Eur Child Adolesc Psychiatry DOI 10.1007/s00787-014-0556-5

REVIEW

Are self-directed parenting interventions sufficient for externalising behaviour problems in childhood? A systematic review and meta-analysis Joanne Tarver • David Daley • Joanna Lockwood Kapil Sayal

•

Received: 8 November 2013 / Accepted: 25 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract Externalising behaviour in childhood is a prevalent problem in the field of child and adolescent mental health. Parenting interventions are widely accepted as efficacious treatment options for reducing externalising behaviour, yet practical and psychological barriers limit their accessibility. This review aims to establish the evidence base of self-directed (SD) parenting interventions for externalising behaviour problems. Electronic searches of PubMed, Web of Knowledge, Psychinfo, Embase and CENTRAL databases and manual searches of reference lists of relevant reviews identified randomised controlled trials and cluster randomised controlled trials examining the efficacy of SD interventions compared to no-treatment or active control groups. A random-effect meta-analysis estimated pooled standard mean difference (SMD) for SD interventions on measures of externalising child behaviour. Secondary analyses examined their effect on measures of parenting behaviour, parental stress and mood and parenting efficacy. Eleven eligible trials were included in the

analyses. SD interventions had a large effect on parent report of externalising child behaviour (SMD = 1.01, 95 % CI: 0.77–1.24); although this effect was not upheld by analyses of observed child behaviour. Secondary analyses revealed effects of small to moderate magnitude on measures of parenting behaviour, parental mood and stress and parenting efficacy. An analysis comparing SD interventions with therapist-led parenting interventions revealed no significant difference on parent-reported measures of externalising child behaviour. SD interventions are associated with improvements in parental perception of externalising child behaviour and parental behaviour and wellbeing. Future research should further investigate the relative efficacy and cost-effectiveness of SD interventions compared to therapist-led interventions. Keywords Disruptive behaviour
ADHD
Self-help
Self-administered
Parent training

Background Electronic supplementary material The online version of this article (doi:10.1007/s00787-014-0556-5) contains supplementary material, which is available to authorized users. J. Tarver
D. Daley (&)
J. Lockwood
K. Sayal Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham NG7 2TU, UK e-mail: [email protected] J. Tarver e-mail: [email protected] J. Tarver
D. Daley
K. Sayal Centre for ADHD and Neurodevelopmental Disorders across the Lifespan (CANDAL), University of Nottingham, Nottingham, UK

Childhood behavioural disorders such as attention-deficit/ hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) are associated with developmentally inappropriate levels of externalising symptoms including aggressive, defiant, hyperactive and impulsive behaviour, and constitute some of the most common reasons for referrals into Child and Adolescent Mental Health Services (CAMHS, [1]). Such disorders are associated with later delinquency, substance misuse, criminality and educational and social problems [2–4]. Early and accessible intervention is therefore a priority, especially since established behavioural problems may be more resistant to treatment [5].

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Adverse familial environments are common in families with children displaying elevated levels of externalising behaviour, leading some to suggest that adverse parenting practices have maintaining or exacerbating effects in the development of disruptive behaviour [6, 7]. Therapist-led behavioural parenting interventions are therefore recommended for the management of externalising symptoms often associated with ADHD and disruptive behaviour disorders [1, 8]. Based on social learning principles, recommended parenting interventions aim to modify parental behaviour to increase the frequency of positive child behaviours whilst reducing the occurrence of non-compliant behaviour. Parents are encouraged to engage with their child in positive, interactive play and are taught behavioural management strategies such as praising good behaviour whilst ignoring minor adverse behaviour. Parenting interventions are well-established as efficacious treatment options for reducing symptoms of externalising behaviour [9, 10]. Despite this, a number of barriers limit the availability of therapist-led parenting interventions. Firstly, access may be dependent on referral to secondary or tertiary services which often have long waiting lists [11]; during this time behavioural problems may escalate [12]. Once intervention is offered, parental adherence to treatment is often problematic. In a parenting programme focused on prevention of conduct problems, the average attendance rate was approximately 60 % [13]. Parents report that practical barriers such as the cost or inconvenient location of services impact on their ability to access treatment for their child [14]; this may be especially true for families living in rural or remote areas [15]. In addition, psychological barriers including perceived stigma can affect parental willingness to attend therapist-led group-based sessions [11]. To this end, there is now growing interest in the development of self-directed (SD) parenting interventions, which provide parents with the materials necessary to teach behavioural strategies to themselves, at home and a time most convenient to them. SD interventions come in multiple formats (e.g. manual, internet, videotape, DVD) and offer varying levels of therapist support to guide the parent through the programme. Given their promising potential to overcome some of the barriers to therapist-led interventions mentioned above, it is important to establish their evidence base using meta-analytical methods. A previous meta-analysis has investigated the effects of media-based parenting interventions delivered via manual, videotape and bibliotherapy formats [16] and concluded that they have a moderate effect on externalising behavioural problems. However, this review only included studies published up to 2005. It is important to update and extend the findings, especially since technological advances mean that the internet now provides an alternative and viable platform for

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accessible parenting interventions [17]. A recent metaanalysis has highlighted the family-wide benefits of groupbased parenting interventions for child behaviour problems [18]. To the best of our knowledge, no meta-analysis has yet investigated the potential therapeutic benefits for parents that may be associated with receipt of SD interventions for externalising child behaviour. This meta-analysis will therefore investigate the immediate post-intervention effects of SD parenting interventions on externalising behaviour in children displaying elevated levels of externalising behaviour. Secondary analyses will examine the effects of SD interventions on parenting behaviours, parenting stress, parenting efficacy and parental mood. An analysis comparing the efficacy of SD interventions for externalising child behaviour relative to therapist-led interventions will also be conducted to establish their feasibility as an alternative option to therapist-led interventions. Finally, brief therapist input over the telephone or the internet may be a viable way to improve the treatment outcomes associated with SD interventions. Therefore, this meta-analysis will include interventions involving telephone or internet contact. However, interventions involving such contact will be removed in sensitivity analyses, to establish what, if any, additional benefit brief therapist input may be able to provide given the cost it is likely to add to the intervention.

Methods Search strategy Trials were identified through electronic searches of PubMed, Web of Knowledge, Psychinfo, Embase and CENTRAL databases. Searches were completed on 20th May 2013. Search terms included either: Attention Deficit Hyperactivity Disorder, Disruptive Behaviour Disorder, Conduct Disorder, Oppositional Defiant Disorder or externalising behaviour with treatment terms: self-administered, self-directed, self-help, parent-administered, bibliotherapy or internet. Design search terms, randomised controlled trial or controlled clinical trial, were also used or design search filters were applied. No publication date or language filters were applied. Trials were also identified through hand search of the reference list of relevant reviews. Eligibility criteria The following eligibility criteria were used for trial identification: (1) randomised controlled trials published in peer-reviewed journals. (2) At least one treatment arm assessing the effects of a SD parenting intervention with no

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face-to-face therapist input, compared to an active control, treatment as usual (TAU) or waitlist control (WLC) treatment arm. Interventions that included therapist input via telephone or the internet were included. An active control was considered as a control group in which participants received a parenting intervention that did not fulfil criteria for the self-help treatment arm (e.g. a therapist-led parenting group). (3) Participants aged between 3 and 12 years and screened for elevated levels of externalising behaviour. This included those scoring above the clinical cut-off score according to a validated behaviour rating scale or meeting diagnostic criteria for ODD, CD or ADHD. In addition, we included studies where children had elevated yet subclinical levels of symptoms. This was considered justified given the call for early intervention for behavioural problems since they are a strong predictor of later and more serious conduct problems [19]; SD interventions may be a useful low-intensity intervention within this population. Where the age range for inclusion in a trial was slightly outside 3–12 years, the trial was included as long as the mean age of children in each treatment arm was between 3 and 12 years. (4) Immediate post-intervention outcome measures that included a psychometrically validated scale of externalising problem behaviour. Trials were excluded if (1) it investigated the additive effect of a SD intervention to medication. However, studies were not excluded if some of the study sample were receiving medication as part of their usual care. (2) The intervention included child- or teacher-focussed components. (3) The paper only reported long-term maintenance effects of a SD parenting intervention and did not include a no-treatment control group in the analysis. Studies were not excluded if children presented with co-morbidities such as autism or learning difficulties. Trial selection Two reviewers (JT & JL) independently screened records and selected studies for study inclusion, with discrepancies resolved by DD. Contact was made with authors if additional information was required to ascertain trial eligibility. This happened in the case of one study [20] which combined data for therapist-led and SD parenting interventions to form an ‘active treatment group’. Contact was made with the author to gain the separated data; however, this was no longer available and consequently the paper was excluded from the review. Study quality The methodological quality of included trials was assessed using the Jadad Scale for randomised controlled trials [21], which has been used to assess study quality in a number of

recent meta-analyses of treatment effects for externalising behaviour [22, 23]. Normally, Jadad criteria would award a point to trials described as ‘double-blinded’. However, as parents are heavily involved in treatment delivery of parenting interventions, it is impossible for parenting intervention trials to be double-blinded. We therefore revised the Jadad criteria and allocated a point to trials that included a blinded measure of externalising child behaviour. Study quality was independently assessed by JT and JL with discrepancies resolved by DD. Studies scoring two or less according to Jadad criteria would be later subject to a sensitivity analysis. Outcome measures Our primary outcome measure was parent report of child externalising behaviour for SD interventions vs. no-treatment control groups. Examples of scales included the Eyberg Child Behaviour Inventory (ECBI, [24]), externalising behaviour scale of the Child Behaviour Checklist (CBCL, [25]), ADHD rating scale [26] or other psychometrically validated measures. Where studies reported outcome data for mother and father data separately [27–30], preference was given to maternal report as mothers generally outnumbered fathers as primary respondents. Insufficient information was available regarding the number of fathers that provided data at each time point to allow a separate analysis of father-reported outcomes or combination of maternal- and paternal-reported outcomes. Finally, following evidence suggesting that psychological interventions may have little effect on behavioural outcomes when analysing data from informants who are probably blind to treatment allocation [22], we conducted a separate analysis of trials that included a blinded observation of child behaviour. For secondary analyses, we examined effects of SD parenting interventions compared to no-treatment control groups for psychometrically validated measures of parental well-being and behaviour. This included an analysis of measures of parental mood which assessed symptoms commonly associated with depression or low-mood, such as lack of interest or enjoyment from activities and feelings of unhappiness (e.g. GHQ-12, [31]). An analysis of measures of parental stress levels was also conducted; measures in this analysis contained items pertaining to parental feelings of irritability or tension (e.g. Parenting Stress Index, [32]). An analysis of parenting efficacy included measures related to parents’ feelings of confidence specifically within their parenting role (e.g. Parenting Sense of Competency Scale, [33]). Finally, an analysis of parental behaviour was conducted (e.g. Parenting scale, [34]). This included measures with items related to parenting behaviour during parent–child interactions, such as levels of

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affect or parental discipline practices. For these analyses we also permitted appropriate subscales of psychometrically validated measures (e.g. depression subscale of the DASS, [35]). Finally, to gauge understanding of the relative efficacy of SD interventions compared to therapist-led interventions, we compared intervention effects for SD interventions vs. active control groups for parent report of child externalising behaviour. Data extraction For all outcomes, we calculated mean change (difference between post-intervention mean and pre-intervention mean) in rating scales. Data were extracted by JT and independently checked by JL. Analyses were run for an outcome as long it had been measured by an appropriate and validated measuring scale, in at least three included trials. Contact was made with authors in two circumstances where unpublished data were required for analyses. Kierfeld et al. [36] provided separated scale data where only total scores for relevant scales were reported in the published paper. In addition, Lavigne et al. [37] provided preand post-test mean and standard deviation data which were not included in the published paper. Analysis strategy Mean change and pre-intervention standard deviation data were entered into RevMan version 5.2 [38] to calculate pooled standard mean difference (SMD). This approach to effect size estimation for pre-post study designs is recommended by Morris [39]. SMD was selected as the appropriate measure of effect because different rating scales were used across included trials. A random effects model was chosen because of the anticipated heterogeneity amongst trials. RevMan uses Hedges’ adjusted G to calculate SMD, which includes an adjustment for small sample bias. The I2 statistic in RevMan was used to analyse heterogeneity amongst trials. However, because this test is not good at detecting heterogeneity in meta-analyses involving a few trials, the p value for significance was set at 0.1 [40]. Due to the small number of trials included in this analysis, we were unable to investigate the effects of publication bias using funnel plots. It has been suggested that analyses need to include substantially more than 10 studies to begin interpreting publication bias [41]. For each outcome, a sensitivity analysis was conducted which removed studies where the SD intervention involved regular therapist contact via telephone or internet. This allowed us to assess the impact of therapist input on the efficacy of SD interventions. Sensitivity analyses also removed studies that included children with

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subclinical levels of externalising behaviour and studies scoring two or less using the Jadad scale for study quality. One trial [42] included two SD treatment arms (SD and enhanced SD) which met criteria for inclusion as SD interventions. Both treatment arms were included in analyses comparing SD interventions with no-treatment control groups (although enhanced SD was removed in sensitivity analyses). Where both treatment arms were included in one analysis, the number of participants in the control group was halved to avoid them being double-counted [40]. It was decided not to combine mean effect sizes across the SD and enhanced SD treatment groups due to differences in the amount of therapist contact. Four trials included an active treatment arm to be included in the analysis comparing the SD interventions with therapist-led interventions. Three of these trials included two active control arms. Where the active control interventions only differed in terms of mode of intervention delivery1 [28, 37], data from the two treatment arms were combined using the calculator function in RevMan to avoid loss of data and potential result choice bias [40]. For Sanders et al. [29], the standard therapist-led Triple P was chosen for this analysis over the enhanced therapist-led Triple P. It was decided not to combine these treatment arms due to differences in treatment content. The enhanced Triple P intervention included an additional component targeting parental partner support; a component which did not feature in the SD version of the intervention. In addition, it was assumed that the standard Triple P bears most resemblance to interventions that families would routinely be offered in clinical practice.

Results Database searches returned 919 records, 730 after removal of duplicates, which were screened on the basis of title and abstract. A further 14 articles were identified from the reference list of the Montgomery et al. [16] review. Thirtyseven full-text articles were subsequently assessed for eligibility. Eleven trials met inclusion criteria and were therefore included in this review (see Fig. 1 for flow of retrieved articles). A hand search of the reference lists of included trials identified six more full-text articles, none of which met criteria for inclusion. The characteristics of included studies are presented in Table 1. Four of the 1

Lavigne et al.’s [37] active intervention arms were nurse-led and psychologist-led parenting intervention in primary care. WebsterStratton et al.’s [28] active intervention arms were group discussion training (GD) and group discussion videotape modelling (GDVM). GD discussed the same topics as GDVM but did not receive videotape material for visual modelling of material.

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Records identified by database searches (N=919)

Records identified by hand search of the reference list of the Montogomery [16] review (N= 14)

Records after removal duplicates (N=744)

Records excluded (N= 707)

Full text articles excluded (N=25):

Full-text articles assessed for eligibility (N=37)

Child not screened for elevated levels of externalising behaviour via psychometrically validated rating scale (N= 12) Not SD (N= 8) Reports long-term outcome data without a no treatment control group (N=2) Included child or teacher focussed components (N= 2) Not randomised controlled trial (N= 1)

Eligible Articles (N=12)

Articles Excluded (N=6):

Articles identified from hand search of reference lists of eligible articles (N=6)

Outcome measures did not include psychometrically validated scale of externalising behaviour (N=2) Child not screened for disruptive behaviour via psychometrically validated rating scale (N= 4)

Eligible Articles (N=12)

Articles excluded from meta- analysis due to inadequate statistical information (N=1)

Eligible Articles included in meta-analysis (N=11)

Fig. 1 Flowchart of retrieved articles for meta-analyses comparing outcomes of SD interventions with no-treatment and active treatment control arms

included studies tested SD interventions that involved therapist input via telephone [30, 36, 42] or internet [12] as part of the SD intervention. All trials that included therapist support via telephone-reported mean call duration of 20 min, with a maximum duration of 30 min. Daley and

O’Brien [43] report the use of weekly non-therapeutic phone calls which served to remind participants to move on to the next stage of intervention, consequently this trial was not removed in sensitivity analyses of studies involving regular therapist contact.

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Jadad rating

3

4

3

3

2

2

2

2

3

3

References

Connell et al. [30]A

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Daley and O’Brien [43]B

Enebrink et al. [12]A

Kiereld et al. [36]A

Lavigne et al. [37]

MarkieDadds and Sanders [52]A

MarkieDadds and Sanders [42] ESDA

Markie Dadds and Sanders [42] SDA

Sanders et al. [53]B

Sanders et al. [29]A

C127 ECBI intensity or C11 on ECBI problem

‘Elevated levels of child behaviour problems on ECBI’

C127 ECBI Intensity or C11 on ECBI problem

C127 ECBI Intensity or C11 on ECBI problem

C127 ECBI Intensity or C11 on ECBI problem

C90th percentile CBCL ext scale

Between 75th and 85th percentile of CBCL ext scale

1SD above mean of Swedish norms on ECBI

C17 on PACS

Clinical range ECBI

Behaviour screen

SD Triple P

Triple-P Online

SD Triple P

SD TripleP ? weekly telephone consultation

SD Triple-P

IY Workbook

Self-help book (ref) ? weekly telephone consultation

Internet PT ? online therapist feedback

SD NFPP (?weekly nontherapeutic phone call)

SD Triple P ? weekly telephone consultation

Self-directed treatment (SD)

WLC

Internetasusual

WLC

WLC

WLC

Standard therapistled Triple P

–

–

–

–

Nurse- or psychologist-led IY

–

WLC

n/a

–

–

WLC

WLC

–

Active control (AC)

WLC

Control

61

60

15

13

21

31

25

46

24

12

SD

71

65

–

–

12d

56

–

12d

3

2–9

2–6

2–6

2–5

3–6

86a

–

3–6

3–12

4–11

2–6

Child age range (years)

–

–

–

–

AC

22

n/a

21

40

19

11

Control

Numbers analysed

Receipt of medication part of exclusion criteria

Receipt of medication part of exclusion criteria

Receipt of medication part of exclusion criteria

Receipt of medication part of exclusion criteria

Receipt of medication part of exclusion criteria

Not specified

Not specified

Not specified

Receipt of medication part of exclusion criteria

Not specified

Medication status

ECBIintensity

ECBIintensity

ECBI intensity

FOS-R-IIInegative child behaviour

FOS-child disruptive behaviourb

–

–

–

ECBIintensity

ECBI intensity

–

–

CBCL Ext

CBCL Ext

–

GIPC-R

PACS

ECBIintensity

–

Observed child behaviour

ECBIintensity

Parentreported child behaviour

–

DASS-21depression

DASSdepression

DASSdepression

DASSdepression

–

DASSdepression

–

GHQ-12

DASSdepression

Parental mood

Outcome measure used in meta-analysis

Table 1 Characteristics of studies included in meta-analyses comparing outcomes of SD interventions with no-treatment and active treatment control arms

–

PTCbehaviour

PSOCefficacy

PSOCefficacy

PSOCefficacy

–

PSBC

–

PSOCefficacy

PSOCefficacy

Parent efficacy

–

PS-laxness and overreactivity

PS-laxness and overreactivity

PS-laxness and overreactivity

PS-laxness and overreactivity

–

PS-laxness and overreactivityc

PPI-harsh and inconsistent discipline

–

PS-laxness and overreactivity

Parentreported parenting behaviour

–

DASS21stress

DASSstress

DASSstress

DASSstress

–

DASSstressc

–

–

DASSstress

Parent stress

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3

3

WebsterStratton [27]A

WebsterStratton et al. [28]A

WLC

IVM

‘Clinically significant number of behaviour problems according to ECBI’

WLC

IVM

[11 ECBI problem scale

Control

Self-directed treatment (SD)

Behaviour screen

GDVM and GD

IVMC ? therapist consultation

Active control (AC)

27

17

SD

27

14

Control

3–8

3–8

51a

Child age range (years)

12

AC

Numbers analysed

Not specified

Not specified

Medication status

ECBIintensity

ECBIintensity

Parentreported child behaviour

DPICS: total child deviance

DPICS: total child deviance

Observed child behaviour

–

–

Parental mood

Outcome measure used in meta-analysis

–

–

Parent efficacy

–

–

Parentreported parenting behaviour

PSI: parent domain

PSI: parent domain

Parent stress

d

c

b

a

B

A

In meta-analyses which included both SD and ESD treatment arms, the n for WLC was halved to n = 6

Separated scale data provided by author

Completed with a subset of participants (n = 54)

Active intervention treatment groups combined

ITT analysis

Analysis included study completers only

SD self-directed intervention, WLC waitlist control group, PT parent training, NFPP new forest parenting programme, IY incredible years parenting programme, Triple P positive parenting programme, IVM individually administered videotape training, IVMC individually administered videotape training ? therapist consultation, GDVM group discussion videotape modelling training, GD group discussion training, ECBI Eyberg child behaviour inventory, PACS parental account of childhood symptoms, GIPCI-R global impressions of parent–child interactions revised, PSOC efficacy scale of the parenting sense of competency scale, GHQ-12 12-item general health questionnaire, PS parenting scale, PSBC problem setting and behaviour checklist, DASS depression, anxiety stress scale, PPI parenting practices interview, CBCL Ext externalising scale of the child behaviour checklist, DPICS dyadic parent interaction coding system, FOS family observation schedule, FOS-R-III revised family observation schedule

Jadad rating

References

Table 1 continued

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Fig. 2 a Self-directed parenting interventions for externalising child behaviour vs. no-treatment control groups. b Self-directed parenting interventions for observed externalising behaviour vs. no-treatment control groups

Self-directed parenting interventions for child externalising behaviour

Z = 1.35, p = 0.18). Heterogeneity in this analysis was also non-significant (v2 [4] = 2.14, p = 0.71, I2 = 0 %).

Parent-reported outcomes

Effects of self-directed parenting interventions on parenting behaviour

Ten trials (11 treatment arms) were included in this metaanalysis that involved 612 participants (Fig. 2). The analysis revealed a large and significant effect of SD parenting interventions on parent report of externalising child behaviour (SMD = 1.01, 95 % CI: 0.77–1.24, Z = 8.31, p \ 0.001). However, a significant amount of heterogeneity amongst trials was also found (v2 [10] = 16.72, p = 0.08, I2 = 40 %). A sensitivity analysis that excluded interventions involving regular therapist input via telephone or internet revealed a reduced yet still large and significant effect of SD parenting interventions on parent report of externalising child behaviour (SMD = 0.83, 95 % CI: 0.63–1.02, Z = 8.28, p \ 0.001). Removal of interventions involving regular therapist contact reduced heterogeneity to non-significance (v2 [6] = 5.52, p = 0.48, I2 = 0 %). Observed child behaviour An analysis of trials that included a blinded observation of externalising child behaviour contained 5 trials and 312 participants (Fig. 2). However, no significant effect of SD interventions was found (SMD = 0.15, 95 % CI: -0.07 to 0.38,

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We investigated the effects of SD interventions on parent report of their use of harsh and inconsistent discipline practices. This analysis included 6 trials (7 treatment arms) and 354 participants (Fig. 3). Analyses revealed that SD interventions have a moderate effect on reducing harsh discipline (SMD = 0.57, 95 % CI: 0.33–0.81, Z = 4.66, p \ 0.001). Heterogeneity in this analysis was non-significant (v2 [6] = 6.83, p = 0.34, I2 = 12 %). Treatment effects on parental report of harsh discipline reduced slightly yet remained moderate after removal of interventions involving regular therapist contact (SMD = 0.51, 95 % CI: 0.20–0.81, Z = 3.29, p = 0.001). This analysis contained 3 studies and 180 participants. Removal of interventions involving regular therapist contact also reduced heterogeneity (v2 [2] = 0.52, p = 0.77, I2 = 0 %). Analysis of the effects of SD interventions for improving levels of lax or permissive discipline included 5 studies (6 treatment arms) and 268 participants and revealed a moderate effect (SMD = 0.51, 95 % CI: 0.11–0.90, Z = 2.52, p = 0.01) (Fig. 3). However, heterogeneity amongst trials was significant (v2 [5] = 5.35, p = 0.07,

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Fig. 3 a SD intervention effects on harsh parenting practices compared to no-treatment control groups. b SD intervention effects on lax parenting practices compared to no-treatment control groups

I2 = 51 %). The effect of SD interventions on lax discipline reduced to non-significance after removal of interventions involving regular therapist contact (SMD = 0.19, 95 % CI: -0.10 to 0.49, Z = 1.27, p = 0.20). Removal of these interventions also reduced heterogeneity to non-significance (v2 [5] = 5.35, p = 0.07, I2 = 51 %). This analysis included three studies and 180 participants. Parental well-being Six studies (7 treatment arms) including 311 participants measured parental mood. SD interventions had a small effect on improving parental mood (SMD = 0.30, 95 % CI: 0.07–0.52, Z = 2.55, p = 0.01) with no evidence of heterogeneity between trials (v2 [6] = 3.99, p = 0.68, I2 = 0 %) (Fig. 4). Removal of interventions involving regular therapist contact reduced the effect of SD interventions on mood a little, yet remained significant (SMD = 0.28, 95 % CI: 0.02–0.55, Z = 2.08, p = 0.04). Seven studies (8 treatment arms) including 351 participants contributed to an analysis investigating the effects of SD interventions on parental stress (Fig. 4). SD interventions were associated with small reductions in parenting stress (SMD = 0.39, 95 % CI: 0.18–0.61, Z = 3.58, p \ 0.001). There was no evidence of heterogeneity between studies in this analysis (v2 [7] = 2.36, p = 0.94, I2 = 0 %) (Fig. 4). Upon removal of interventions involving regular therapist input, the effect of SD interventions on parental stress remained significant (SMD = 0.31, 95 % CI: 0.07–0.56, Z = 2.50, p = 0.01).

Finally, we conducted an analysis of the effects of SD interventions on parenting efficacy. This analysis included 6 studies (7 treatment arms) and 311 participants (Fig. 4). Results revealed a large effect of SD interventions on parenting efficacy (SMD = 0.91, 95 % CI: 0.52–1.30, Z = 4.57, p \ 0.001). There was significant heterogeneity between trials in this analysis (v2 [6] = 13.32, p = 0.04, I2 = 55 %) (Fig. 5). On removal of interventions involving regular therapist contact, SD interventions continued to have a moderate effect on parenting efficacy (SMD = 0.77, 95 % CI: 0.20–1.35, Z = 2.64, p = 0.008). However, significant heterogeneity between trials remained (v2 [3] = 10.14, p = 0.02, I2 = 70 %). Visual inspection of the forest plot suggested that the large effect reported by Daley and O’Brien [43] may be responsible for the heterogeneity. Upon removal of this study, heterogeneity dropped to non-significance (v2 [2] = 0.97, p = 0.62, I2 = 0 %) whilst SD treatment effects remained moderate (SMD = 0.56, 95 % CI: 0.25–0.86, Z = 3.61, p \ 0.001). Self-directed parenting interventions vs. therapist-led interventions for disruptive child behaviour To establish the relative efficacy of SD interventions compared to the traditional format of therapist-led intervention, we ran an analysis comparing SD interventions vs. active control groups (parenting interventions involving regular face-to-face therapist contact) for parent-reported child behaviour (Fig. 5). Four trials (352 participants)

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Fig. 4 a Effects of self-directed parenting interventions on parental mood vs. no-treatment control groups. b Effects of self-directed parenting interventions on parental stress vs. no-treatment control

groups. c Effects of self-directed parenting interventions on parenting efficacy vs. no-treatment control groups

Fig. 5 Self-directed interventions vs. therapist-led active control groups for externalising child behaviour

included an active control arm. Whilst results showed a trend to favour interventions involving face-to-face therapist contact, no significant difference was identified when comparing SD with therapist-led interventions for parental report of externalising child behaviour (SMD = -0.13, 95 % CI: -0.49 to 0.24, Z = 0.68, p = 0.49). However, significant heterogeneity was identified in this analysis (v2 [3] = 7.43, p = 0.06, I2 = 60 %).

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Removal of trials with children with non-clinical levels of externalising symptoms Kierfeld et al.’s [36] study was the only trial that included children with subclinical levels of externalising behaviour. Removal of this study left the results largely similar. SD interventions continued to have a large effect on parentreported externalising child behaviour (SMD = 0.98, 95 %

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CI: 0.73–1.23, Z = 7.62, p \ 0.01) and parenting efficacy (SMD = 0.84, 95 % CI: 0.41–1.28, Z = 3.78, p \ 0.01). Effects on harsh discipline strategies (SMD = 0.58, 95 % CI: 0.29–0.88, Z = 3.86, p \ 0.01) remained moderate, whilst SD interventions continued to have a small effect on measures of parenting stress (SMD = 0.35, 95 % CI: 0.12–0.58, Z = 2.97, p \ 0.01) and parental mood (SMD = 0.32, 95 % CI: 0.08–0.57, Z = 2.56, p = 0.01). However, the effects of SD interventions on levels of parent-reported lax discipline dropped to non-significance after removal of the Kierfeld et al. [36] study (SMD = 0.41, 95 % CI: -0.02 to 0.84, Z = 1.88, p = 0.06). Study quality Removal of studies allocated two points according to Jadad criteria changed the findings slightly. SD interventions continued to have a large effect on parent-reported child externalising behaviour (SMD = 1.00, 95 % CI: 0.71–1.28, Z = 6.82, p \ 0.01) and parenting efficacy (SMD = 1.08, 95 % CI: 0.56–1.59, Z = 4.08, p \ 0.01). The effects of SD interventions on harsh discipline strategies remained moderate (SMD = 0.66, 95 % CI: 0.28–1.04, Z = 3.38, p \ 0.01). SD interventions also continued to have a moderate yet substantially increased effect on parent-reported use of lax discipline strategies (SMD = 0.77, 95 % CI: 0.09–1.44, Z = 1.89, p = 0.0.3). Meanwhile, SD interventions continued to have a small effect on parenting stress (SMD = 0.38, 95 % CI: 0.14–0.62, Z = 3.06, p \ 0.01). However, the effect of SD interventions on parental mood dropped to non-significance (SMD = 0.25, 95 % CI: -0.01 to 0.51, Z = 1.89, p \ 0.06).

Discussion Given their potential to overcome barriers that limit accessibility to therapist-led parenting interventions, this meta-analysis aimed to establish the efficacy of SD parenting interventions for children displaying elevated levels of externalising behaviour. Analyses revealed a large effect of SD interventions on parent report of externalising child behaviour. Moreover, this effect remained large (albeit slightly reduced) after removal of interventions that involved regular therapist input via telephone or internet. The results reported herein are therefore in agreement with Montgomery et al. [16] in supporting the efficacy of SD parenting interventions for externalising child behaviour. However, despite the impressive effect size for measures of parent-reported child behaviour, this finding was not upheld by our analysis of independent observations of child

behaviour. The improvement in parental perception of child behaviour could be the result of reporter-bias after parental involvement in treatment delivery. This is similar to the findings from a series of meta-analyses recently reported, where the effects of non-pharmacological interventions for ADHD (with the exception of two dietary interventions) dropped to non-significance when analysing data from informants who were ‘probably blind’ to treatment allocation [22]. On the other hand, these findings are in conflict with those reported by Furlong et al. [10], where the beneficial effects of group-based parenting interventions were evident for both parent-reported and independently observed measures of child behaviour. It is possible that SD interventions are at even greater risk of reporterbias as parents are likely to invest even more time into a SD intervention. Alternatively, parental perception in behaviour could reflect real improvements in behaviour at home that were not apparent in artificial clinic observations. Either way, the current findings support the importance of supplementing parent report of child behaviour with more objective measures when trialling interventions for externalising child behaviour [22]. Secondary analyses revealed a moderate effect of SD interventions on parent-reported use of harsh or inconsistent discipline practices; an effect that remained after removal of interventions involving regular therapist contact. SD interventions also had a small effect on reducing self-reported lax discipline practices. However, this effect dropped to non-significance after removal of interventions involving regular therapist contact and after removal of studies including children with subclinical levels of symptoms. The ability of SD interventions to improve lax discipline practices is therefore questionable. Motivation from a therapist may be required to encourage parents to take a firmer stance in their discipline practices. Since adverse discipline practices have often been implicated in the development and/or maintenance of externalising child behaviour problems [44–46], assessing the impact of interventions on parenting behaviour is paramount. Psychosocial adversity is common in families of children displaying externalising behaviour problems [6]. Our analyses revealed small but significant beneficial effects of SD parenting interventions on parental mood and parenting stress. However, the small effect of SD interventions on parenting mood should be interpreted with caution since the effect dropped to non-significance after removal of lower quality studies. SD parenting interventions also had a large effect on parenting efficacy that reduced to moderate levels in the sensitivity analysis removing trials with therapist input. However, significant heterogeneity was identified in this analysis despite removal of interventions involving therapist input. Upon exploration, heterogeneity was reduced after removal of the large effect reported by

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Daley and O’Brien [43]. We are unable to offer a conclusive explanation as to why receipt of this intervention was associated with much larger increases in parenting efficacy. We speculate that it may be due to sampling bias. The sample recruited by Daley and O’Brien [43] was on a waiting list for ADHD assessment. As these parents had identified a problem yet were awaiting treatment, it is possible that they were low in parenting efficacy whilst high in motivation to complete the SD intervention. On the other hand, the weekly phone call (although non-therapeutic) that participants received as part of this intervention may be accountable for this larger increase in parenting efficacy; it may have encouraged parents to have more active engagement in the intervention, hence improving their feelings about their parental role. Despite this, the large effect on parenting efficacy found in this analysis is an impressive one and substantially larger than the effect size of 0.34 reported by Barlow et al. [18] in their analysis of group-based parenting interventions. It is plausible to assume that the self-taught nature of the SD interventions may result in the larger increase in parenting efficacy reported herein. Our final analysis that compared the efficacy of SD interventions with therapist-led interventions revealed no significant difference on parent-reported measures of externalising behaviour. Interestingly, this result would indicate that SD interventions may be comparable to therapist-led interventions in improving child behaviour as perceived by parents. Insufficient data were available to compare SD vs. therapist-led interventions on objective observations of child behaviour. More clinical trials that compare objective outcome measures for SD vs. therapistled interventions are needed before any firm conclusions can be made. This finding should also be considered in the light of the sampling biases that may occur between SD and therapist-led treatment samples. It is possible that parents attracted to SD intervention trials are more motivated and literate; factors which may inflate treatment effects for SD interventions somewhat. Despite our uncertainty of their relative efficacy compared with therapist-led interventions, our results highlight the potential therapeutic benefits of SD interventions for child and parent. Of note, some of the effects on parental well-being and behaviour reported herein were small in magnitude according to traditional conventions of effect size interpretation [47]. However, the detrimental effects of parental psychosocial adversity have been widely cited [48] and even small improvements in parental well-being, especially when children are young and spend the majority of their time with their parents [49], could improve longterm child outcomes. SD interventions may therefore be an efficacious treatment option that could be implemented in clinical practice in a number of ways. Firstly, our findings

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may be of particular salience to those who argue that accessible and cost-effective parenting interventions should be offered at the population level as a preventative intervention for adverse child behaviour [11]. In addition, SD interventions could be seen as a viable alternative to therapist-led interventions where practical or psychological barriers are preventing access to treatment. Alternatively, SD interventions could be offered to cases of less severe behavioural problems or whilst families are on waiting lists, as part of a stepped care approach to treatment. If families later require therapist-led intervention, one could speculate that prior completion of SD intervention may improve therapist-led outcomes, since we found that SD interventions are capable of improving aspects of parental well-being known to moderate the treatment outcomes of therapist-led interventions [50, 51]. However, at present this argument is purely speculative and a matter awaiting future research. It is also possible that completion of a SD parenting intervention may demotivate parents from attending a therapist-led training session, particularly if they experienced little clinical benefit from the SD intervention. There are a number of limitations to this meta-analysis. Firstly, nine of the included studies only report findings for study completers. This may have inflated treatment outcomes as participants with negative treatment experiences are more likely to drop out. Secondly, due to insufficient data available, we only analysed post-intervention outcomes and cannot be sure to what extent treatment effects were maintained. Seven of the trials included in this meta-analysis included an analysis of long-term treatment maintenance [12, 29, 30, 37, 42, 52, 53]; however, only one of the studies included the control group in long-term analyses [53]. We were therefore unable to conduct an analysis of long-term treatment effects. Whilst the follow-up durations and findings varied between studies, they generally reported maintenance or improvement in child behaviour and measures of parental behaviour and well-being. The one exception to this was the study of Markie-Dadds and Sanders [52] who reported decreases in parenting efficacy from post-intervention to follow-up. Where data were separately reported, we focussed on maternal report of child behaviour as mothers were largely the primary respondents in included trials. There is growing evidence about the specific effects of paternal behaviour on child outcomes [54] and so this is an important matter to be addressed in future research into the efficacy of SD interventions. There is scope for SD interventions to be developed specifically for fathers. Group-based parenting interventions may be a particularly unattractive option for fathers since males are less likely to seek help if they perceive the treatment to be targeting a skill deficit [55].

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Another possible limitation to this study is the combination of measures of ADHD and ODD/CD like behaviours into an analysis of externalising child behaviour. There are currently insufficient data available to permit a separate analysis of treatment effects for these disorders. However, this constitutes an important area for future research, particularly given the more robust evidence-base supporting the efficacy of parenting interventions for the treatment of disruptive behaviour compared to ADHD symptoms [10, 22]. Finally, although the Jadad scale is a commonly used scale to assess study quality within meta-analyses [22, 23], it should be noted that the scale may not provide the most stringent test of risk of bias in the trials included in this analysis [40]. Future research For all outcomes, pooled effect sizes reduced after removal of interventions that involved regular therapist contact via phone or internet. Future research should clarify the clinical significance of this therapist input due to the additional cost it is likely to add to the intervention [15]. In addition, whilst it seems plausible to assume relative cost-effectiveness compared to therapist-led interventions, this needs to be confirmed in future analyses. Secondly, like all interventions, SD interventions will not be appropriate for everyone (e.g. people with literacy problems or no access to the internet). Future research should therefore investigate moderators of SD parenting interventions. This should include an analysis of how child co-morbidities may impact on SD treatment outcomes given their association with poorer treatment outcomes following therapist-led parenting interventions [51]. Furthermore, RCTs should include analyses of long-term outcomes that include control groups. This seems particularly important following the intriguing finding that recipients of SD interventions can show continued improvement from post-intervention to follow-up. It is of note that none of the included trials included measures of potential adverse effects of SD interventions. As such interventions are likely to be relatively labour intensive, it is possible that SD interventions may have adverse effects in other areas of family functioning. This therefore provides another important avenue to be addressed in future controlled trials. Finally, there is also a need for future trials of SD parenting interventions to include more independent measures of primary outcomes to remove the influence of expectation bias that is bound to be present in parent-reported outcomes. Acknowledgments JT and KS are partially funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Nottinghamshire, Derbyshire, Lincolnshire and JT is

partly funded by the Institute of Mental Health at the University of Nottingham. Conflict of interest Professor Daley has served as a speaker or adviser for or received funding or travel support from Eli Lilly, Janssen-Cilag, UCB, and Shire. Professor Daley has also been involved in the development, implementation, and evaluation of the New Forest Parenting Programme for children with ADHD and has received royalties from sales of a New Forest Parent Training selfhelp book.

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