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Original Investigation |

Internet-Assisted Parent Training Intervention for Disruptive Behavior in 4-Year-Old Children A Randomized Clinical Trial

Andre Sourander, MD, PhD1,2; Patrick J. McGrath, OC, PhD, FRSC, FCAHS3,4,5,6; Terja Ristkari, RN, MNSc1; Charles Cunningham, PhD7; Jukka Huttunen, BM1; Patricia Lingley-Pottie, PhD3,5,6; Susanna Hinkka-Yli-Salomäki, PhLic1; Malin Kinnunen, RN1; Jenni Vuorio, MSc1; Atte Sinokki, BSc1; Sturla Fossum, PhD8; Anita Unruh, PhD9
[+] Author Affiliations
1Department of Child Psychiatry, University of Turku, Turku, Finland
2Turku University Hospital, Turku, Finland
3Centre for Research in Family Health, IWK Health Centre, Halifax, Nova Scotia, Canada
4Faculty of Science, Dalhousie University, Halifax, Nova Scotia, Canada
5Strongest Families Institute, Halifax, Nova Scotia, Canada
6Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
7Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
8Center for Child and Adolescent Mental Health, North Norway, University of Tromsø, Breivika, Norway
9Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada
JAMA Psychiatry. 2016;73(4):378-387. doi:10.1001/jamapsychiatry.2015.3411.
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Importance  There is a large gap worldwide in the provision of evidence-based early treatment of children with disruptive behavioral problems.

Objective  To determine whether an Internet-assisted intervention using whole-population screening that targets the most symptomatic 4-year-old children is effective at 6 and 12 months after the start of treatment.

Design, Setting, and Participants  This 2-parallel-group randomized clinical trial was performed from October 1, 2011, through November 30, 2013, at a primary health care clinic in Southwest Finland. Data analysis was performed from August 6, 2015, to December 11, 2015. Of a screened population of 4656 children, 730 met the screening criteria indicating a high level of disruptive behavioral problems. A total of 464 parents of 4-year-old children were randomized into the Strongest Families Smart Website (SFSW) intervention group (n = 232) or an education control (EC) group (n = 232).

Interventions  The SFSW intervention, an 11-session Internet-assisted parent training program that included weekly telephone coaching.

Main Outcomes and Measures  Child Behavior Checklist version for preschool children (CBCL/1.5-5) externalizing scale (primary outcome), other CBCL/1.5-5 scales and subscores, Parenting Scale, Inventory of Callous-Unemotional Traits, and the 21-item Depression, Anxiety, and Stress Scale. All data were analyzed by intention to treat and per protocol. The assessments were made before randomization and 6 and 12 months after randomization.

Results  Of the children randomized, 287 (61.9%) were male and 79 (17.1%) lived in other than a family with 2 biological parents. At 12-month follow-up, improvement in the SFSW intervention group was significantly greater compared with the control group on the following measures: CBCL/1.5-5 externalizing scale (effect size, 0.34; P < .001), internalizing scale (effect size, 0.35; P < .001), and total scores (effect size, 0.37; P < .001); 5 of 7 syndrome scales, including aggression (effect size, 0.36; P < .001), sleep (effect size, 0.24; P = .002), withdrawal (effect size, 0.25; P = .005), anxiety (effect size, 0.26; P = .003), and emotional problems (effect size, 0.31; P = .001); Inventory of Callous-Unemotional Traits callousness scores (effect size, 0.19; P = .03); and self-reported parenting skills (effect size, 0.53; P < .001).

Conclusions and Relevance  The study reveals the effectiveness and feasibility of an Internet-assisted parent training intervention offered for parents of preschool children with disruptive behavioral problems screened from the whole population. The strategy of population-based screening of children at an early age to offering parent training using digital technology and telephone coaching is a promising public health strategy for providing early intervention for a variety of child mental health problems.

Trial Registration  clinicaltrials.gov Identifier: NCT01750996.

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Figure 1.
Consort Flow Diagram

ITT indicates intention to treat; RCT, randomized clinical trial.

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Figure 2.
Timeline of the Study

The themes of the 11 sessions are as follows: (1) noticing good behavior, (2) spreading attention around, (3) ignoring whining and complaining, (4) transitional warnings and when-then statements, (5) planning ahead in the home, (6) the behavior chart, (7) planning ahead outside the home, (8) working with daycare, (9) timeout, (10) problem-solving relapse prevention, and (11) putting it all together. SFSW indicates Strongest Families Smart Website.

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