Evidence for efficacy of parent-based interventions on parental characteristics
- 432 Downloads
Behavioral disturbances in children especially those associated with attention-deficit disorders are among the most common reasons for psychiatric referral in this age group . The prevalence is rising in recent years and has reached 7.3% worldwide . It has been stated that in the US, one in five children in high school are diagnosed with ADHD , and probably, the vast majority are treated with medication. The most common agents employed are stimulants such as methylphenidate and antipsychotic medications such as risperidone and aripiprazole.
These trends have led to concern among physicians regarding the overuse of psychotropic medications in children . Consequently, the interest in non-medication therapy for children with externalizing disorders has greatly increased.
The most commonly used therapies are those based on parental training such as behavioral parental training (BPT), positive parenting program (triple P), parent–child interaction therapy (PCIT), and nonviolent resistance (NVR)  The reasons for this focus are the fact that most clinicians recognize that parental influence is critical in understanding the psychopathology and etiology of these conditions and that maladaptive parental styles are among the most predictive factors of the clinical course in these children [5, 6]. In addition, it is now well recognized that parents are potentially major agents of change for these youngsters. This understanding has led to the development of therapeutic interventions focused on parents. Such programs aim to promote change in parental behavior, parental perception, attachment patterns, and parental understanding of how they as parents influence their children . The common assumption behind all these strategies is that ineffective parenting is basic to the formation of externalizing difficulties and that improving parenting can have a major influence on the child’s future. Thus, NVR (nonviolent resistance training) which is the program used in our own institution has as its major focus the alleviation of parental distress. Among the reasons for the popularity of all these parental approaches is their cost effectiveness and proven efficacy [8, 9]. Both the NICE as well the APA guidelines recommend parental interventions as a first line therapy for ADHD in preschool or elementary school aged children .
To further understand the value of these interventions, it is important to demonstrate how they influence change in parents and parenting and if these changes are lasting and continue after the program has ended. In this issue of European Child & Adolescent Psychiatry, Webber et al. (2019) review these issues in detail using a meta-meta analytic approach. They summarize the effects of parent-based interventions for children with externalizing behavior problems, as they influence parental characteristics. They looked at four major characteristics: parenting, parental perceptions, parental mental health, and parental relationship quality.
The authors found significant but moderate effects for parent reports of parenting and parental perception which continued through follow-up. The effects on parental mental health and parental relationship were small and showed only partial significance.
The authors are to be congratulated on this first systematic and methodologically sound review of this important topic showing how parental interventions in children with externalizing behaviour problems change not only the children, but also the parents themselves. Overall, it appears that these interventions have positive effects on parenting at least by maternal report. These positive effects seem to result from the direct attempts to influence the parents in areas such as positive parenting and the enhancement of parental capability.
The findings of this meta-meta-analysis should encourage the further and more extensive use of these strategies in the management of behavioural difficulties in children with consequent benefits for both children and parents. Therapies that improve parenting may influence the whole family including siblings and the extended family.
There are, however, two caveats stressed by the authors. The first is that there is not as yet a good active control comparison and most studies used wait list controls. In addition, most of the data in these studies are based on maternal reports, and in many studies, it was only the mother who was the actual recipient of the training. Both the rather limited literature and our own study  have shown that inclusion of fathers has extensive benefits for all concerned—children and parents . Future efforts should thus include studies of how fathers could be engaged in such treatments. This is easier said than done, but it definitely is an achievable goal .
- 3.Schwarz A, Cohen S (2013) More diagnoses of hyperactivity in new C.D.C data: a rapid rise in rates. The New York Times, April 1, 2013, p A1Google Scholar
- 4.Omer H (2004) Non-violent resistance: a new approach to violent and self-destructive children. Cambridge University Press, New YorkGoogle Scholar
- 9.Dretzke J, Frew E, Davenport C, Barlow J, Stewart-Brown S, Sandercock J, Bayliss S, Raftery J, Hyde C, Taylor R (2005) The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children. Health Technol Assess. https://doi.org/10.3310/hta9500 Google Scholar
- 12.Schorr-Sapir I, Gershy N, Omer H (2019) The efficacy of 'nonviolent resistance' parent training for treating ADHD in children (in preparation).Google Scholar