Christine Puckering

How evidence-based is an 'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of Triple P

BackgroundInterventions to promote positive parenting are often reported to offer good outcomes for children but they can consume substantial resources and they require rigorous appraisal.MethodsEvaluations of the Triple P parenting program were subjected to systematic review and meta-analysis with analysis of biases. PsychInfo, Embase and Ovid Medline were used as data sources. We selected published articles reporting any child-based outcome in which any variant of Triple P was evaluated in relation to a comparison condition. Unpublished data, papers in languages other than English and some book chapters were not examined. Studies reporting Eyberg Child Behavior Inventory or Child Behavior Checklist scores as outcomes were used in the meta-analysis.ResultsA total of 33 eligible studies was identified, most involving media-recruited families. Thirty-one of these 33 studies compared Triple P interventions with waiting list or no-treatment comparison groups. Most papers only reported maternal assessments of child behavior. Twenty-three papers were incorporated in the meta-analysis. No studies involved children younger than two-years old and comparisons of intervention and control groups beyond the duration of the intervention were only possible in five studies. For maternally-reported outcomes the summary effect size was 0.61 (95%CI 0.42, 0.79). Paternally-reported outcomes following Triple P intervention were smaller and did not differ significantly from the control condition (effect size 0.42 (95%CI -0.02, 0.87)). The two studies involving an active control group showed no between-group differences. There was limited evidence of publication bias, but there was substantial selective reporting bias, and preferential reporting of positive results in article abstracts. Thirty-two of the 33 eligible studies were authored by Triple-P affiliated personnel. No trials were registered and only two papers contained conflict of interest statements.ConclusionsIn volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions.See related commentary: http://www.biomedcentral.com/1741-7015/10/145

Disruptive behaviour disorders: a systematic review of environmental antenatal and early years risk factors

Disruptive behaviour disorders (DBDs), including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) are chronic disorders with significant overlap in aetiology and presentation. An integrative examination of environmental risk factors is lacking. Six literature searches of web-based bibliographic databases were completed to identify literature on DBDs in general and five disorders in particular: CD, ODD, ADHD, deficits of attention, motor control and perception, and reactive attachment disorder. Searches were filtered to focus on studies including diagnostic assessment, focussing on environmental risk and protective factors in the first 4 years of life. The database searches generated 9806 papers of which 47 were reviewed after filters had been applied. The evidence suggests links between a number of early life risk factors and DBDs, including prenatal cigarette smoking and alcohol use, prenatal viral illness, maternal stress and anxiety, low birthweight, peri-partum and early neonatal complications, parental stress and parenting styles in infancy, early deprivation, adoption and separation. Despite the understanding that there is sharing of risk factors between the DBDs, there has been a disproportionate focus on the role of certain risk factors at the expense of others and the field is weakened by difficulties in controlling for all potential confounding variables.

Taking Control: A Single Case Study of Mellow Parenting

A single case study is presented illustrating the theoretic approach and practical implementation of Mellow Parenting, a group intervention for families of young children where there are parenting problems. The parents in this case had a long history of marital violence, and, following the breakdown of their relationship, the father continued to terrorize the family, with adverse effects on the mothers and childrens mental health. The mother felt unable to relate to her son, aged 2, because of her own profound depression and the similarity between him and her former partner. He had marked eating problems and her daughter had been referred to child psychiatry with severe separation and sleeping problems. In the course of the group, the mother grew in confidence and began to separate her feelings about her partner from the needs of her young son. A one year follow-up showed that she had been able to move away from the area, make a secure and affectionate base for her children and begin a course of adult education to further her career. The combination of support for herself and practical parenting workshops was effective both in her own emotional containment and in mobilizing her ability to contain her childrens distress.

Should we aspire to screen preschool children for conduct disorder

Life-course persistent conduct disorder is a major public health problem with implications for individual health and for society at large. Recent evidence has shown that treatment can be cost-effective, and early symptom detection is improving. We weigh the evidence for and against the introduction of population screening for conduct disorder in early childhood using Wilson and Jungner’s criteria.

Rebuilding relationships: a pilot study of the effectiveness of the Mellow Parenting Programme for children with Reactive Attachment Disorder.

Mellow Parenting is an intensive parenting programme which has been shown to be effective in improving the psychosocial functioning of very vulnerable babies and preschool children. We used a complex interventions model to evaluate its use with school-age children with Reactive Attachment Disorder (RAD), a serious disorder of social functioning associated with maltreatment. The programme had a positive effect on mothers’ mental health, but had no measurable effects on symptoms of RAD or on parent—child interaction, although the variation between families after the group suggested that some had responded more than others. Mellow Parenting is an effective programme for vulnerable families with younger children and may be a useful adjunct in the treatment of school-age children with RAD, but it cannot be considered a definite treatment for RAD in this age group. The search continues for safe and effective treatments for RAD in school-age children.

Predictors of diagnosis of child psychiatric disorder in adult-infant social-communicative interaction at 12 months.

To establish which social interactive behaviours predict later psychiatric diagnosis, we examined 180 videos of a parent-infant interaction when children were aged one year, from within the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Sixty of the videos involved infants who were later diagnosed with a psychiatric disorder at seven years, and 120 were a randomly selected sex-matched control group. Interactive behaviours for both the caregiver and the one year old infant were coded from the videos according to eight holistic categories of interpersonal engagement: Well-being, Contingent Responsiveness, Cooperativeness, Involvement, Activity, Playfulness, Fussiness, and Speech. Lower levels of adult activity and speech in interaction at one year significantly predicted overall diagnosis of child psychiatric disorder.

Association between parent-infant interactions in infancy and disruptive behaviour disorders at age seven: a nested, case-control ALSPAC study.

BackgroundEffective early intervention to prevent oppositional/conduct disorders requires early identification of children at risk. Patterns of parent-child interaction may predict oppositional/conduct disorders but large community-based prospective studies are needed to evaluate this possibility.MethodsWe sought to examine whether the Mellow Parenting Observational System (MPOS) used to assess parent-infant interactions at one year was associated with psychopathology at age 7. The MPOS assesses positive and negative interactions between parent and child. It examines six dimensions: anticipation of child’s needs, responsiveness, autonomy, cooperation, containment of child distress, and control/conflict; these are summed to produce measures of total positive and negative interactions. We examined videos from the Avon Longitudinal Study of Parents and Children (ALSPAC) sub-cohort who attended the ‘Children in Focus’ clinic at one year of age. Our sample comprised 180 videos of parent-infant interaction: 60 from infants who received a psychiatric diagnostic categorisation at seven years and 120 randomly selected controls who were group-matched on sex.ResultsA negative association between positive interactions and oppositional/conduct disorders was found. With the exception of pervasive developmental disorders (autism), an increase of one positive interaction per minute predicted a 15% (95% CI: 4% to 26%) reduction in the odds of the infant being case diagnosed. There was no statistically significant relationship between negative parenting interactions and oppositional/conduct disorders, although negative interactions were rarely observed in this setting.ConclusionsThe Mellow Parenting Observation System, specifically low scores for positive parenting interactions (such as Responsiveness which encompasses parental warmth towards the infant), predicted later psychiatric diagnostic categorisation of oppositional/conduct disorders.

‘Me and my Bump’: An interpretative phenomenological analysis of the experiences of pregnancy for vulnerable women

Eight pregnant women, considered to be ‘vulnerable’ due to exposure to a number of underlying risk factors, participated in semi-structured interviews regarding their experiences of pregnancy and of Mellow Bumps, a 6-week targeted antenatal intervention. Interview transcripts were explored using interpretative phenomenological analysis. The analysis revealed five superordinate themes: pregnancy as a time of reflection; the body being taken over; pregnancy as an emotional rollercoaster; relationships as important; separating identities. Pre- and post-natal attachment theories were found to be useful in interpreting the data. Findings suggest that pregnancy may be ‘normalising’ and provide an important opportunity for building more positive representations of the self. Findings also provide clinical support for the assertion that the attachment relationship begins before birth. The Mellow Bumps intervention was uniformly seen as helpful. It appeared to nurture prenatal attachment relationships, playing a potentially protective role, by helping to establish the foundations for secure mother–infant relationships in the future. Meeting similar women and engaging in ordinary, supportive conversation during Mellow Bumps seemed to reduce feelings of isolation and stigma. Implications for clinical practice are considered.

Motor activity at age one year does not predict ADHD at seven years

We have examined the predictive utility of motor activity in infancy towards diagnosis of attention deficit hyperactivity disorder (ADHD) in later childhood. We conducted a nested case‐control study using videos of infants in the Avon Longitudinal Study of Parents and Children (ALSPAC). Sixty videos of children who received any Development and Well‐being Assessment (DAWBA) psychiatric diagnosis at age 91 months (including 16 with ADHD) plus two controls per case were selected for data analysis. Body movements were measured at age one year: associations between motor activity‐derived variables using factor analysis, and later ADHD diagnoses were sought. No significant association was found between infant motor activity and later ADHD. A positive association between motor activity and inattentive ADHD was found in males. Motor activity at age one year did not predict ADHD at age seven years. The positive association with inattentive ADHD in males requires further investigation. Copyright

Parent-infant vocalisations at 12 months predict psychopathology at 7 years.

Highlights ► Reduced caregiver vocalisations were associated with development of disruptive behaviour disorders. ► Higher infant vocalisations were associated with disruptive behaviour disorders. ► Study into parental vocalisation behaviours early in life may be clinically important.