improving parenting skills for families of young children in pediatric settings a randomized...

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JAMA Pediatrics Journal Club Slides:Improving Parenting Skills

Perrin EC, Sheldrick RC, McMenamy JM, Henson BS, Carter AS. Improving parenting skills for families of young children in pediatric settings: a randomized clinical trial. JAMA Pediatr. Published online November 4, 2013. doi:10.1001/jamapediatrics.2013.2919.


• Disruptive Behavior Disorders

– Symptoms evident as early as 1 to 3 years of age.

– Symptoms typically continue into adolescence.

– Often result in academic underachievement, reduced social competence, and various mental health disorders.

– Common but modifiable.

• BUT

– Infrequently identified early.

– Intervention based on mental health referral.

– Fewer than 25% treated.

Introduction


Intervention

• Parent-training programs have been shown to be effective.

• The Incredible Years (IY) program in particular has received support in multiple randomized clinical trials.

However,

• Evidence-based parent-training programs are not widely available.

• Evidence for their feasibility and efficacy in primary care settings is limited.

Objective

• To test the efficacy of offering an evidence-based parenting program within pediatric practices to parents of 2- to 4-year-old children with early evidence of disruptive behaviors.

Introduction


• Study Design– Routine screening for disruptive behavior at 2- and 3-year well-child

care visits.– Eligible parents were enrolled and assigned by random number to

immediate intervention (parent-training group [PTG]) or waiting list (WL) control group.

– PTG: 10-week version of the IY parent-training program (see http://www.incredibleyears.com).

– Leaders were study psychologists plus members of the pediatric staff (nurse, social worker, pediatrician).

• Setting and Sample– Four federally qualified health centers, 7 suburban pediatric practices.– Parents of 345 children enrolled.

• 29% Nonwhite/non-Hispanic• 26% With annual income less than $20 000.

Methods


Methods• Outcomes

– Early Childhood Behavior Inventory (ECBI).– Parenting Scale.– Standardized observation of parent-child interaction (coded according to

Dyadic Parent-Child Interactive Coding System−Revised).– Assessments before intervention, immediately following intervention, 6

months later, and 12 months later.

• Limitations

– Slow recruitment resulted in the following:• Fewer participants in WL groups than intervention groups.• Intervention groups without control in 6 practices. These participants

were analyzed as a separate condition: nonrandomized PTG.

– Videotaped observations technically challenging.

– Only about half of parents who acknowledge disruptive behavior in their toddlers are able to participate fully in parent-training intervention.

– Research burden high; loss to follow-up.


830Consented To Contact

290Provided time 1 data & assigned to conditions

485 did not enroll

345Enrolled

55Dropped out

150 Randomized

123Assigned directly to PTG

89PTG

61WL

18< 3 PTG sessions

50 F/U

11 D/O

71≥ 3 PTG sessions

67 F/U

5 F/U

4 D/O

13D/O

73≥ 3 PTG sessions

50< 3 PTG sessions

7F/U

65 F/U

8D/O

43 D/O

17 Dropped out

Note. PTG = parent training group; WL = waitlist; F/U = follow-up; D/O = dropped out

Results• Overall: 144 of 212 families

(68%) assigned to intervention completed at least 3 IY sessions.

• High fidelity to the IY protocol was maintained throughout the study.


Waitlist Condition

Randomized PTG

Non-randomized PTG

5

7

9

11

13

15

17

Pre-Treatment

Post-Treatment

6-month follow-up

12-month follow-up

Results: ECBI Problem Scale

• In both parent-training conditions, parents’ reports of child disruptive behaviors were lower than baseline at all follow-up assessments.

• Both parent-training conditions were superior to WL at all follow-up assessments.• ECBI Intensity Scale followed same pattern with 1 exception (nonsignificant at 6-month

follow-up).


Waitlist Condition

Randomized PTG

Non-randomized PTG

2.2

2.4

2.6

2.8

3

3.2

Pre-Treatment

Post-Treatment

6-month follow-up

12-month follow-up

Results: Parenting Scale

• In both parent-training conditions, self-reports of negative parenting behaviors were lower than baseline at all follow-up assessments.

• Both parent-training conditions were superior to WL at all follow-up assessments.


Waitlist Condition

Randomized PTG

Non-randomized PTG

-0.1

0

0.1

0.2

0.3

0.4

0.5

Pre-Treatment

Post-Treatment

6-month follow-up

12-month follow-up

Results: Standardized Observation of Parent-Child Interaction

• In both parent-training conditions, observed negative parent-child interaction was lower than baseline at both follow-up assessments.

• Both parent-training conditions were superior to WL at both follow-up assessments.


Comment

• Results support feasibility and effectiveness of parent training for young children in pediatric settings.

• For parents who are able to participate, the intervention is successful across a wide range of risk.

• Pediatric office staff can be trained to deliver the evidence-based parent-training intervention.

• Sustainability of parent training provided within pediatric practices is dependent on changes in health insurance policies.


• If you have questions, please contact the corresponding author:– Ellen C. Perrin, MD, Division of Developmental-Behavioral Pediatrics,

Floating Hospital for Children, Tufts Medical Center, 800 Washington St, Ste 854, Boston, MA 02111 ([email protected]).

Funding/Support

• This study was funded by the National Institute of Mental Health R01 grant MH076244-01.

Conflict of Interest Disclosures

• None reported.

Contact Information

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