an 11-session Internet-assisted parent training program that included weekly telephone coaching. MAIN OUTCOMES AND MEASURES: Child Behavior Checklist version for preschool children (CBCL/1.5-5) externalizing scale (primary outcome), other CBCL/1.5-5 scales and subscores, Parenting Scale, Inventory of Callous-Unemotional Traits, and the 21-item Depression, Anxiety, and Stress Scale. All data were analyzed by intention to treat and per protocol. The assessments were made before randomization and 6 and 12 months after randomization. RESULTS: Of the children randomized, 287 (61.9%) were male and 79 (17.1%) lived in other than a family with 2 biological parents. At 12-month follow-up, improvement in the SFSW intervention group was significantly greater compared with the control group on the following measures: CBCL/1.5-5 externalizing scale (effect size, 0.34; P < .001), internalizing scale (effect size, 0.35; P < .001), and total scores (effect size, 0.37; P < .001); 5 of 7 syndrome scales, including aggression (effect size, 0.36; P < .001), sleep (effect size, 0.24; P = .002), withdrawal (effect size, 0.25; P = .005), anxiety (effect size, 0.26; P = .003), and emotional problems (effect size, 0.31; P = .001); Inventory of Callous-Unemotional Traits callousness scores (effect size, 0.19; P = .03); and self-reported parenting skills (effect size, 0.53; P < .001). CONCLUSIONS AND RELEVANCE: The study reveals the effectiveness and feasibility of an Internet-assisted parent training intervention offered for parents of preschool children with disruptive behavioral problems screened from the whole population. The strategy of population-based screening of children at an early age to offering parent training using digital technology and telephone coaching is a promising public health strategy for providing early intervention for a variety of child mental health problems. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01750996.

Remote population-based intervention for disruptive behavior at age four: study protocol for a randomized trial of Internet-assisted parent training (Strongest Families Finland-Canada).

BACKGROUND: Oppositional Defiant Disorder (ODD) is characterized by angry and noncompliant behaviour. It is the most common disruptive behaviour disorder (DBD), with prevalence estimates of 6-9% for preschoolers and is closely linked to several long-term difficulties, including disorders of conduct, mood, anxiety, impulse-control, and substance abuse. ODD in children is related to parental depression, family dysfunction, and impairments in parental work performance. Children displaying early DBDs exhibit more symptoms of greater severity, more frequent offences, and commit more serious crimes later in life. The goal of the Strongest Families Finland Canada (SFFC) Smart Website intervention research program is to develop and evaluate an affordable, accessible, effective secondary prevention parent training program for disruptive behaviour in preschoolers to prevent the negative sequelae of ODD. Strongest Families is an 11-session program with two booster sessions that focuses on teaching skills to: strengthen parent-child relationships; reinforce positive behaviour; reduce conflict; manage daily transitions; plan for potentially problematic situations; promote emotional regulation and pro-social behaviour and decrease antisocial behaviour. METHODS/DESIGN: This protocol paper describes an ongoing population-based randomized controlled trial (RCT) of high-risk 4 year-olds attending well-child clinics in Turku, Finland and environs to examine the effectiveness of the Strongest Families Smart Website intervention compared to an Education Control condition. Randomization consists of a 1:1 ratio for intervention versus the education group, stratified by the child's sex. The participants randomized to the intervention group receive access to the Strongest Families Smart Website and weekly telephone coaching sessions. The participants randomized to the Education Control condition receive access to a static website with parenting tips. Children are followed using parental and daycare teacher measures at 6 and 12 months after randomization. DISCUSSION: The Strongest Families Smart Website intervention is hypothesized to improve parenting skills, reduce child disruptive behaviour, reduce parental distress and improve family functioning. These results will likely inform subsequent investigations, public policy, and early treatment of childhood disruptive behaviour problems. TRIAL REGISTRATION: ClinicalTrials.gov # NCT01750996.