Client engagement in health interventions is considered to be a critical ingredient in the recipe for successful treatment (Bright et al., 2015). In interventions targeting children, parent engagement is an essential component because parents act as gatekeepers to accessing interventions (Ingoldsby, 2010) and because their attitudes and actions can support or erode the directions of therapeutic intervention (Haine-Schlagel & Walsh, 2015; Staudt, 2007). Across allied health fields, parent engagement (or involvement, participation, investment; see Haine-Schlagel & Walsh, 2015, for a discussion of terminology) is understood to bolster the effectiveness of a given intervention, as well as promote broader benefits for families (Chacko et al., 2012; King et al., 2019; Nock & Ferriter, 2005). Parent engagement has been empirically linked with better outcomes for children and the maintenance of treatment outcomes over time (Najdowski & Gould, 2014; Nix et al., 2009; Nock & Ferriter, 2005), as well as generalisation of treatment gains to untrained settings (Manassis et al., 2014; Moore & Symons, 2011). Parent engagement in child-focused interventions has also been correlated with increased parent satisfaction with services, consistent session attendance, decreased parental stress and increased parental confidence, as well as improved family relationships (Dowell & Ogles, 2010; Kingsley & Mailloux, 2013; Novak & Honan, 2019). Given the body of literature linking parent engagement to treatment success, increasing attention has been directed toward examining the concept of engagement and identifying what constitutes engagement in child-focused interventions.

In conceptualising the role of engagement in mental health services for ‘at risk’ children, Staudt (2007) described engagement as a dynamic process, involving both behavioural (e.g., performance of tasks necessary to implement treatment) and attitudinal (e.g., emotional investment resulting from the belief that treatment is worthwhile) components. Staudt cautioned that merely participating in treatment may not be sufficient to say that families are engaged, and that behavioural dimensions (e.g., keeping appointments, participating in sessions, completing homework) may in fact be the result of strong parent engagement, rather than a factor contributing to its establishment. King et al. (2014) described engagement in paediatric mental health treatment as “a multifaceted state of affective, cognitive, and behavioural commitment or investment in the client role over the intervention process” (15, p. 2). Under this model, parent engagement involves emotional connection with a therapist (affective dimension), individual perceptions of self-efficacy to carry out the intervention (behavioural dimension), and sense of readiness for change and belief that benefits will arise from being involved in treatment (cognitive dimension), leading to parents’ uptake of strategies within therapeutic sessions and beyond (King et al., 2014).

Exploring this “important but poorly understood component of effective service delivery” (D’Arrigo et al., 2017, p. 340) from an occupational therapy lens, D’Arrigo et al. (2017) emphasised that engagement is a process, rather than a static state, and can be influenced by many factors specific to the client and their unique context. However, authors caution that heavy reliance on measuring behavioural dimensions of ‘being engaged’ within sessions may hamper the identification of features present in the engagement process, and ultimately limit understanding of what comprises engagement and when it is most successfully fostered (D’Arrigo et al., 2018). More recently, Melvin and colleagues (2020) canvassed literature on speech-language therapy interventions to identify and describe engagement of parents. They defined it as a “complex, multifaceted state” (Melvin et al., 2020, p. 2665) of interaction, where clinicians have an important role in helping parents to become and stay engaged, highlighting interpersonal features as pivotal in parent engagement.

A reading of the current literature on parent engagement leads us closer to an agreed definition of parent engagement as “a state of involvement, commitment, and investment, which changes over the course of the intervention … having affective, cognitive, and behavioural components” (King et al., 2022, p. 1621). This conceptualisation of parent engagement provides some insight into what is frequently described as a changeable, multifaceted, and complicated phenomenon, argued to be critical to the success of child-focused interventions.

Despite shared agreement that engagement of parents is important, that engagement is a process, and that clinicians play a role in shaping engagement (King et al., 2022), it is still not clear what specific clinician skills or responses foster and preserve parent engagement. Importantly, we do not yet know the degree to which findings about parent engagement generated within one discipline are relevant to clinicians working in other areas. Questions remain about the degree to which understandings about parent engagement can be generalised across allied health fields working to further child rehabilitation and skill development by involving parents (such as occupational therapy, psychology, and speech-language therapy; D’Arrigo et al., 2017). Past reviews, while comprehensive, have not combined literature across disciplines in allied health, so it is difficult to identify which learnings around engagement are unique to a certain field, and which are transferrable across clinical professions. Gaining insight here may guide clinicians in accessing appropriate parent engagement research, to drive the development of clinical tools for promoting engagement across disciplines.

The objective of the current review was to identify and synthesise qualitative literature exploring the concept of parent engagement, as it relates to allied health interventions for children. The review aimed to scour literature across allied health disciplines, to ascertain features that are important in understanding how parents become and remain engaged in child-focused interventions, and identify the factors that promote and detract from parent engagement. Thematic synthesis was selected as the overarching framework for the study, supporting the focus on combining existing qualitative research to inform clinical decision making and practice within allied health disciplines which prioritise parent engagement, The review was guided by the following research question developed using a PICo framework (Population, Interest, Context): What factors impact parent (Population) engagement (Interest) in literature on selected child-focused interventions (Context)?

Method

Researcher Description

The first and third authors are behavioural psychologists working part time in clinical practice and part time within a clinical training programme. The second author is a speech-language therapist who also works across clinical and education settings. The authors have practical experience working with parents in clinical interventions and experience formulating and conducting literature reviews, alongside familiarity with broader qualitative research methods. The research team have an interest in expanding understandings of parent engagement in allied health interventions, particularly as these inform the ‘so what?’ of clinical practice across settings (including disciplines, fields of work, and intervention delivery contexts).

Research Design

A systematised review methodology was used to identify and analyse existing allied health research. Described as a technique including “one or more elements of the systematic review process while stopping short of claiming that the resultant output is a systematic review” (Grant & Booth, 2009, p. 102), systematised reviews are appropriate when criteria for a systematic review (e.g., requirements for multiple reviewers) cannot be successfully met within the constraints of the project. Additionally, the systematised review methodology does not require the use of critical appraisal and quality assessment of included studies, allowing for broader inclusion of studies under analysis. In the current review, systematised methods facilitated comprehensive searching, thorough study selection and data extraction, with identification and synthesis of the main findings led primarily by the first author. The initial literature search yielded both qualitative and quantitative studies pertaining to parent engagement. However, only qualitative studies are included in the current review because thematic synthesis is considered best suited to studies which are primarily qualitative in nature.

Thematic synthesis (Thomas & Harden, 2008) was selected as the framework for the review, providing an overarching direction as well as specific guidance on data analysis and meaning making. Thematic synthesis was developed as a tool to combine qualitative primary data in ways that inform decision making and practice in health settings (Thomas & Harden, 2008), making it highly applicable for the current study. This approach aims to overcome the relative scarcity of procedural guidance for synthesising qualitative research in literature reviews, while avoiding the pitfalls of “de-contextualising findings” (2008, p. 46) by combining research outcomes in ways that may not necessarily mirror the primary research products. Thematic synthesis provides a three-step process for integrating the findings of primary studies which employ qualitative methods and is therefore highly appropriate for literature reviews. Steps include (i) line by line coding of findings in primary source articles, according to specific meaning and context, (ii) development of descriptive themes through exploring similarities, differences, and hierarchies of ideas in initial coding, and (iii) creation of analytic themes related to the research question by moving beyond the explicit content of the studies toward higher order ideas.

Protocol Development

The protocol for this systematised literature review was developed in collaboration with the research team (listed authors) and a subject librarian based at the authors’ affiliated institution. Informal scoping searches of the literature were conducted to assess the number and range of possible identified studies. This led to a refinement of the search terms, to retrieve the most relevant literature which would address the research question. During protocol development, PROSPERO and Google Scholar databases were searched, to ensure no recent systematic reviews had been published on the topic. This step also confirmed that no protocols were registered which could duplicate the findings of the review. The protocol for the current review is publicly accessible.

Search Strategy

Electronic searching was conducted across five databases (CINAHL, Embase, MEDLINE, PsycINFO, and Scopus). These were selected based on the comprehensiveness of material they index and relevance to the topic area under study. No date range was applied to the search; studies were considered from the earliest date determined by the database until the final date of searching. Reference lists of included studies were reviewed, to locate any studies missed by searching methods (in line with backward citation searching, or footnote chasing methods; Haddaway et al., 2022). Citation tracking (or forward citation searching, pearl growing; Booth, 2016; Haddaway et al., 2022) strategies were employed using the Google Scholar ‘cited by’ function, to identify any recent published literature. Additionally, studies published by authors of already included publications were checked for relevance, to support a comprehensive search. These final searching steps were completed on 1 September 2022. It was anticipated that hand searching of key journals would be employed as a rigorous search tool; however due to the breadth and diversity of publication outputs identified in the database search, this was judged not to be a feasible searching strategy (i.e., no ‘main’ or key publication sources were identified which would warrant hand searching).

Aligned with the aim of this review, the search considered primary research generated in the disciplines of behaviour analysis, occupational therapy, psychology, and speech-language therapy. In consultation with subject matter experts, it was agreed that this list, while not exhaustive of allied health fields supporting parents in child-focused interventions (for example, excluding social work and art therapy), represented the key disciplines that work alongside families with an ultimate focus on behaviour change for children (e.g., prioritising development or rehabilitation of children through therapeutic input) within service delivery models which prioritise working in home settings (e.g., as opposed to school- or hospital-based intervention delivery). All selected fields were judged to (a) likely employ similar goals and approaches to including parents in therapeutic interventions, (b) have a developing literature on engaging parents within intervention, and (c) have peer-reviewed journals of quality research, made available for literature searching. In this review, child-focused interventions were defined as: therapies or treatments which aim to improve child behaviours in line with identified goals, either directly (working with a child to promote change) or indirectly (working with agents for change in the child's environment).

Identified keywords were applied in database searches (in title, abstract, and keywords). Truncations (*), and Boolean operators (AND/OR) were used where relevant to specific databases. Searching using mapped headings was incorporated for relevant databases. An example of search terms is provided in Table 1. Given the variability of terms used to describe engagement across disciplines, several predicted synonyms were searched, including adherence, compliance, involvement, and participation.

Table 1 Example search terms for PsycINFO database (Ovid interface)
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Study Selection

After duplicates were removed, the first author screened all studies by title and abstract against the inclusion criteria. Studies were included if they were (a) peer-reviewed, (b) reported primary data, (c) included parents of children receiving intervention (or clinicians delivering intervention) as the primary participants, and (d) measured or described some element of parent engagement. Studies were excluded if they (a) were non peer reviewed or secondary sources (grey literature), (b) focused solely on engagement of children in treatment, (c) were based in an education or medical setting (such as daycare facilities or hospitals) or (d) involved the delivery of medication as the sole intervention. Studies which were not available in the English language, or not available in full text through authors’ institutional library network, were also excluded. If the suitability of any study for inclusion was unclear from screening the title and abstract, it was assigned to full text review.

Remaining studies were screened in full text. A calibration approach was applied, where all authors independently and simultaneously screened a selection of full text articles for a decision on whether the studies met inclusion criteria. Any disagreements between coding decisions were discussed until 100% agreement was reached. Subsequent rounds of calibration were carried out with different sets of randomly selected studies, until all authors were consistently scoring studies for inclusion or exclusion with high fidelity. Following each round of calibration, the inclusion criteria were adjusted to best facilitate answering the research question and to afford high levels of agreement across coders. Three rounds of calibration were conducted, for a total of 42 studies (8%) jointly screened for agreement at full text. Following calibration, the selection criteria at full text review were modified. Specifically, studies where parents were not the agents’ delivering interventions for their children (or where insufficient information was provided to determine if parents were delivering the intervention) were excluded. Further, studies where a component of intervention was educational or medical in focus (e.g., in mixed method or multi-site research) were excluded, to prioritise the focus on literature with parents as the main intervention agents.

Once the criteria for inclusion and exclusion at full text were adjusted in calibration, the first author screened the remaining studies. A final round of selection resulted in a subsequent exclusion criterion; articles where the main focus was something other than the engagement of parents in intervention were excluded. Again, a calibration approach was applied, where a subset of included studies (10 studies, 10%) was simultaneously and independently reviewed against this final exclusion criteria by the research team, and disagreements were resolved through discussion to 100% agreement. At this stage, only qualitative studies were retained for analysis, and studies which were quantitative in design were excluded. Figure 1 shows the flowchart of the search strategy for the review. Across calibration steps conducted at study selection, inclusion, and data extraction phases, agreement between researchers ranged between 67–100% before discussion. Lower agreement ratings predominantly occurred during the initial calibration of the inclusion and exclusion decision tool applied to the full text review of studies.

Fig. 1
figure 1

Flow diagram showing the search strategy for this review

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Data Extraction and Analysis

Once the complement of included studies was identified, the first author read each study in entirety and extracted key data including reference details, participant characteristics, intervention characteristics, methodological variables, and data collection strategies (see Table 2 below).

Table 2 Description of studies included in thematic synthesis
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QSR International’s NVivo software (New NVivo v. 1.7) was used to manage the thematic synthesis. In step 1, study abstracts, results or findings, and discussion sections were scanned for any information pertaining to the research question. Relevant information was inductively coded, with new codes generated in response to novel ideas raised in each article. During this stage, calibration was used as a teamwork strategy to balance the time-consuming nature of the task with a focus on complete and comprehensive analysis. Here, one study was randomly selected and coded by the research team as a group. This allowed for development of initial codes and discussion about ideas generated in the article, as well as specific approaches to coding to be utilised in the process. The first author went on to code approximately half of the qualitative studies independently, before another round of group coding on a novel study was performed. Following discussion (including development and refinement of codes) the first author coded the remaining studies. Step 2 involved the research team reworking the initial codes into a hierarchical structure and developing new codes, or descriptive themes, which captured the meaning of ideas present in the initial coding. Step 3 involved revising, reworking, and restating the descriptive themes into higher order ‘analytical’ themes, which interpreted the findings of primary studies in light of the research question, and with some level of inference beyond what was explicitly reported in each study (Thomas & Harden, 2008). This step included the formulation and refinement of a visual representation of themes generated in this analysis. Analysis steps were achieved through collaboration between the research team including group discussion and consensus-making across analysis workshops. Workshops were scheduled with sufficient time in between to allow for researchers to review and reflect on the data and generated themes, occurring approximately every 4–6 weeks.

Rigour

To enhance the credibility and rigour of the literature review, collaboration within the research team was utilised. The first author was primarily responsible for searching, study selection, data extraction and the first stage of coding, with support from the research team through calibration approaches and regular meetings for discussion and review. Group discussions occurred frequently (approximately fortnightly) throughout the project, to help ensure that the interpretation of studies aligned with the study context and the research question. An audit trail was developed and used throughout the study to record study-related decisions made during team discussions and to document the process of decisions and justifications related to the research tasks and analysis. Other techniques such as reflective journaling, peer discussion, and debriefing were used to support the rigour of the process and analytic outcomes of the study (Braun & Clarke, 2021, 2023; Johnson et al., 2020). These approaches helped to identify and navigate bias in the interpretations of the source articles by questioning assumptions, challenging interpretations, and exploring different perspectives of the data, all of which helped to bolster the rigour of the review and analysis.

Results

Search Results

The initial search yielded a total of 8824 studies after duplicates were removed, with the majority of these studies (N = 8274) excluded by title and abstract (Fig. 1). Studies were typically excluded by title and abstract if they did not describe a child-focused intervention (e.g., the intervention was focused on parents or change for another stakeholder, N = 1824), did not describe or measure the engagement of parents or clinicians (e.g., measured child engagement in treatment, N = 1775), or did not report primary, peer-reviewed data (e.g., discussion articles, secondary sources, or reviews, N = 2021).

Of the 550 studies reviewed at full text, 99 were initially selected for inclusion, reduced to 59 studies once the refined exclusion criterion was applied. Combined with 12 additional studies identified through backward and forward citation searches, 71 studies were included in the final analysis (less than 1% of the total search). Of these included studies, almost half (N = 33) were broadly quantitative in nature and were therefore excluded from this review. The remaining studies (N = 38) were designated as qualitative in method and were analysed using thematic synthesis.

Characteristics of Included Studies

Of the 38 qualitative studies included in this analysis, the majority were published after 2015, with 12 (32%) published since 2020 (range: 1982—2022). Included studies were conducted in Australia (n = 11), the USA (n = 9), the UK (n = 8), and Canada (n = 6), with a small number of studies from other countries (Denmark, Iran, New Zealand, Turkey, all n = 1).

Included studies were in the disciplines of speech-language therapy (n = 11), occupational therapy (n = 9), psychology (n = 6), physiotherapy (n = 4) and behaviour analysis (n = 2), with a small number studying multiple disciplines. Approximately one third of studies used the term ‘engagement’ to describe the phenomena under study, while other labels such as involvement, participation, and adherence were commonly used to describe parents’ roles in interventions for their children. Data collection methods were predominantly individual interviews (n = 31) and focus groups or group interviews (n = 6), with some studies utilising other methods such as observation, surveys, and diary recording. Thematic analysis was the most commonly cited analytic method (n = 14), followed by grounded theory (n = 6), framework analysis (n = 5), phenomenological approaches (n = 5) and content analysis (n = 4).

A small handful of studies provided specific details about the intervention under investigation (such as the protocol or steps for intervention delivery and data collection), however the majority failed to provide this information. While this may be the result of publication constraints on the level of detail provided in written reports, it could have implications for understanding the impact of intervention type (e.g., the specific treatment offered) on engagement of parents.

Thematic Synthesis

Five themes were developed using thematic synthesis, namely: a) societal context, b) interpersonal context, c) clinician features, d) family features, and e) relationship as engagement. The intersection of the themes is illustrated in Fig. 2.

Fig. 2
figure 2

Diagram showing relationship between themes generated in this review

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These themes can be seen to have increasing levels of impact the closer they sit to the phenomena of interest (engagement), with societal context (a) exerting some influence over the nature and shape of parent engagement, but with clinician and clinician features (c and d) having a more direct impact on the development of engagement as relationship (e). Each of the themes and subthemes are explored below, with sample quotes from included studies provided as examples. Table 3 outlines the themes and subthemes generated in this analysis.

Table 3 Overview of themes and subthemes generated within the review
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Societal Context

Studies in this review described elements of the context surrounding an intervention, (particularly ‘higher level’ organisational, social, or environmental factors), as having an influence over parent engagement. While some studies did not address broader contextual factors, many reported that awareness and consideration of these elements plays a role in explaining parent engagement, particularly in identifying barriers to engagement (Anderson et al., 2014; Gmmash et al., 2022; King et al., 2015; Levickis et al., 2020; Tse & Hall, 2008; Yasui & Wakschlag, 2015).

Organisational barriers Organisational factors, such as delivery requirements and service specifications, impacted parent engagement by defining how families could be involved in an intervention (e.g., where, for how long, and with what level of intensity). Parents expressed frustration and disengagement when there were long waitlists, or exclusion policies preventing them from accessing services they deemed helpful for their children (Anderson et al., 2014; Granger et al., 2012; Lundkvist-Houndoumadi et al., 2016), particularly when families ‘didn’t understand why they have to wait that long’ (Watts Pappas et al., 2016). Anderson and colleagues (2014) commented that:

Single-service exclusion policies (where a child could only access one service at a time) had been particularly difficult … As a result of such policies, [one family] could either receive device-specific services from a cerebral-palsy organisation or Picture Exchange Communication System (PECS)-focused therapy from an Autism service provider, but could not access both organisations simultaneously. (p. 78)

The lack of consistent funding for intervention delivery came through clearly as a barrier to engagement of parents (Melvin et al., 2022), with parents describing an “ongoing tug-of-war between desires to do everything they could for their child countered by a lack of professional support available” (Novak, 2011, p. 206). This was compounded for rural families, who cited long travel times and lack of transport (Holmes et al., 1982; King et al., 2015) as constraints to their full engagement. For some families, having few experienced clinicians or available services close to home led them to seek out less convenient (e.g., further away) interventions and practitioners, impacting the amount of time they had available to be involved in interventions (Anderson et al., 2014; Phoenix et al., 2020).

Organisational barriers included constraints on what clinicians could offer families as part of the intervention. For example, when organisational policies impacted parent involvement in services by excluding families who missed a specified number of appointments without prior notice, creating challenges for families (King et al., 2020; Phoenix et al., 2020; Yasui & Wakschlag, 2015). This inflexibility of provision impacted the ability for clinicians to try and foster parent involvement, as illustrated by Phoenix et al. (2020):

Administrative expectations about having calendars booked with clients in advance meant that service providers had limited flexibly with scheduling clients, causing tension when service providers and their clients expected timely responses to address client needs. (p. 2157)

Societal barriers and stigma Studies highlighted how a lack of understanding, or misunderstandings, in society prevented families from either accessing, or being fully engaged in, interventions that were suggested to be helpful for their children (Kahjoogh et al., 2020; King et al., 2015, 2020; Klatte et al., 2019; Klein et al., 2022; Levickis et al., 2020; Lundkvist-Houndoumadi et al., 2016). For example, in discussing treatment for Juvenile Idiopathic Arthritis (JIA), Jones et al. (2009) found that “all parents commented on the lack of knowledge in the community regarding JIA. At times, this created difficulties for families in accessing the treatment, resources and facilities required to participate effectively” (p. 252).

Broader cultural beliefs about the nature of physical or developmental differences were a barrier to some families in seeking out and following through with interventions, for fear of how these actions would be perceived by others in their communities (King et al., 2015, 2020; Klatte et al., 2019). Inherent is the idea of ‘stigma’ and fear of losing face within communities or extended families, which “creates significant barriers to participating in parenting programs.” (Glogowska & Campbell, 2000, p. 3). Clinicians working with immigrant families described parents’ cultural beliefs about the nature and causes of disability as a barrier to families taking an active part in intervention:

I also noticed that some families become paralyzed by their distress and can’t seem to take action. They see it as a curse and ... Yeah. It’s very common, and we have trouble getting them to take action because of it’ (King et al., 2015, p. 1376)

Conversely, other studies described that socio-cultural understandings of disability could compel parents to want to engage with child-focused intervention and meant that families faced barriers to engagement when they could not access the services they expected or wanted. For example, Levickis and colleagues (2020) recount the story of one parent seeking speech-language support:

For me it’s strange because in our country they more saw maybe if she not speaking normal they give some medical, they go to different doctors, all, but here no. They say, need waiting. What waiting? That’s why I’m worried.’. (p. 611)

Relatedly, societal expectations of parent roles and gender stereotypes was identified as playing a part in explaining engagement of parents. Mothers were frequently cited as the ‘key parent’ involved in intervention, where “mom is almost always the go-between,” (Klein et al., 2022, p. 6), who routinely “handles the kid stuff” allowing dad to disengage or fail to engage in treatment efforts for his children, adding increased pressure to mothers (Klein et al., 2022; Sicouri et al., 2018). This societal assignation of parents to specific ‘roles’ in intervention delivery also contributes to what Sicouri and colleagues (2018) called a “father … reported stigma associated with asking for help” in which fathers avoided engaging in interventions in case this involvement was “viewed as a sign of weakness or an indication that they were not coping” (2018, p. 223). Again, societal attitudes and ideals were found to have an impact on the place of parents in child-focused intervention, with mothers being the ‘main’ participants (Klein et al., 2022; Phoenix et al., 2020; Sicouri et al., 2018).

Time as a barrier The recurring idea that time (or more explicitly, not having enough time) presents a pervasive challenge to securing engagement in child-focused service provision came through clearly in the review. Studies described parents who were faced with ‘too much at once’ at the outset of therapy, impacting their engagement (Segal & Beyer, 2006). In recounting an experience of early intervention services, one family stated:

[we were] swamped by the recommendations for home practice coming from [child’s] occupational therapist, physiotherapist, SLP, and others – at times adding to more than 27 hours of homework per day: ‘... and that didn’t take into account that she needed to be fed, she needed to sleep, she needed to have a bath, and she just needed to be a kid!’ (Anderson et al., 2014, p. 79)

Intense commitments of time, or ‘time pressures’ of therapy (Edwards et al., 2003; Lundkvist-Houndoumadi et al., 2016) lead some families to report overwhelm, with one mother involved with occupational therapy reporting “The stress is all the time, you not only have to do the therapy for that hour you also have to continue with it throughout the week.” (Edwards et al., 2003, p. 245), a factor which led therapists in this study to conclude that “having a ‘really crazy schedule’, … impeded the mother’s ability to be involved in the therapy sessions, thus decreasing carry-over and caregiver empowerment.” (2003 p. 248). Some studies described time pressures as “an important factor that caused some mothers to give up on certain goals.” (Kahjoogh et al., 2020, p. 5) and a factor that left families feeling “unable to meet the demands therapy placed on them” (Lundkvist-Houndoumadi et al., 2016, p. 483).

Engaging effectively with child-focused interventions was reported to require high levels of coordination from families and clinicians, which, if done well, was a strength. For example: “Being flexible, considerate and understanding family priorities and routines, as well as scheduling and re-scheduling appointments where possible, were several ways that therapists built strong parent-therapist relationships and fostered parent engagement.” (D’Arrigo et al., 2020a, p. 2886).

If coordination was not achieved successfully, however, this posed a barrier to parent engagement (Anderson et al., 2014). This was particularly evident when trying to schedule therapy around work commitments or office hours (D’Arrigo et al., 2020a; Lundkvist-Houndoumadi et al., 2016), or when balancing the competing priorities or juggling of other necessary parenting tasks:

.. you look at [family] routines, and days don't always go as planned and dinner isn't always as planned, and I think that parents might have really good intentions, but life happens and 2-hour intervals go without sometimes parents remembering to do [the protocol]. So I think that is the really tough part, that's the big part.’. (Segal & Beyer, 2006, p. 506)

Some families preferred home programmes for this reason, as it was ‘easier’ to juggle their competing caregiving responsibilities in the home context. For example, Novak (2011) explained that parents perceived home-based intervention to have multiple benefits of “(a) eliminating the need to “rush off” to therapy; (b) simultaneous performance of domestic duties such as cooking meals at the same time as supporting the child; and (c) simultaneous caregiving to siblings such as homework supervision” (Novak, 2011, p. 203).

Interpersonal Context

Elements of interpersonal connection, such as social positioning, learning history and perspective, were identified as important ingredients in parent engagement. These factors can be seen to contextualise or ‘colour’ the specific interactions between clinicians and families which contribute to, or detract from, parent engagement.

Empowerment (and disempowerment) Evident in reviewed studies was a recognition of the role of empowerment and disempowerment in explaining parent engagement. Here, there was a unified perspective that parents come to interventions with overtly less power and control than clinicians; and a reflection that clinicians need to acknowledge this imbalance as they work to understand the context of families and the actions that might promote engagement (D’Arrigo et al., 2020a; Davies et al., 2017; Granger et al., 2012; Hinojosa & Anderson, 1991; King et al., 2015, 2020; Phoenix et al., 2020; Piggot et al., 2003). In exploring parent experiences of speech-language therapy for preschool children, Glogowska and Campbell (2000) found that during intervention “parents feel at their least powerful, and certainly less powerful than the therapist” (2000, p. 401). Parents reported a perception of the clinician as an ‘expert’ with specialised knowledge, with some preferring clinicians to hold the power of making decisions (Davies et al., 2017; Granger et al., 2012; Hinojosa & Anderson, 1991) and driving the intervention forward. For other families, this power imbalance was challenging to navigate: “Well, I don’t see how it can be a partnership when you’re dealing with professional people. It’s their job, you can’t tell them what to do” (Watts Pappas et al., 2016, p. 236).

Parents reported unheard complaints (“So I wrote a complaint letter here and jumped up and down, and of course nothing happened. So yeah I wasn’t overly keen to embrace it”; Anderson et al., 2014, p. 80), prioritisation of clinical imperatives over parent priorities (Davies et al., 2019), and lack of opportunity for in-depth discussion, all of which led to “feelings of disillusionment with therapy” (Glogowska & Campbell, 2000, p. 402). Additionally, when exploring parent participation in Incredible Years training, Flores et al. (2015) reported that parent shame related to perceived ‘parental incompetence’ (or ‘dwindling self-efficacy’ as described by Plath et al., 2016) could contribute to a feeling of disempowerment, followed by limited engagement in sessions. Power imbalance also created challenges for some practitioners. For example, in recounting rehabilitative work with families, one speech-language therapist commented: “They don’t discuss things with us, and even when we ask them, ‘What do you think about this? Do you think this makes sense?’ [They say] ‘Well yes, if you say so’’’ (King et al., 2015, p. 1376).

While acknowledging the inherent disempowerment of parents within interventions for their children, other studies noted the fluidity of empowerment and disempowerment, and the ability for clinicians to build empowerment of parents (D’Arrigo et al., 2020a; King et al., 2015, 2020). D’Arrigo and colleagues described that in situations where “parents experienced a sense of empowerment this indicated active engagement in therapy” (2020a, p. 2886). Specifically, empowerment was thought to be fostered by including parents in decision making (Anderson et al., 2014; King et al., 2015, 2020) and problem solving (D’Arrigo et al., 2020a), identifying parent priorities (Anderson et al., 2014; King et al., 2015), and reinforcing the position of parents as experts of their children (Phoenix et al., 2020; Piggot et al., 2003).

Confidence (and doubt) Closely related to empowerment was the place of confidence (or doubt) when entering a therapeutic intervention, and the impact of this positioning on parent engagement. A majority of studies described parents as generally lacking confidence at the onset of the intervention and building in confidence as the intervention progressed (Gmmash et al., 2022; Klatte et al., 2019; Levickis et al., 2020; Retamal-Walter et al., 2022; Tse & Hall, 2008). Some parents reported arriving to an intervention doubtful about the success of the intervention or the therapeutic process. This was particularly the case if interventions were for a family’s first child (Phoenix et al., 2020), if the family had limited prior experience of therapeutic treatments (Melvin et al., 2021; Novak, 2011), or if they had experienced unsuccessful interventions in the past which “shattered their self-confidence” (Tse & Hall, 2008, p. 167). Yet others experienced ambivalence about the intervention at the start:

A common characteristic that all parents in this study shared was a sense of being open-minded about the PBS interventions and willing to try, despite all participants also acknowledging some uncertainty as to whether PBS would work. (Botterill et al., 2019, p. 97)

Confidence, as described in the review, is thought to develop over time and with success in the intervention (King et al., 2015; Novak, 2011; Piggot et al., 2003; Plath et al., 2016; Yasui & Wakschlag, 2015). Levickis et al. (2020) described that:

The successful engagement of parents as learners is clearly important in order to give them confidence and to enhance their knowledge of language development and language difficulties, as well as teach them strategies for promoting their child’s language learning (p.612)

Issues of confidence and doubt are not exclusive to parents. Davies et al. (2019) noted that speech-language therapists held varying levels of confidence about their own skills and the likely success of an intervention at its onset. Further, the degree to which therapists saw parents as engaged and enjoying therapy impacted clinician engagement, with enthusiastic parents helping “the therapist feel positive and confident in themselves as a therapist” (D’Arrigo et al., 2020a, p. 2884). The circularity of this concept of confidence is illustrated by D’Arrigo and colleagues (2020a) who reported that “therapists… demonstrations of confidence could help parent engagement as they conveyed capability” (p. 2889). This was echoed by parents receiving speech-language therapy in Watts Pappas et al. (2016) who felt “you gain confidence in the therapist if you know they are confident in what they are doing” (p. 233). Therapist confidence in their own skills and abilities had a flow on effect for parents gaining in confidence. In turn, seeing parents gain skills and abilities within sessions afforded the therapist even greater certainty in their skillset and provided ‘a lot of hope’ that intervention effects will continue (Melvin et al., 2021). While a mutually informing and complicated relationship exists between the feelings of confidence of parents and clinicians, it is an important consideration in the broader interpersonal context around parent engagement.

Beliefs, values, and expectations Arguably a critical component of the interpersonal context is the importance of beliefs, values, and expectations, of both parents and clinicians, in informing parent involvement in allied health interventions. Specific motivations, values, and ideas about what and how interventions should develop play a part in setting the scene for strong parent engagement or contribute to disengagement (Phoenix et al., 2020). Parents indicated that they wanted the best for their child and believed that seeking a specific intervention would help them to achieve optimal outcomes (King et al., 2015; Phoenix et al., 2020; Watts Pappas et al., 2016). Davies et al. (2017) described that: "All the parents expressed a willingness to be involved in speech and language therapy, in order to support their children, despite considerable uncertainty about what would be expected of them" (p.177).

Parents generally perceived that interventions would be relevant and effective, beliefs which fostered their involvement in the intervention (Hock et al., 2015; King et al., 2020). When parents were ‘not entirely convinced’ by the intervention principles and methods, they were quick to disengage from intervention (Holmes et al., 1982; Sicouri et al., 2018). When two or more parents within a family did not share congruent beliefs about the value of therapy (e.g., when mum was ‘on board’ but dad “thinks this is for crazy people”), this contributed to one or both parents being less involved (Klein et al., 2022, p. 6).

It was clear from the reviewed studies that parents held multiple ideas about what would happen in interventions, with some expecting the clinician would ‘do’ the intervention directly (Davies et al., 2017), that parents would be given a plan to follow (Harrison et al., 2007), that the clinician would ‘drive’ therapy in session and model what to do at home (Dixon-Woods et al., 2006), or that they as parents would play a collaborative role in developing the intervention (King et al., 2020; Watts Pappas et al., 2016). In Granger and colleague’s (2012) study on early intensive behavioural intervention, parents who had not expected to play a ‘dual role’ of parent and therapist by ‘doing’ an intervention at home reported fatigue, feelings of obligation, and consequent relief on ending their involvement as interveners. Other parents had no idea what to expect, which created uncertainty and fear: “‘I was a nervous wreck... I,’cos I didn’t honestly know what to expect when I got there. I didn’t know what they expected...’.” (Glogowska & Campbell, 2000, p. 398).

Parents were also reported to have varied priorities for the intervention. For example, in Botterill et al. (2019) “Some parents identified wanting to be given practical advice and support to use themselves, some wanted a better understanding of the behaviour and for others, the priority was more about bringing others in the support network on board” (2019, p. 96). Some parents hoped that intervention would improve their parenting (Flores et al., 2015; Watts Pappas et al., 2016). Some wanted more knowledge and information about what their child was experiencing (Hock et al., 2015; Novak, 2011). Several parents reported wanting assurance and understanding from a knowledgeable professional (Grossoehme et al., 2013; Levickis et al., 2020; Melvin et al., 2022). Still others hoped that being involved would improve their parent–child relationship (Flores et al., 2015; Retamal-Walter et al., 2022). A minority of studies explored the parent expectation or belief that therapy would ‘fix’ their child (Davies et al., 2019), or that it would offer a ‘magic wand’ (Levickis et al., 2020) or ‘magic bullet’ (Tse & Hall, 2008) to address child behaviours or skill development delays, such as talking. Summarising the importance of parent beliefs and values to understanding engagement, Phoenix et al. (2020) identified that values and beliefs were considered by parents to be the most essential element affecting their engagement in therapy:

I’d have to say values because that’s the root of it all, right? That’s the fire that ignites me into going. If I didn’t believe it I wouldn’t do it, right? And go through all of the logistics and all those things, so I’m going to have to say my values… my values and how much I value the effectiveness and the practice of going to therapy, how important it is for his development (p. 2156)

Importantly, studies emphasised that clinicians also bring beliefs and expectations into therapeutic interactions which can affect parent engagement: either beliefs which bolster efforts to engage parents, or beliefs which challenge the place of active parent involvement. Notably, across disciplines and interventions, clinicians who saw value in their specific therapeutic approach and believed it would benefit families to be involved were more likely to focus on, and try to foster, parent engagement (Botterill et al., 2019; Davies et al., 2019; Hinojosa & Anderson, 1991; King et al., 2015; Melvin et al., 2021; Segal & Beyer, 2006). When clinicians valued involving parents and expected parents to take an active role, they reported greater success in getting parents engaged and keeping them engaged (D’Arrigo et al., 2020a, 2020b; Melvin et al., 2021, 2022; Phoenix et al., 2020). The degree to which clinicians felt parents should be involved did vary across studies, from parents “casually observing therapists' interactions with and treatment of their children” (Hinojosa & Anderson, 1991, p. 277) to parents co-creating and having “ownership of what arises in the therapy process, including goals, plans, intervention choices” (King et al., 2020, p. 24).

Interestingly, a minority of studies identified that not all clinicians hold positive, affirming beliefs about parents, or expectations that they will have success. Canvassing perspectives of speech-language therapists in Turkey, Durgungoz and Emerson (2021) reported hesitancy on the part of therapists to involve parents, in the case that they may ‘interfere’ or ‘negatively affect’ sessions, and child progress more generally. Another study reported that clinicians expected parents of anxious children may be anxious themselves, a feature which could hinder productive treatment (Lundkvist-Houndoumadi et al., 2016). Clearly then, clinician beliefs and expectations of parents’ capacity and ability were hypothesised to influence the degree to which clinicians actively promote and encourage full engagement of parents in interventions.

Clinician Features

It was apparent in this review that the specific behaviours and attributes of clinicians are factors in understanding how engagement is constructed and negotiated. The ways clinicians are (e.g., personal features) and ways that they behave (e.g., what they do in intervention delivery) make a clear contribution to the engagement of parents in interventions.

Clinician characteristics When clinicians were experienced (knowledge) personable (personality) and shared similarity in formal dimensions with families (i.e., gender identification or cultural affiliation), engagement of parents was supported. Primarily, parents emphasied that when they perceived the clinicians as being experienced, knowledgeable, and skilled, this encouraged them to become and stay involved (Anderson et al., 2014; Botterill et al., 2019; Lundkvist-Houndoumadi et al., 2016; Melvin et al., 2022; Watts Pappas et al., 2016). Clinicians who were not seen as experienced or where experience was variable (e.g., ‘experience as ‘pot-luck’; Anderson et al., 2014, p. 78), were described by parents as ‘a source of frustration’ and contributed to parents feeling less likely to stick with interventions (Anderson et al., 2014).

Personality and personability play a role in informing engagement. When providing advice to early intervention therapists, parents interviewed by Gmmash et al. (2022) stated that they “recommended … therapists be supportive, encouraging, and trusting” (p. 425). Parents reported the most success in interventions when therapists were “happy, helpful, supportive” and faced more difficulty maintaining engagement when therapists were perceived as “pushy” (Gmmash et al., 2022, pp. 424–425). Further, parents interviewed by Retamal Walter et al. (2022) reported “displaying calmness and using a soothing voice” enabled a positive treatment environment and promoted continuing with telepractice intervention (2022, p. 7). Harrison and colleagues (2007) built on this idea, suggesting that being ‘caring and affectionate’ toward the child was valuable for parents in building connection with a clinician and intervention. Being fun, engaging and “trying to be creative on the spot” were also desirable therapist traits (Retamal-Walter et al., 2022, p. 7).

Additionally, a small number of studies explored the need for ‘fit’ in personal characteristics, toward engaging parents. Clinician age, specifically, being older and having life experience (Harrison et al., 2007), and clinicians having their own children (Hock et al., 2015) were cited as characteristics which may bolster engagement, where there was a match of life stage or outlook between clinicians and parents (Klein et al., 2022). In terms of gender identification, fathers regularly reported wanting to work with male clinicians. For example, one father commented: “A white woman who doesn’t look like she has children trying to teach me about parenting my kid?’. I think there’s a huge issue around that.” (Klein et al., 2022, p. 7). Male therapists shared this perspective:

I think as a dad myself, it’s probably a little bit easier for me to connect with dads and for them to listen, especially given the very conservative and old school mentality of the region that I live in, it’s many times easier for a male caregiver to listen to another male (Klein et al., 2022, p. 9)

Equally, clinicians sharing similar cultural values (Flores et al., 2015; Yasui & Wakschlag, 2015), spiritual values (Grossoehme et al., 2013), and responding in ways considered by parents to be culturally appropriate (e.g., delivering ‘directives’ during coaching or not; Klein et al., 2022), or asking for parent opinions on treatment options (Granger et al., 2012)) are personal features thought to play a role in negotiating parent engagement.

Clinician behaviours An essential element contributing to parent engagement in the reviewed studies was the behaviours clinicians performed as part of work with parents. With respect to protective factors, clinicians demonstrating an awareness or understanding of context and family needs and being responsive to these needs by adjusting their behaviour to fit, were repeatedly identified as ways to promote parent engagement. The skill of “being vigilant to parent/s’ needs” and the ability to “adapt sessions to suit family characteristics and circumstances” in one study “underpinned effective engagement with parents.” (D’Arrigo et al., 2020a, p. 2884). This finding was consistent and universal across reviewed articles. Exemplifying one way that clinicians engaged in flexible responding to support parent engagement, a mother interviewed in Gmmash et al. (2022) described:

It was EXTREMELY helpful when the therapist allowed/encouraged me to record the activity; this allowed me to review it later and show it to other family members for them to see proper technique. Seeing the activity performed by itself, then seeing it incorporated into a daily/family routines. (p. 427)

Informed by training and professional experience, behaviours such as: using coaching and modelling techniques with parents, building interventions into daily routines, and incorporating collaborative goal setting were judged to be important to fostering engagement. Embedding intervention into daily routine was seen to have benefits for managing limited time resources and for generalisation of the skills parents were learning in therapeutic settings: “Instead of perceiving home programs as an additional and competing caregiving responsibility, parents structured their child’s life so that the program activities became “a part of life.” (Novak, 2011, p. 203).

Applying family-centred, collaborative, methods for selecting therapy goals worked to elucidate family priorities and expectations and align them with the purpose of therapy (Botterill et al., 2019; King et al., 2020; Klatte et al., 2019; Piggot et al., 2003). When parents were involved in choosing goals, they generally experienced stronger engagement with the intervention (Phoenix et al., 2020). For example, King et al. (2015) found that: “A key aspect of building a collaborative relationship was engaging in mutual goal setting: ‘‘just to have really open conversations with families when you’re setting goals. ‘What is actually important to you?’’’ (p. 1377).

Interestingly, the behaviour of performing direct therapy with a child was perceived as having mixed impact on parent engagement. In some studies, clinicians performing tasks directly with the child (or ‘leading’ intervention in a session) was protective, allowing a calm space for focused therapy (Durgungoz & Emerson, 2021), facilitating feelings of comfort and safety for the child (Davies et al., 2019; King et al., 2020) and by providing opportunities for parents to learn through observation (Harrison et al., 2007; Watts Pappas et al., 2016). Such was the case in Hinojosa and Anderson (1991), where “mothers universally acknowledged that they learned to care for and deal with their children by casually observing therapists' interactions with and treatment of their children” (p. 277). Contrastingly, other studies reported parent experience of discomfort with direct work between clinicians and children. Some families reported being ‘put off’ by this approach (Glogowska & Campbell, 2000; Hinojosa & Anderson, 1991), preferring to be shown how to perform tasks themselves (Anderson et al., 2014).

Family Features

Essential to understanding parent engagement in the review was an exploration of family characteristics and behaviours.

Family characteristics Individuality in the makeup of each family system informs how parents can become engaged or disengaged in child-focused interventions. Importantly, logistical or practical constraints on a family, notably work commitments and other childcare responsibilities, were reported by parents to impede their full involvement in therapeutic efforts for their children.

In addition to missing work, parents were also frustrated by having to pull children out of school or daycare to attend appointments. When there was more than one child in the home, parents often had challenges finding childcare while they were ... attending therapy appointments. (Phoenix et al., 2020, p. 2154)

Balancing therapy demands was fraught with challenges for working parents, particularly affecting the ability for working fathers to be engaged in intervention (Hock et al., 2015). As one study exploring father involvement stated: “one big logistical barrier is that dads in general are less likely to be available during the work day.” (Klein et al., 2022, p. 6). This was particularly relevant for families with other children, where engagement in interventions for one child required balancing the needs of other siblings (Granger et al., 2012; Hinojosa & Anderson, 1991; Jones et al., 2009; Tse & Hall, 2008). Interestingly, some parents discussed including siblings as ‘therapeutic partners’ which helped in this negotiation of responsibilities and in some cases benefitted therapy for the target child (Edwards et al., 2003; Gmmash et al., 2022; Melvin et al., 2021; Novak, 2011), ultimately bolstering parent engagement.

Where flexibility was afforded to parents around scheduling and time commitments, or when other helpful adults could be recruited for support, engagement was enhanced:

Therapists additionally described flexible scheduling to accommodate limited availability. They described enacting this flexibility by both working evening hours and scheduling in advance: “sometimes I’ll set up an appointment with the other caregiver, if they know the father’s schedule, two weeks out to re-arrange it, to let them know ahead of time, and so there just goes – more planning goes into engaging fathers.”. (Klein et al., 2022, p. 7)

Single parent families represented another family characteristic impacting engagement. In the studies under review, this impact was generally in the form of a barrier to being engaged (D’Arrigo et al., 2020a, 2020b). Reporting on the perspectives of occupational therapists, D’Arrigo et al. (2020a) wrote:

Personal circumstances, such as single parenting, parental relationship breakdown, domestic violence and having children in the foster care system added to the stress and burden for some parents. Therapists reported that because of these family circumstances or dynamics, therapy was not always the family’s priority. (p. 2886)

In addition, studies identified that the cultural values of a family play a part in engagement. Specifically, cultural identification is thought to inform each family’s “preferred method of learning, communicating, establishing relationships and support” (Edwards et al., 2003, p. 249), their opinions on treatment options, and their role in those treatments (King et al., 2015). Within research on a brushing protocol intervention, Segal and Beyer (2006) described that parent involvement in the intervention could be impacted by cultural attitudes; and that when “touching another person is considered inappropriate in a particular culture” the intervention will not be adopted (p. 504). Perhaps surprisingly, and despite clinicians commenting on the role of cultural positionality in engagement, parents in the reviewed studies did not routinely identify their cultural perspectives as a factor in determining their engagement in child-focused interventions.

Summarized by Phoenix et al., (2020) the complexity and changeable nature of family’s context and particular situation plays a strong part in determining parent engagement and explains changes in levels of engagement over time. In discussing the ‘normative life events’ that impact engagement, authors acknowledged:

Families often pointed out that therapy happens in the context of their lives, and some phases of life are more conducive to therapy than others… having another child could increase engagement when mothers were home on maternity leave and had more time for attending appointments or decrease therapy engagement if mothers were tired by a pregnancy. Parents also faced significant legal battles, changed jobs, moved across cities or provinces, got divorced, and got married. These periods of major change taxed families’ time and emotional resources, leaving limited capacity for engagement in therapy. (p. 2157)

Child characteristics were also considered as part of the family context informing engagement. Parents describe that their child’s particular personality, preferences, and disposition either made their involvement in interventions easy, or extremely challenging (Jones et al., 2009). Where children were seen to be cooperative (Glogowska & Campbell, 2000), comfortable in intervention delivery with the therapist (King et al., 2020) and able to understand the task and activities in therapy (Lundkvist-Houndoumadi et al., 2016), parents reported greater involvement in sessions (Melvin et al., 2021) and in carrying over approaches at home (Segal & Beyer, 2006). When therapeutic activities were “enjoyed by their children” and children felt happy to participate, parents explained this “facilitated their own involvement” (Melvin et al., 2022, p. 6). On the flip side, when children did not enjoy or prefer taking part in the intervention, parent motivation to persevere and stay engaged with the practice of strategies reduced markedly (Watts Pappas et al., 2016).

Family behaviours Just as clinician behaviours make a clear contribution to engagement or disengagement of parents, actions within the wider family system also have an impact. Key to this subtheme is the positioning of families in particular roles, such as advocate or liaison agent (“negotiating access to appropriate help, often in the face of resistance”; Davies et al., 2017, p. 177, and “facilitating communication between two or more individuals working with their child”; Granger et al., 2012, p. 73), intervener (“parents actively took part in therapy sessions by interacting with the child and the therapist, as opposed to just observing or standing back”; D’Arrigo et al., 2020a, p. 2888) or as directors or ‘case managers’ (Phoenix et al., 2020) (“making decisions about the way the sessions unfolded, managing the educators’ schedule, or verifying the work accomplished”; Granger et al., 2012, p. 74). Lundkvist-Houndoumadi et al. (2016) explained that “some engaged families came up with new ways to support their child’s communication by doing intervention in their everyday contexts. Some family members discussed how they took initiative to modify intervention activities so they would work better for their child.” (2016, p. 368).

Behaviours including routinely travelling long distances to attend therapy (Anderson et al., 2014), attending meetings related to therapy (Davies et al., 2017), sharing feedback with school or educational settings (Phoenix et al., 2020), involving other family members, such as grandparents, in delivering therapy techniques (Melvin et al., 2021), asking questions of the clinician (Plath et al., 2016), providing clinicians with honest feedback (D’Arrigo et al., 2020a), communicating information across professionals or services (Granger et al., 2012) and seeking out materials and resources that could assist with intervention delivery at home (Kahjoogh et al., 2020) were all considered to contribute to parent engagement, as well as being a product, or exemplification, of strong engagement. Facilitating and leading intervention within therapy sessions and outside of therapy were identified as important facets of parent behaviour which informed levels of parent engagement over time. For example, Klatte et al. described that “parents’ engagement was viewed by the participants as about being present at therapy sessions and being involved in therapy activities.” (2019, p. 557).

Critically, the ability to recruit and maintain support from wider family networks was found to impact engagement. Generally, this involved practical and emotional support from extended family and friends allowing stronger parent engagement to develop (Botterill et al., 2019; King et al., 2015, 2020; Melvin et al., 2021; Yasui & Wakschlag, 2015). Considering the place of extended family in fostering parent involvement in interventions, Phoenix et al. (2020) wrote: "Grandparents helped ... especially for young parents who relied on grandparents for general childhood and medical advice; they also helped ... by paying for devices or private therapy, helping with travel and attending appointments with the child." (p. 2157).

Of note here is the finding that studies which reported on parent behaviours typically shared the perspective of clinicians, not of parents, which could have implications for how this subtheme is understood within the wider review.

Relationship as Engagement

The culmination of societal, interpersonal, clinician, and family factors identified in the review converge in the final theme of ‘relationship as engagement’. As indicated earlier, both parties arrive to an intervention with specific characteristics and behaviours that impact their interaction within child-focused therapy. According to the findings of reviewed studies, these factors inform how relationships between parents and clinicians are established and maintained; relationships which ultimately explain levels of engagement or disengagement of parents in interventions. The development of a collaborative relationship between parents and clinicians, which fosters engagement, is impacted by communication (between clinicians and parents about roles, boundaries, and modes of collaboration) and less overtly, by child progress (positive developments or improvements).

Communication The crucial role of communication between families and clinicians in building a strong relationship and solid engagement was apparent in the review. Communication involves clear delivery of information, and careful listening, to help fully understand the needs, desires, and expectations of parents entering into an intervention, and to identify the specific features and requirements of an intervention (King et al., 2020). Necessarily, genuine, honest communication (Anderson et al., 2014) was described as “at the heart’’ of building a therapeutic relationship (King et al., 2015) and required of clinicians and parents to create optional engagement. Phoenix et al. elegantly summarised that: “parents and service providers both identified communication as one of the most important factors in determining whether a parent would be engaged in therapy or not.” (2020, p. 2158). King and colleagues (2015) went further to describe optimal clinician communicative behaviours: “Therapists discussed the importance of conversation and dialogue with the family to get a good sense of what the direction of therapy should be” and “exploratory listening was also an important part of trying to understand the family situation, as therapists mentioned asking many questions.” (2015, p. 1377).

In identifying parent communicative strategies that supported full involvement in occupational therapy for children, D’Arrigo and colleagues (2020a) noted that parents:

Shared updates, feedback and checked/clarified aspects of therapy with the therapist. Parents gave honest feedback on whether a strategy worked or didn’t work. Some parents conducted their own research and communicated these findings with the therapist and other key stakeholders. (p. 2888)

Open sharing of clear, honest information was thought to facilitate parent understanding of clinician expectations (Klatte et al., 2019), elucidate parent expectations and hopes for therapy (Granger et al., 2012; King et al., 2020), allow parents to make informed decisions (D’Arrigo et al., 2020a) provide space for parent concerns to be identified and problem solving to occur (D’Arrigo et al., 2020b; Melvin et al., 2022), communicate respect for each other and negate power imbalances (Phoenix et al., 2020; Yasui & Wakschlag, 2015), help clinicians to understand family context and select strategies which might best ‘fit’ (Melvin et al., 2021; Piggot et al., 2003), and create a safe environment for parents to take the lead (King et al., 2015). Providing space and opportunities for parents to ask questions, seek clarification, share feedback, and make suggestions for change moved the relationship toward a more collaborative or co-working dynamic, which parents in the studies reported to further their position as active agents in the intervention (D’Arrigo et al., 2020b; Granger et al., 2012; King et al., 2020; Watts Pappas et al., 2016).

Sometimes, clinicians listening to parent concerns outside of a specific therapy goal was supportive of building a strong relationship, leading parents to make comments such as: “It was a wonderful experience. I’ve never had someone to listen to me as [the occupational therapist] did” (Kahjoogh et al., 2020, p. 6), and “sometimes these discussions were more important than the time spent in direct treatment [of children]” (Hinojosa & Anderson, 1991, p. 1337). Clinicians shared this perspective, emphasising the place of “validating or affirming the parent as a person, taking an interest and encouraging the parent” (King et al., 2015, p. 1337) as a way to create a safe environment to engage parents. In this way, curating a ‘therapeutic relationship’ through open communication can be seen to directly relate to engagement and indirectly inform parent wellbeing (Botterill et al., 2019).

Communicative behaviours occurred across modalities (e.g., in person, email, text message, written notes) with key features of ‘good’ communication contributing to strong working relationships including ‘listening for’, ‘being open to’ and ‘validating the desires and expectations’ of families right from the start’ (King et al., 2015). When communication skills were not utilised effectively within a therapeutic connection, parents described feelings of “anger, upset, and disillusionment” (Phoenix et al., 2020, p. 2155) at not being heard and understood, and ultimately disengaged from interventions in one way or another (Davies et al., 2017; Glogowska & Campbell, 2000; Klatte et al., 2019).

Child improvements Another highly endorsed component of building relationships toward engagement was that of child improvements or progress throughout intervention. In this way, parents who saw their child making progress were reportedly protected against becoming “less engaged or even totally disengaged” during intervention delivery (D’Arrigo et al., 2020a, p. 2887). Progress was defined individually by parents, as moving toward identified goals (Flores et al., 2015; Kahjoogh et al., 2020; King et al., 2015; Melvin et al., 2022), physical improvements in strength, mobility, or vision (Dixon-Woods et al., 2006; Jones et al., 2009; Piggot et al., 2003), children demonstrating new skills (Holmes et al., 1982; Klatte et al., 2019; Melvin et al., 2022; Phoenix et al., 2020), being more ‘responsive to therapy’ (Gmmash et al., 2022) or showing social or emotional changes, particularly being happier and calmer (Phoenix et al., 2020; Segal & Beyer, 2006).

The cyclical nature of engagement is evident here, where “parental involvement is a crucial factor for an intervention to be successful” (Durgungoz & Emerson, 2021, p. 7) and equally, success in intervention (in the form of children making progress) motivates parents to remain engaged (Klatte et al., 2019; Lundkvist-Houndoumadi et al., 2016; Melvin et al., 2021, 2022). Parents described feelings of trust and hope when interventions ‘start to work’, which spurred them to stay involved. Glogowska and Campbell (2000) summarised this from a speech-language perspective:

Parents expressed that seeing improvement in their child’s skills gave them a feeling of being successful, particularly when their child exceeded others’ expectations. Parents felt challenged when they perceived their child’s progress to be slow. (p.426)

Unsurprisingly, when children were not making gains toward intervention goals, or parents did not perceive any improvements, parents reported feelings of doubt (Dixon-Woods et al., 2006), frustration (King et al., 2015; Lundkvist-Houndoumadi et al., 2016) and disillusionment (Grossoehme et al., 2013; Tse & Hall, 2008) which contributed to less participation and lower levels of engagement. Clinicians describe a need to bring improvements to the attention of parents regularly, to maintain their motivation. For example, Novak (2011) reports that “therapists’ observations, both positive and negative, were perceived as important. This was because parents found it difficult to observe or remember changes, whereas parents perceived therapists to be objective “outsiders” (2011, p. 205).

Discussion

The purpose of this systematised qualitative literature review was to explore the factors that impact parent engagement in child-focused interventions, in allied health fields including behaviour analysis, occupational therapy, psychology, and speech-language therapy. The findings of this review identify that clinician and parent experiences of parent engagement in child-focused intervention are complicated by the dynamic contexts in which interventions are delivered. Themes of societal context, interpersonal context, and parent and clinician features developed in the review illustrate the many factors that are involved in determining how parents enter into interventions for their children and how parent engagement can form, develop, maintain, or erode. Ultimately, the theme of relationship as engagement emphasises that engagement is a relational process, which changes over time and is influenced by how effectively a strong, working relationship is developed between parents and clinicians. The degree to which clinicians can use skills of communication and evidence of child improvements to foster relationship may help to explain levels of parent engagement and changes in this engagement over time.

The results of this review support the perspective that parent engagement is both a state and a process (Bright et al., 2015; Melvin et al., 2020). All reviewed studies, across intervention types and allied health disciplines, acknowledge the dynamic nature of engagement as something that can be fostered, but easily lost, or shift over time, as well as something that can exist within sessions, outside of sessions, or both, to varying degrees. Echoing Melvin and colleagues’ (2020) review of early speech-language therapy intervention, these findings confirm that the process of engagement is non-static and changing, and that parents may not be ‘engaged’ straight away. Although the dynamic nature of parent engagement could be seen to create tensions and challenges for clinicians working in allied health provision (such as how to maintain motivation of parents when limited child progress is observed, or what to do when resources such as time are limited within service provision), it may also foster optimism for clinicians and parents involved in child-focused intervention; that engagement can be built and nurtured over time, even if it is not initially apparent.

Central to the understanding of parent engagement in this review is the finding that engagement is primarily a relational process. This review highlights that the specific features of a strong therapeutic relationship, such as clear and honest communication and monitoring for therapeutic improvements over time, contribute to building and maintaining relationships within the intervention setting, which ultimately foster parent engagement in the intervention. This finding aligns closely with King and colleagues’ (2020) conceptualisation of ‘engagement as connection’, where the level of interpersonal connection that is felt between parent and clinician, as well as their connection to the goals and techniques included in that intervention approach (King et al., 2020, p. 22) inform the core element of engagement: that of relationship. This perspective is echoed in literature on adult rehabilitative treatment (Bright et al., 2015) and child mental health services (Haine-Schlagel & Walsh, 2015) where relational processes within therapy and rehabilitation provision are critical to understanding engagement. King et al.’s (2014) conceptualisation of engagement involving affective, cognitive, and behavioural components is supported in this synthesis of broader allied health literatures. Indeed, engagement can be understood as having distinct emotive and relational components, where the negotiated relationship between families and clinicians sets the tone for how families will be involved based on factors such as trust, clear communication, collaboration and seeing the fruits of the labour in progress for their children. This point is clearly articulated by Melvin et al. (2022), who found that when clinicians were able to establish ‘open two-way communication’ high levels of engagement were maintained, and problem solving was possible when engagement waned or became less optimal. Here, literature considering the concept of ‘therapeutic alliance’ might further understanding of the ways that helping professionals can build and nurture strong working relationships with families, toward ensuring engagement in the helping intervention (Elvins & Green, 2008). Outcomes of studies across allied health fields confirm recent conceptual literature and describe ways that clinicians from varying professional backgrounds can utilise relationship-forming approaches, and communicative skills, to foster engagement of parents across diverse interventions. Importantly, for allied health clinicians collaborating with parents, focus on building strong working relationships as the first step of intervention delivery is likely to bolster ongoing parent engagement and associated child benefits.

Explicit in this review is the finding that parent engagement is negotiated by both parties (parents and clinicians) and is mediated by the specific contexts they bring with them into intervention (e.g., their expectations, values, confidence, learned behaviours, and personal characteristics), rather than being the responsibility of either party in isolation. Reminiscent of Staudt’s (2007) early conceptual work on parent engagement in mental health, research across a range of allied health fields highlights that engagement is negotiated between those delivering an intervention, and those ‘receiving’ and intervention, namely parents and families. Necessarily, some characteristics and behaviours of both clinicians and parents are critical in forming engagement. Specifically, clear communication, the negotiation of expectations, clinician awareness of family context and constraints, and the ability to work flexibly and be responsive to context are all critical for strong parent engagement which is maintained over time. The combined studies in this review demonstrate that although engagement can look different for different families (Melvin et al., 2020; Pozniak et al., 2023) some factors, or processes, involved in establishing and maintaining engagement are applicable across interventions and allied health fields.

The global findings of this review suggest that, for allied health practitioners, a lot can be learned from related literatures and applied to specific clinical practice around engaging parents. Primarily, the universality of effective, responsive, and empathic communication in fostering engagement can be readily adopted by clinicians and applied across disciplines and across child-focused interventions. Accessing literature of other allied health fields can help to better inform how clinicians respond to the dynamic space of interacting with parents; and promote parent engagement.

Notwithstanding, there are many ‘higher level’ factors (considered in this review under the theme of societal context) which play a role in negotiating the engagement of parents and yet sit outside the specific control (or ability to moderate) of clinicians or parents. Elements such as organisational restrictions on service delivery, stigma and cultural beliefs, as well as constraints on time that can all impede, or form a barrier, to full engagement of parents in interventions. As alluded to by Staudt (2007), there are undoubtedly some factors which impact engagement that are not amenable to clinician-level adjustment or change. However, clinicians should not be disheartened by this fact. As exemplified in this review, building awareness of these factors, as they relate to understanding a specific family, their needs, and desires, can help to bolster engagement at an interpersonal level, in spite of ‘big picture’ barriers like access and time.

Limitations

Some limitations of the current review deserve mention. Notably exclusion of review articles and secondary sources from the systematised review could be seen as a limitation, restricting the inclusion of potentially relevant ideas from the analysis. Despite this, the sheer number of included studies lends confidence that the review has generated a comprehensive account of the literature on this topic, across related fields.

Many search terms applied in this review were judged to be synonymous with ‘engagement’, including participation, involvement, and adherence. While breath of search terms was considered useful for canvassing literature across distinct allied health fields (with potentially specific jargon or language to explain the phenomena of interest) arguably these terms are not synonymous with engagement as it is more recently defined (D’Arrigo et al., 2018; Haine-Schlagel & Walsh, 2015). There remains a need for a comprehensive concept formation of engagement and increasing consistency of terms used to describe parent engagement, both within and across fields working to support children and families. This refinement of language would arguably support a more fine-grained analysis of what engagement is, how it can be sensitively measured, and effectively realised.

Relatedly, while this review offers some insight into the phenomena of parent engagement, there remain questions about how parent engagement (or lack of engagement) informs the intervention outcomes of children for which the intervention is targeted. Further research could explore the relationship between parent engagement and paediatric outcomes of therapeutic intervention, toward investigating exactly how parent engagement impacts the treatment outcomes experienced by the children targeted for intervention.

Although some studies included in the review presented both clinician and parent voice in their analysis of engagement, some did not. Reasons for this could be many: the inclusion of both perspectives sitting outside the methodology of a particular study, or strict publication requirements which limit the scope of a published work. However, the predominance of clinician perspectives over parent experience may mean that the findings in this review are not fully representative of parent understandings of their own engagement in interventions. Future research in this area could consider giving equal weight to the perspectives of both parties involved in an intervention context, to avoid extrapolating findings beyond what is consistent with parent experiences.

Conclusion

This review applied thematic synthesis to qualitative allied health literatures exploring engagement of parents in child-focused interventions. The results of the review, in concordance with a growing body of conceptual literature on the nature of parent engagement, highlight key take home messages for clinicians who are convinced by the value of parent involvement in intervention. Namely, that engagement is relational at its core, and negotiated. Critically, the findings of the review affirm that having a keen awareness of—and ability to respond flexibly to—the unique contexts and needs of families will help clinicians to foster strong therapeutic relationships and promote engagement. In examining engagement research across allied health disciplines, this review affords a unique perspective on parent engagement in child-focused treatments, one that supports clinicians applying research findings generated by related fields into their own practice, to foster skills around building engagement, The findings of the review demonstrate that while engagement is a fluid process and changes with time and input, there are elements which are consistent across disciplines, interventions, and approaches. Although a concept formation that comprises all facets of parent engagement is still forthcoming, and there is an ongoing need to balance research prioritising the parent voice with that of clinician perspectives, clinicians within allied health fields can use these findings in combination to inform the development of best practice guidelines in fostering parent engagement.