Introduction

Disruptive behaviour, anxiety, and strain in the parent–child relationship are the most common reasons for families with children under age six to be referred for mental health services [1]. Anxiety disorders and disruptive behavioural disorders are very common in children under the age of six, with prevalence rates close to 10% each, which is very similar to rates amongst older children [2, 3]. Early intervention has been shown to positively impact later socio-emotional functioning and success in the school environment [4]. Treatment options can include parent coaching interventions, parent–child dyadic therapies, child-focused therapies (e.g., play therapy), and less commonly, pharmacotherapy [5]. Given developmental needs and the primacy of the parent–child relationship for this population (i.e., those under the age of six), involving the parent(s) and/or caregivers is crucial to the success of any treatment plan to address early childhood anxiety disorders or disruptive behaviour disorders [6, 7].

Two theoretical models which most commonly underpin these early childhood mental health interventions are behaviourism and attachment theory [1]. Behavioural-based parenting interventions have a rich evidence base, particularly for the treatment of disruptive behaviour [8]. A model for behavioural parent training that was developed by Hanf [9, 10] has been foundational to most subsequent behavioural parent training interventions, including the Incredible Years [11], and Helping the Noncompliant Child [12, 13]. The Hanf model drew from family systems theory, social learning theory, and operant conditioning principles to coach parents in the skilled use of positive reinforcement and restricted use of aversive consequences. Parents are taught positive parenting skills, particularly use of parental attention (in the form of praise and child-centered play) and positive reinforcement (such as incentive rewards), to shape and increase appropriate behaviour (e.g., compliance) in their children. Parents are also taught how to limit inappropriate child behaviour through prevention strategies (e.g., environmental and instructional accommodations) and select, purposeful use of consequences (e.g., removal of privileges). Moderate effect sizes for improvements in child disruptive behaviour is a well-established outcome for behavioural-based parenting interventions amongst several meta-analyses, and many studies have shown effectiveness with this intervention approach across settings and populations [14,15,16,17,18,19,20]. Further details of some behavioural-based parenting interventions can be found in Box 1.

Attachment-based parenting interventions draw on elements of attachment theory as first developed by Bowlby [21] and Ainsworth [22]. It is held widely among contemporary experts that one of the most useful applications of attachment theory is in the development of therapeutic interventions to support young children and their caregivers [23]. Therapeutic targets of attachment-based parenting interventions generally fall within two domains. The first target seeks to enhance caregivers’ reflective functioning capacities. The second target seeks to promote caregiving behaviours associated with secure attachment. The scope of attachment-based interventions is quite varied, with some interventions focusing more explicitly on enhancing caregiver reflection and others focusing more explicitly on the promotion of sensitive caregiving behaviours. Attachment-based interventions share a common goal of creating a therapeutic milieu of safety for caregivers, which creates the opportunity for caregivers to reflect and develop new parenting skills.

Among those attachment-based interventions with the strongest evidence base are Child Parent Psychotherapy (CPP) [24, 25], Video-feedback to Promote Positive Parenting (VIPP)[26, 27], and Attachment and Biobehavioural Catch-Up (ABC) [28]. Circle of Security (COS), an intervention directly informed by attachment theory, also has an emerging evidence base [29]. Attachment-based interventions have been shown to increase attachment security, increase parental sensitivity and improve emotional regulation skills in children [30, 31]. Other outcomes noted in studies of attachment-based interventions include reductions in parenting stress and reduced rates of disruptive behaviours in children [32, 33]. Attachment-based interventions have been implemented successfully with families at higher risk for parent–child relational problems, such as adoptive families and families whose members have been exposed to significant adversity, such as poverty, domestic violence and other forms of trauma [30, 34]. Further details of some attachment-based parenting interventions can be found in Box 1.

There have been strong opinions and misconceptions between practitioners who are predominantly behavioural-based or attachment-based [35]. For instance, behavioural strategies can be portrayed as undermining attachment security, while attachment approaches can be seen as permissive. Rather than seeing these approaches as contradictory, our perspective aligns with a rich literature that views both these approaches as complementary [1, 36, 37]. Both types of interventions emphasize positive parenting with concepts that are similarly aligned. That is, the behavioural focus on positive attention and setting limits is consistent with the attachment focus of “being with” and “taking charge”, respectively. In fact, Troutman has provided a framework for coaching parents from an integrated behavioural- and attachment- based perspective [1], and there are interventions that are both behavioral-based and attachment-based. One such intervention with an extensive evidence base is Parent–Child Interaction Therapy [12, 20].

The Gap in the Literature and Study Purpose

While historically, there has been an emphasis on the importance of delivering interventions in-person, tele-mental health services have become increasingly popular [38]. Virtual delivery of services increases access to underserved populations (e.g., rural communities), and reduces barriers for families (e.g., reduces travel and childcare demands). During the COVID-19 pandemic, there was a seismic shift across the board in healthcare from a default of in-person care to reliance on virtual care to enable safe care delivery. However, this shift was motivated by necessity rather than evidence. Now that health care services are transitioning back to in-person care delivery, health care teams are re-evaluating how to strike the balance between in-person and virtual care provision. An understanding of the existing evidence-base regarding virtual care delivery can help to inform this decision-making process.

Several reviews have shown the effectiveness of virtual delivery of mental health services for children and adolescents [39,40,41], including a practice guideline published by the American Telemedicine Association [42]. While these guidelines included some considerations specific to those age six and under, the research on which they were based was mostly with children and youth over age six. A recent scoping review reported on the nature and range of early childhood mental health interventions [6]. However, this review only included articles published before 2013 and the authors acknowledged there were a number of studies of interventions delivered online that have been published since then. The purpose of the current scoping review was to respond to this gap in the literature by mapping available evidence of virtually-delivered parent coaching interventions to promote early childhood mental health.

Methods

A scoping review of the literature was conducted between Dec. 15, 2020 and April 22, 2021 according to published methodology [43,44,45]. Scoping reviews are well suited to comprehensively mapping out available research in emerging areas such as this in contrast to systematic reviews, which are ideal for answering targeted questions by appraising the quality of a fairly sophisticated evidence base and synthesizing the results [46]. As is typical for scoping reviews [43], our search strategy was iterative, meaning that, as we became more familiar with the literature, we repeated steps in the scoping review process using additional, more sensitive and specific, search terms in an effort to ensure that our scoping review was comprehensive in its coverage of the available evidence. In our first set of searches, we searched the databases PubMed, CINAHL, and PsycINFO using the terms: “telepsychiatry”; “telemental health”; “e-health”; “psych*”; “telehealth”; “telemedicine”; “videoconferencing”; “teleconferencing”; and “videoteleconferencing” (See Supplemental material for exact search strings). For all searches, the following filters were applied: “Human”, “English”, “infant/ preschool” (defined by PubMed and CINAHL as 1 month—5 years, and by PsycINFO as 2 months—5 years). No filter was applied for publication date, so all publications in those databases until April 22, 2021 were included.

The first author assessed the titles and abstracts of all articles identified in the databases for relevance. All authors collaboratively drafted the inclusion and exclusion criteria for determination of eligibility, but this was iteratively refined over the course of reviewing titles and abstracts of identified records (Table 1). As part of this refinement process, the second author reviewed the first author’s screening of the titles and abstracts of the first 100 records for categorization into eligible, ambiguous (needs full text review), and ineligible. An Excel spreadsheet was used to support tracking and categorization, and provided an audit trail. Once the inclusion and exclusion criteria had been solidified, the first author reviewed the rest of the titles and abstracts of all articles identified using the first set of search terms. The full list of potentially eligible articles (those categorized as either ‘ambiguous’ or ‘eligible’) was then reviewed by the second author (n = 129). The full articles were obtained for those publications that were judged by both authors to be relevant, or to require further information to determine whether they met inclusion criteria. Reference lists of all potentially relevant review articles that were identified in the searches were reviewed to identify any additional articles for inclusion which hadn’t been identified in the initial searches. Review strategy and preliminary results (28 eligible articles) were assessed by two clinical investigators in the field (at the authors’ home institution; one with expertise in behavioural-based interventions, one with expertise in attachment-based interventions) to identify potential areas/articles that were missing. Based on this expert review and the preliminary results, we conducted a second set of searches of the databases PubMed, CINAHL, and PsycINFO using the same filters, but with the addition of the terms: “attach*”; “behav*”; “online”; “virtual”; “digital”; “remote”; and "mental health". Again, the reference lists of all potentially relevant review articles that were identified in the searches or suggested by the clinical investigators were reviewed for additional eligible articles. Also based on a recommendation from the clinical investigators, the first author searched clinicaltrials.gov for any studies that were registered but for which we had not found published results.

Table 1 Final inclusion and exclusion criteria
Full size table

Full texts of all potentially relevant articles were reviewed by the first author, with secondary review by the second author of any articles whose eligibility was ambiguous. The focus of the full-text screening for articles categorized as ‘ambiguous’ was to search for information relevant to the inclusion and exclusion criteria, when it was not available in the abstracts. For example, the most common detail missing from the abstract was the average age of children who participated. At this stage, the authors recognized that, while most articles identified in the searches that were targeting difficulties in the parent–child relationship were not delivered virtually, there were a subset of records describing such interventions using video feedback. The authors felt that video feedback could be well suited to virtual delivery, given the compatibility and efficacy of video-conferencing platforms in healthcare [47]. Thus, we agreed upon an exploratory sub-aim for the review. This exploratory sub-aim was to describe the use of video feedback for interventions targeting difficulties in the parent–child relationship. For this sub-aim, articles identified in the course of the search that reported the use of video feedback in the context of interventions directed towards the parent–child relationship were summarized descriptively, without data charting. When the final set of eligible records had been determined, the first author drafted the fields for charting the data, and then all three authors met to review the data charting form and process, as recommended [43, 44]. After incorporating feedback into the charting form, the first author charted five articles and then shared the completed forms with the co-authors for review and further feedback. After incorporating this round of feedback, the first author completed data charting for the remaining eligible records which presented original research. Results were collated and summarized descriptively.

Results

A total of 1146 records were identified, and 777 were screened, following removal of duplicates. Figure 1 presents the process by which we identified eligible records for inclusion, with details about reasons for exclusion. A summary mapping out features of the available literature is presented in Table 2, detailed characteristics of all eligible original research articles included in the main analysis (n = 30) are presented in Table 3, and descriptions of adaptations of included interventions for virtual delivery are in Box 1.

Fig. 1
figure 1

Flow diagram

Full size image
Table 2 Summary of features of included articles (n = 30)
Full size table
Table 3 Detailed characteristics of all eligible articles (n = 30), ordered within each category according to intervention name (alphabetical), study design (strongest to weakest), and finally in chronological order for those of the same intervention and study design
Full size table

The majority of eligible literature was published in the past five years (n = 24, 80%), and only three records (10%) were published over a decade ago. From a methodological perspective, included articles were mainly randomized controlled trials (RCT; n = 22, 73.33%) focused on intervention outcomes; there were very few studies that included qualitative methods or focused on intervention process. The vast majority of participants in eligible studies were White, with only three studies (10%) for which more than a third of participants were racially/ethnically diverse [48,49,50]. Eligible ages for the children included in the studies ranged from 1.5 to 10 years, but the majority of studies included only children 6 years or younger (n = 20; 66.67%). Less than a quarter (n = 7, 23.33%) of the studies included in this review presented results for mothers and fathers separately [49, 51,52,53,54,55]; mostly parents were considered altogether and the majority of participants were mothers. Further, most studies reported numbers of males/females for children receiving interventions, but few reported analyses of differences in outcome by sex of the child.

Feasibility

There is strong evidence that behavioural-based parent-coaching interventions targeting disruptive behaviour or anxiety in the early childhood population can be delivered virtually. All studies that measured parent satisfaction reported moderate-high intervention satisfaction or acceptability. With regards to program completion, on average, three quarters of participants completed therapist-guided behavioural-based programs (76.9%), while only a third of participants completed self-guided behavioural-based programs (33.68%). For self-guided programs, most participants completed half the available modules. Intervention engagement and satisfaction were generally greater with increasing therapist involvement [50, 54, 56, 57]. The three attachment-informed parent-coaching interventions identified in this review demonstrated the feasibility of delivering the interventions online. The study of the Emotional Attachment and Emotional Availability (EA2) program reported a remarkable 100% completion rate (with individual make-up sessions conducted). Participant feedback from the Child Parent Relationship Therapy (CPRT) online program highlighted a number of positive themes including convenience, ability to work at one’s own pace, accessibility, and benefits of not having to travel and being able to participate from one’s own home. Studies of internet-delivered Parent–Child Interaction Therapy (I-PCIT) have reported completion rates of 60–70%, with qualitative feedback from participants noting strong therapeutic alliance and lower barriers to I-PCIT compared to PCIT delivered in clinic.

For interventions using videoconferencing technology, loss of connection/disruption to the intervention was noted, and this represented a more significant barrier for geographically remote regions with poorer internet connectivity. It was possible to overcome this barrier if programs had the financial resources to provide participants with high quality internet, as seen in one study that sent participants an internet ‘dongle’ to access highspeed internet for mobile devices [58]. Few studies compared virtual delivery of interventions to in-person delivery, but participants in one such study noted fewer barriers to engaging in the intervention when delivered virtually [48], and this finding is echoed in the one qualitative study included in this review [58].

Only one study reported a cost analysis [50], and found a significantly higher start-up cost to delivering the intervention virtually (Technology-enhanced Helping the Noncompliant Child (TE-HNC)—$671/family) compared to treatment as usual (in clinic HNC—$10/family). It is important to note that the cost of the TE-HNC intervention included providing each family with a smartphone, including service plan, and tripod for use in video recording home practice sessions. Given the increasingly ubiquitous presence of smartphones in households, and decreasing costs of service plans, these start-up costs would be significantly reduced in the current (and likely future) technology climate. Interestingly, the implementation costs of mastering a skill in TE-HNC were slightly less (M = $80) compared to in-clinic HNC (M = $82). The costs of TE-HNC were lower because families in this group were able to master skills and complete the program more quickly, with a mean of eight sessions compared to an average of 10 sessions for the in-clinic HNC group. Thus, even with the greater intensity of therapist engagement in the TE-HNC group, therapists spent less time on this group overall, resulting in a lower implementation cost.

Efficacy

For parent–child relationship concerns, virtual delivery of the attachment-informed intervention EA2 demonstrated efficacy in improving parent–child attachment and child problem behaviour [59], and an online version of CPRT demonstrated positive outcomes in the domain of parental acceptance of their children [60], all with large effect sizes.

Efficacy in improving child anxiety symptoms was demonstrated for the virtual delivery of the behavioural-based interventions BRAVE Online and Cool Little Kids Online, and the behavioural- and attachment-based intervention Internet-delivered Coaching Approach behaviour and Leading by Modeling (I-CALM; an adaptation of I-PCIT) (although the evidence for I-CALM is weak—only one case study [49]). BRAVE-Online demonstrated medium effect sizes in improvements in severity and symptoms of child anxiety, and child functioning, while Cool Little Kids Online demonstrated slightly lower magnitudes of small—medium effect sizes in child anxiety symptoms and child functioning. Remission rates for the two interventions were dramatically different post-intervention, with 60.1% for Cool Little Kids Online, compared to 34.8% for BRAVE-Online. However, at the 6-month follow-up assessment for BRAVE-Online, there was a remission rate of 70.6%, along with an increase in module completion rate (from 42.1% completion of module 5 (including the exposure session), to 73.9% completion of module 5).

Efficacy in improving child disruptive behaviour symptoms was demonstrated with at least one RCT, and generally large effect sizes, for the virtual delivery of the behavioural-based interventions Helping the Noncompliant Child (HNC), “Parenting Matters” (therapist-guided bibliotherapy), Promoting Engagement for ADHD Pre-Kindergartners (PEAK), Research Unit on Behavioral Interventions—Parent Training (RUBI-PT), Strengthening Families, Triple P, and “Wackelpeter und Trotzkopf” (therapist-guided bibliotherapy), and the behavioural- and attachment-based intervention I-PCIT. Only one study reported remission rate, which was a study of I-PCIT reporting a remission rate of 55% [48]. Effect sizes for intervention impact were larger, in general, as intensity of the intervention increased. This was demonstrated directly in some RCTs of interventions of differing intensity. For example, larger effect sizes were found for the group that had virtually delivered TE-HNC (which included smartphone enhancements like skills videos, daily progress surveys, mid-week video calls, and text reminders) compared to the group that had HNC in clinic [50]. Reliable and clinically significant change post-treatment in terms of child behaviour was demonstrated for the majority of participants for TE-HNC, I-PCIT, self-directed Triple P, enhanced self-directed Triple P, self-directed Triple P Online, and enhanced Triple P Online [48, 50, 51, 54, 61, 62].

Efficacy to enhance parenting skills was demonstrated, with generally medium—large effect sizes, for virtual delivery of the interventions I-PCIT, Strengthening Families, Triple P, and “Wackelpeter und Trotzkopf” (therapist-guided bibliotherapy). Evidence of efficacy for improving indirect parenting outcomes (e.g., parental distress or inter-parental conflict) was more inconsistent, but more likely with increasing intervention intensity. For example, no changes in distal parental outcome variables were found for a brief 5-session self-guided Triple P online program [63], whereas significant improvements in parental stress and inter-parental conflict were found for an 8-session Triple P online program, and further improvements in parental depression and anxiety were found when the Triple P online program had practitioner support [56].

Effectiveness

This scoping review identified only two implementation studies—one for the Strongest Families Smart Website (SFSW) [64] and one for I-PCIT [61]. The implementation study of SFSW reported on the feasibility of its implementation in a real-world primary care context. It demonstrated higher engagement with the program (higher completion rate, time spent on the website, and number of coaching phone calls) relative to a comparison group in a previously published RCT [65], as well as similar levels of satisfaction with the website and coaches. It is important to note that ratings of child psychopathology were significantly higher in the implementation study, which could potentially explain the greater levels of program engagement for this group.

The implementation study of I-PCIT reported on both feasibility and effectiveness of its implementation in a real-world primary care context. It demonstrated similar levels of engagement and satisfaction to a comparison group in a previously published RCT [48]. In terms of effectiveness, 88.2% of those who completed treatment were below clinical cut-off at post-treatment assessment for frequency of disruptive behaviours (Eyberg Child Behavior Inventory-Intensity) and 82.4% were below cut-off for number of behaviours perceived by the family to be problematic (Eyberg Child Behavior Inventory-Problem), with very large and large effect sizes, respectively.

Exploration of Parent Coaching Interventions Using Video Feedback to Improve the Parent–Child Relationship

Although this review only identified two studies of virtually-delivered parent coaching interventions that were solely attachment-based, and focused on parent–child relationship concerns, both interventions used video feedback to review parent–child interactions, which is a common therapeutic tool within attachment-based interventions [66]. The positive impact of video feedback in attachment-based interventions has been highlighted in two meta-analyses. The first meta-analysis found attachment-based interventions using video feedback to be more effective across outcomes than interventions that did not include a component of video-feedback [30]. The second meta-analysis, focusing specifically on family interventions that incorporate video feedback as a therapeutic tool, found video feedback to have a positive impact on parenting behaviour and parental attitude, as well as positive effects on the development of children [67]. One of the attachment-based interventions with the strongest evidence base is the Video-feedback Intervention to promote Positive Parenting (VIPP). This intervention relies on video-feedback, as does its various adaptations: VIPP-SD (Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline) [68], VIPP-AUTI (Video-feedback Intervention to promote Positive Parenting adapted to Autism) [69], and VIPP-Co (Video-feedback Intervention for Co-parents of infants at risk for externalizing behaviour problems) [70]. Another video-feedback intervention with evidence from randomized controlled trials is AVI (Attachment-based Video Feedback Intervention) [71, 72].

Video-feedback has also been explored as an add-on to existing evidence-based interventions such as the Family Check Up [73]. In a preliminary study examining the effect of adding a video-feedback intervention component to the assessment feedback session of the Family Check-Up Intervention, researchers found that reviewing and engaging in feedback about videotaped interactions between parents and their children at age two predicted reduced caregivers’ negative relational schemas at age three, which acted as an intervening variable on the reduction of observed parent–child coercive interactions recorded at age five. Video-feedback has been applied successfully in interventions targeting populations with parents and children at risk for parent–child relational problems to promote attachment and reduce physiological dysregulation [66]. Further, it has shown potential in the context of cross-cultural healthcare delivery to racial or ethnic minority families [74]. When used intentionally, video feedback can act as a clinical engagement tool that can be used to enhance therapist cultural competence, and strengthen therapeutic alliance between clinicians and clients who come from different cultural backgrounds.

Discussion

This scoping review mapped out literature regarding the virtual delivery of parent-coaching interventions for disruptive behaviour, anxiety, or parent–child relationship in the early childhood population. The vast majority of this literature has focused on interventions with a behavioural basis (with or without an additional foundation in attachment theory) targeting disruptive behaviour, delivered on an individual basis by therapists to White families. Although this review documented that the majority of publications investigating virtual delivery of parent coaching interventions were categorized as primarily behavioural- or attachment-based (n = 24, 80%), we advocate the benefits of both approaches for supporting families in the field of early childhood mental health.

There is consistent evidence supporting the feasibility of delivering parent-coaching interventions virtually, with high satisfaction and acceptability, and fewer barriers to access. Having said that, it is important to note the remaining potential for disparities in access for rural communities with limited internet infrastructure and other populations with lower resources, such as low-income families. In terms of efficacy, there is solid evidence that virtually-delivered behavioural-based interventions can improve child disruptive behaviour and parenting skills, with medium to large effects. These outcomes are in keeping with, or at times stronger than, available evidence supporting the delivery of these interventions in-person. Though effectiveness studies remain largely undocumented in the literature, there are two published studies that demonstrate successful implementation and strong outcomes in real-world primary care contexts of virtually-delivered interventions for child disruptive behaviour that are either behavioural-based or both behavioural- and attachment-based.

This review brings into focus the lack of published research on the efficacy of virtually-delivered interventions that are (1) solely attachment-based, and/or (2) focused on parent–child relationship concerns. That being said, although the pilot studies of EA2 online and CPRT online included in this review were limited by their small sample sizes and lack of randomization, both studies provide preliminary evidence of the efficacy of the virtual delivery of interventions targeting parent–child relationship concerns for caregivers and young children that are solely attachment- and/or relationship-based (not behavioural-based). They also highlight the potential benefits of video feedback in virtual care settings. Video feedback as a therapeutic tool within parent coaching interventions may be particularly amenable to virtual care delivery and is worthy of further study. For instance, there is a recent development of a virtually-delivered VIPP intervention [75].

Implications for Practice

The global adoption of virtual health care during the COVID-19 pandemic has reinforced the benefits of virtually delivered interventions, which will likely continue to expand into the foreseeable future. For early childhood mental health interventions that focus on virtual coaching of parents and caregivers, there are several evidence-based programs that practitioners can consider. For the treatment of anxiety in the early childhood population, Cool Little Kids Online is an excellent option—it performed very well in terms of remission rate, and is an entirely self-guided intervention and so has a lower initial investment cost [76]. Minimal information was provided regarding characteristics of the populations studied, however, so further research is needed to explore the suitability of this intervention for different groups. Therapist involvement, for example, in the BRAVE-Online or I-CALM interventions, would likely be particularly important for tailoring treatment to the needs of specialized groups.

For the treatment of disruptive behaviour in the early childhood population, self-directed Triple P is a solid program [77]—either online (TPOL), or using the hard copy book and workbook, depending on internet availability and parent preference [55]. Reliable and clinically significant improvements in child disruptive behaviour have been demonstrated in multiple RCTs for parents using the self-directed Triple P intervention, which offers a lower therapist-time investment. The studies supporting the self-guided Triple P intervention were conducted with parents who were mainly White, highly educated, and of a moderate-high socio-economic status, although two studies did provide evidence in support of the efficacy of the intervention for parents who lived in rural areas, with lower levels of education, and of lower socio-economic status. Thus, therapist involvement in the interventions TE-HNC, I-PCIT, and enhanced Triple P (Online) would be key to tailoring treatment to be linguistically and culturally sensitive and appropriate for populations who are racialized or otherwise disadvantaged. Further, it is vital to consider and take steps to mitigate the risk of magnifying health inequities resulting from the digital divide, in which marginalized families are disproportionately excluded from virtually-delivered care [78].

Limitations

This review was limited to articles published in English, so more evidence may exist in support of virtual delivery of these interventions in other languages, to more racially/ethnically diverse populations. Our use of the “infant/preschool” filters in the literature databases could have excluded some articles focused on children who were 6 years old (since the filters had an age limit of 5 years old). However, we did exclude 16 articles at the full-text review stage because their participants had a mean age greater than 6, so the filters did not screen out all research on populations over 5 years old. Additionally, we excluded articles that focused on providing interventions to parents of children with genetic syndromes or medical comorbidities that could impact engagement in the interventions; thus, we are unable to comment on the evidence base that may or may not exist in support of the feasibility, efficacy, or effectiveness of virtually delivering these interventions to these populations. As always, it is important to remain cognizant of the potential publication bias whereby studies with negative/non-significant results are more likely to be unpublished, thus biasing our findings towards intervention efficacy and effectiveness. Finally, given that this was a scoping review, rather than a systematic review, we did not evaluate the quality of the evidence or conduct an assessment of bias, and as such, this limits our capacity to draw conclusions in terms of practice recommendations or implications. The nature of the scoping review does, however, enable identification of gaps in the literature and recommendations for avenues that would be worthwhile for future research.

Future Research

In particular, there is an urgent need for research to address the significant gaps in the literature identified by this review with respect to the virtual delivery of interventions for the early childhood population that are (1) solely attachment-based, and/or (2) focused on parent–child relationship concerns. Other potentially fruitful avenues of inquiry with currently limited literature bases for the early childhood population include the virtual delivery of: (1) group interventions, (2) interventions targeting anxiety, and (3) interventions to marginalized populations and rural populations. Future studies could also compare the “felt experience” of participants in virtually-delivered interventions versus in-person interventions, and whether this may impact intervention outcomes. It would also be useful for future research to include qualitative methods, studies of intervention process in addition to outcome, sex- and gender-based analyses, and to prioritize involvement of fathers/co-parents.

Finally, it would be worthwhile for future research to investigate the relative effectiveness, including cost-effectiveness, of different integrated care models. There is some preliminary evidence from this scoping review of the potential effectiveness of implementing a stepped-care model, in which patients first receive brief, low-intensity interventions, and initial non-responders “step up” to receive additional and/or more intensive treatment. This is supported by our scoping review given that: (1) brief online interventions that are entirely self-guided can improve outcomes and may be sufficient for a subset of the population in need, and (2) interventions of greater intensity have been demonstrated to have greater clinical impact. Future research could compare, for example, the unidirectional stepped care model versus a mechanism to screen referrals to triage those whose children have more severe symptoms into higher intensity interventions up-front (e.g., tiers of service), and the intersect between virtual versus in-person delivery of service at each stage or intensity level of intervention.

Summary

In this scoping review of the literature regarding virtually-delivered parent-coaching interventions for disruptive behaviour, anxiety, or parent–child relationship in children under age 6, data were extracted from 30 eligible articles. The majority of these studies focused on interventions with a behavioural basis (with or without an additional foundation in attachment theory) targeting disruptive behaviour which were delivered individually, by therapists, to White, non-Hispanic parents. While evidence is somewhat limited, particularly with respect to the virtual delivery of solely attachment-based interventions and/or those targeting the parent–child relationship, the evidence that exists does support the efficacy of virtually delivering parent-coaching interventions to improve child disruptive behaviour, child anxiety, and the parent–child relationship for the early childhood mental health population. Avenues for future research in the area of virtual delivery of parent coaching interventions for the early childhood population identified by this review include: solely attachment-based interventions, interventions focused on the parent–child relationship or anxiety, delivery in a group format, inclusion of marginalized populations, rural populations, and fathers/co-parents, qualitative studies, studies focused on intervention process, sex- and gender-based analyses, and analyses of different integrated care models, including cost-effectiveness analyses.

Box 1 Descriptions of virtually-delivered parent coaching interventions
Full size table