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CHAPTER 37

Parenting programs

Stephen Scott1 and Frances Gardner2

1Department of Child and Adolescent Psychiatry, Institute of Psychiatry, London, UK2Department of Social Policy & Intervention, University of Oxford, Oxford, UK

Introduction

A parenting program is a specific intervention designed toimprove the overall quality of parenting that a child receives.Parenting programs aim to help the way mothers and fathersrelate to their child: primarily by changing their behavior inmoment-to-moment interchanges throughout the day, althoughthey also address parental beliefs and feelings. Change isachieved through the training of specific skills such as collab-orative play, selective attention and praise to promote sociablebehavior, and clear rules backed by consistently applied conse-quences to reducemisbehavior.There is a structured sequence ofsessions that build up each of the competencies.This approach tointervention, in which the emphasis is usually on understandingthe parent’s views and giving themnondirective general support,but not coaching them, is distinct from counseling (Chapter 40);it differs from psycho-education in which a parent is informedabout the nature of the child’s disorder and given advice onmanagement but not trained. In family therapy, the therapisttypically addresses thewhole family system, oftenwith a primaryemphasis on a deeper understanding of interpersonal processesand meanings; it is the change in understanding, rather thanskills, that should lead to changes in relationships (Chapter 40).Parenting programs often aim to improve child symptoms

as well as improving the quality of the relationship, but this isnot inevitable. Thus where neglectful or abusive parenting hasbeen uncovered, the goal may be to improve positive parentalengagement with the child and reduce harsh emotional andphysical practices, whether or not the child is displaying prob-lems (Chapter 29). Moreover, where there are child-specificemotional or behavioral problems, parenting programs mayhelp, whether or not suboptimal parenting has contributed tocausing the problem. Thus programs can help parents to bettermanage children with problems that are mainly geneticallyinfluenced, such as autistic spectrum disorders (Chapter 51)

Rutter’s Child and Adolescent Psychiatry, Sixth Edition.Edited by Anita Thapar, Daniel S. Pine, James Leckman, Margaret J. Snowling, Stephen Scott and Eric Taylor.© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.

or children with obsessive-compulsive disorder (Chapter 61)although parenting quality is satisfactory at the outset.Furthermore, where there are child symptoms and parenting is

less than optimal, this does not necessarilymean that the parent-ing caused the child’s problems. Parent–child relationships arebidirectional and more difficult child behavior can elicit harsherparenting. Several lines of evidence show this, from the classicexperiment in which parents with relatively well-behaved chil-dren were asked to look after children with behavioral problemsand became harsher andmore critical (Anderson et al., 1986), toexperiments showing that where disruptive child behavior suchas ADHD is reduced by medication, parenting quality improves(Schachar et al., 1987). Two areas of child functioning whereparenting has been strongly implicated as causing difficulties areconduct problems and insecure attachment; we concentrate onthese domains in this chapter, but refer to others.

Styles of parenting addressed by parentingprogramsAs there are many different theories of what constitutes goodparenting, there are many different approaches incorporated inintervention programs. We focus here on those dimensions thatare well empirically supported and that have led to proven inter-vention programs.

Dimensions of parenting addressed in interventionsderived from social learning theorySocial learning theory evolved from general learning theoryand behaviorism (Bandura, 1977). The notion is that children’sreal-life experiences and exposures directly or indirectly shapebehavior; processes underlying this learning can be diverse. Ininterventions, there has historically been a near-exclusive focuson externally observable behavior rather than children’s innermental states (Patterson, 1982). Operant behavioral principlesof reinforcement and (noncoercive) consequences are applied

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immediately after the child has acted/responded; there is lessemphasis on classical, stimulus-controlled conditioning (Scott,2008). Moment-to-moment exchanges are crucial: if a childreceives an immediate reward for their behavior, such as get-ting parental attention or approval, then they are more likely torepeat the behavior, whereas if they are ignored or an unwelcomesanction is applied, then they are less likely to do it again.Patterson (1982) showed how children’s aggressive behaviors

were learned from and reinforced by parallel negative behaviorsby parents. A negative parenting style appears to have a causalrole in leading to conduct problems, even after allowing forchild effects. The association has been repeatedly found in (i)large-scale epidemiological investigations, such as those in NewZealand and UK (e.g., Isle ofWight); (ii) intensive clinical inves-tigations such as Patterson’s work mentioned earlier; and (iii)numerous naturalistic studies of diverse samples using amixtureof methods (e.g., Gardner et al., 1999; Denham et al., 2000).The parenting behaviors identified are high criticism and hos-tility, harsh punishment, inconsistent discipline, low warmth,involvement and encouragement, and poor supervision.A further important dimension is supervision of child activity,

and monitoring their whereabouts and activities outside thehome. Careful monitoring has greater effects in neighborhoodswhere there are many risks such as drugs and violence (Pettitet al., 1999). Monitoring is not just a matter of parents beinggood “policemen,” as knowing where a child is , in part, dependson the child having a good enough relationship to tell the parentwhat they are doing (Racz & McMahon, 2011). Therefore,enabling parents to impose effective discipline depends ontheir also developing a positive relationship, skills addressedin most modern programs. These elements promote childpositive behavior and affect and provide a more positive rela-tionship context for parental disciplinary interventions. Theyimprove child behavior (Gardner, 1987) and attachment (Scottet al., 2011).More recently, social learning models have increasingly

considered inner cognitive or “mindful” processes such asattributions and expectations that underlie parents’ behavior(Snarr et al., 2009). More negative attributions about a childpredict poorer child outcomes over and above observed parentalbehavior (Doolan, 2006), and addressing them in interventionsleads to better child outcomes (Sanders et al. (2004). Beliefscan vary considerably across cultures, with more traditionalsocieties showing more authoritarian views, particularly amongfathers. Parenting programs based on “Western” values need toaddress different cultural beliefs regarding how best to bringup a child, but if they do this, they can be equally effective inimproving parenting in ethnic minority groups (Reid et al.,2001; Scott et al., 2010a).

Dimensions of parenting addressed in interventionsderived from attachment theoryAttachment theory (Bowlby, 1969/1982; Chapter 6) focuses onthe extent to which the relationship provides the child with

protection against harm and a sense of emotional security,resulting in a “secure base” for exploration. The theory pro-poses that the quality of parental care, particularly sensitivityand responsiveness to the child’s emotional needs (“sensitiveresponding”), promotes a relationship characterized by warm,expressive to-and-fro interchanges (“mutuality”), leading tosecure attachment. Evidence shows that sensitive respondingis important in promoting attachment security, but less thantheorized (De Wolff & van IJzendoorn, 1997; Chapter 6). Lon-gitudinal studies confirm that attachment security does notshape subsequent development deterministically, but interactswith child and family factors to influence outcome (Sroufe et al.,2010). A particularly harmful parenting style is frighteningand abusive parenting, which is associated with “disorganised”attachment patterns—meta-analyses confirm a strong associ-ation with maltreatment (Cyr et al., 2010). Disorganization isassociated withmany forms of child psychopathology, especiallyconduct problems (Fearon et al., 2010), although it is importantto note that it occurs in 15% or more of normal populations.Over time, attachment relationships are internalized and

carried forward to influence expectations for other impor-tant relationships, by an “internal working model.” In the lastdecade, progress has been made in measuring internal workingmodels, in childhood using doll-play story-stems (Green et al.,2007) and in adolescence using semi-structured interviews(Shmueli-Goetz et al., 2008). These measures have shown thatattachment insecurity continues to be associated with higherlevels of psychopathology in middle childhood (Green et al.,2007; Futh et al., 2008) and adolescence (Scott et al., 2011), andwith less sensitive parenting in both periods (Scott et al., 2011;Matias et al., 2013). Some aspects of parenting, however, are notemphasized in attachment accounts of parenting, such as cog-nitive stimulation or consistent discipline; yet studies of child(Matias et al., 2013) and adolescent (Scott et al., 2011) secu-rity found that consistent discipline independently predictedsecure attachment, beyond sensitive responding. Interven-tion programs designed to increase attachment security couldbeneficially target limit-setting as well as sensitive responding(O’Connor et al., 2013).

Biological effects of parentingBesides affecting children’s psychological processes, parentinginfluences a wide array of biological processes. Physiologically,harsh and abusive parenting often leads to altered stress hor-mone levels, with chronically elevated cortisol andmuch greatersecretion in response to threat or stress, with slower rates ofreturn to normal levels (Chapters 23, 29). Moreover, inflam-matory responses are elevated in those who are abused anddepressed (Chapters 29, 30), and harsh parenting is associatedwith structural brain changes (Chapters 23, 29). Finally, a seriesof elegant studies in rats led by Meaney and in chimpanzees bySuomi have shown that changes in parenting lead to epigeneticchanges (notably acetylation and methylation) in sections ofgenes that control protein synthesis (Chapter 25).


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The implications of these biological findings for parentinginterventions are not yet clear. The physiological changes maybe partly reversible by intervention, thus children taken awayfrom abusive parenting into foster care show improved cortisolsecretion patterns (Fisher et al., 2006). Whether improvingthe parenting environment leads to measurable epigenetic orbrain changes is uncertain at present. Even if biological changesare alterable, they may contribute to behavioral traits thatreduce susceptibility to improved parenting, a subject we nowaddress.

Child characteristics that may affect susceptibilityto the effects of parentingSome child disorders and traits have high heritability, forexample, ADHD, autism, and callous-unemotional traits, lead-ing some to assume that they are less susceptible to interventionefforts. However, as we shall see, this is not always the case.

Inherited characteristics and behavioral phenotypesThe effects of parenting can differ according to the characteris-tics of children. Adoption studies are one way of investigatingthis (Chapter 24). In a large follow-up study, Bohman (1996)divided early adopted infants into those whose birth parentshad been criminal or alcoholic, representing higher congenital(genetic plus early environmental) risk, versus those who werenot. Adopting parents were categorized the same way, to indexmore and less favorable child-rearing conditions. Police contactby age 17 was 3% versus 12% for children with low versus highcongenital risk favorably reared, suggesting a substantial inher-ited component under good conditions. For those raised underunfavorable conditions, the rates were 7% and 40% respectively.This study, replicated since, shows that some children have amuch greater liability to poorer outcomes under stressful rearingconditions, a so-called diathesis-stress model. An implicationis that higher congenital risk does not necessarily condemn achild to poor outcomes, indeed improving parenting may havelarger effects with such individuals. Moreover, better parentingcan help mitigate congenital risk through attachment security.Bergman et al. (2010) showed that mothers who had higheramniotic fluid cortisol levels had infants with poorer cognitivedevelopment at 17 months, but this effect disappeared if theinfant was securely attached.Longitudinal observational studies suggest that children with

different characteristics may need different parenting styles.Kochanska (1997) reported that, for temperamentally fearfulchildren, gentle parental control was associated with optimalbehavioral/emotional regulation whereas temperamentallymore aggressive (“fearless”) children required firmer control toachieve the same positive results, a finding that has been repli-cated for children with difficult/irritable temperament, who farebetter under conditions of firmer control (Bates et al., 1998).More recently, the possibility has been explored that rather

than just confer liability to poorer outcomes under stressfulrearing, some child characteristics may also confer liability to

better outcomes under benign conditions, the so-called differ-ential susceptibility hypothesis (Ellis et al., 2011), whereby somechildren are relatively impermeable to their surroundings whileothers are more sensitive. Experimentally, Scott and O’Connor(2012) found that antisocial children who were more emo-tionally dysregulated (tantrums and anger outbursts) showeda greater response to improved parenting than those who weredisobedient in a more controlled way. However, while differen-tial susceptibility is an exciting theory, more replication of find-ings is necessary to characterize the scope and size of its impact.These findings have implications for parenting programs.

Firstly, intervention effects are likely to vary according to childcharacteristics, for example, children with autistic traits maychange less, whereas those with irritable temperaments maychange more. Secondly, parenting programs should not followa “one size fits all” rigid approach, but rather the content shouldbe varied according to child characteristics.

Specific genotypesIn a classic paper, Caspi et al. (2002) found that a variant ofa gene coding for an enzyme regulating the level of the CNSneurotransmitter Monoamine Oxidase (MAOA) conferredworse antisocial outcomes in the presence of harsh parenting.The effect has been confirmed in meta-analyses, but it is small.Furthermore, emerging studies identify genotypes that conferdifferential susceptibility to interventions. However, the field isbeset by failure to replicate findings and if found, we will needto know the specific mechanism of action through which suchgenes exert their effect.

Programs for children with conductproblems

These are almost exclusively based on social learning theory.Characteristics of some of the more widely used programsare given in Table 37.1, the basic content of a typical pro-gram in Table 37.2 and pros and cons of a group-based versusindividual-based delivery in Table 37.3.

EffectivenessOutcomesPrograms based on social learning theory have evolved over 50years and there is a larger evidence base for this interventionthan any other intervention in child mental health.TheNationalInstitute for Health and Care Excellence for England and Wales(NICE) conducted a meta-analysis of 54 randomized controlledtrials (RCTs) of parenting programs for prevention or treatmentof conduct problems/disorders in 4150 children aged 3–10 yearsagainst any control (43 studies vs. waiting list or no treatmentcontrols, 11 vs. management as usual) (NICE, 2013). The resultwas a moderate effect size of 0.54 sd on parent-rated outcomes,0.40 sd by independent observation, and 0.69 sd by indepen-dent researcher evaluation. Follow-up 1 year later showedpersistent effects but a halving of their magnitude. Interestingly,

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Table 37.1 Characteristics of some widely used programs.

Name Target population Levels and delivery modes Evidence Comments, website,dissemination

Incredible years A series of parentgroup programs frombabyhood to age 12

Universal : 6 weeksIndicatedPrevention: 14 weekTreatment: 18–24 weeks

50 RCTs, 10 by developer,40 independentreplications confirm effects

Developer CarolynWebster-Stratton. One of themost intensive programs inclinical process and supervisionwww.incredibleyears.com

Triple P A range of programs atall levels and ages

Universal: On line; broadcastmediaSelective: short one offsessions up to 4 weeksIndicated 6–8 weeks

Over 50 RCTs bydeveloper; 3 independentreplications, some failingto show effects

Developer: Matt Sanders.Comprehensive range of levelswww1.triplep.net/

Parent–childinteraction therapy

child disruptive andparenting difficultiesincluding maltreatment

Parent /child dyad is livecoached by therapist over12–20 sessions.

Several RCT’s by developerand independentevaluators show effects

Developed by Sheila Eyberg.www.pcit.org/

Parentmanagementtraining Oregon

Behavioral problems4–12; parents withmental healthproblems or separating

Individual program: 19–30sessions, Group 14 sessions

RCT’s by programdeveloper andindependents show effects

Developer: Marion Forgatch.

Strengtheningfamilies (10–14)

Universal preventiveprogram for age 10-14

Seven 2 h sessions whichinclude whole family andseparate parent and childgroups.

Two RCTs by programdeveloper show someeffects

Developer Karol Kumpfer.Well developed across manycountrieswww.strengtheningfamiliesprogram.org/

Nurse familypartnership

Preventive for young,disadvantaged firsttime mothers

Trained nurses visit mother athome during pregnancy andfirst 24 months of child’s life

Three RCTs have shownvaried and long-lastingeffects

Developer:David Olds.www.nursefamilypartnership.org

Table 37.2 Content of a typical social learning program.

Part 1: Promoting a child-centered approachPlay is covered in the first 2–3 sessions. Instead of giving directions, teaching, and asking questions during play, parents are instructed simply to give a runningcommentary on their child’s actions. Parents are asked to practice these techniques for 10min every day

Part 2: Increasing acceptable child behaviorPraise and Rewards. The parent is required to praise their child for lots of simple, desirable everyday behaviors such as playing quietly on their own, eatingnicely, getting dressed the first time they are asked, and so on. Later sessions go through the use of reward charts.

Part 3: Setting clear expectationsClear Commands. Parents are taught to reduce the number of commands, but to make them much more authoritative. The manner should be forceful (notsitting down, timidly requesting from the other end of the room; instead, standing over the child, fixing him in the eye, and in a clear firm voice giving theinstruction). Commands should specify what the parent does want the child to do, not what he or she should stop doing (“please speak quietly” rather than“stop shouting”).

Part 4: Reducing unacceptable child behaviorConsequences for unacceptable behavior should be applied as soon as possible. They must always be followed through and simple logical consequences areencouraged: if water is splashed out of the bath, the bath will end; if a child refuses to eat dinner, there will be no pudding; etc.Ignoring This sounds easy but is a hard skill to teach parents. Whining, arguing, swearing, and tantrums are not dangerous and can usually safely be ignored.The technique is very effective.Time Out from positive reinforcement remains the final “big one” as a sanction for unacceptable behavior. The child is put in some boring place for apreviously agreed reason (hitting, breaking things, etc —not minor infringements) for a short time (say 5min). However, the child must be quiet for the lastminute.

there was no generalization to the school setting—overall, forall programs, teacher ratings showed no change. No adverseeffects or harms were recorded. However, it may be that mod-est changes in teacher-rated behavior occur with some moreintensive programs —for example, a recent meta-analysis

(Menting et al., 2013) of 50 trials of Incredible Years found asmall but significant effect on classroom behavior (0.13 sd).Similar findings for parent-reported outcomes were reported inother meta-analyses, for example, by Cochrane Collaboration(Furlong et al., 2012). The latter also analyzed impacts on



Table 37.3 Pros and cons of delivering parenting programs in individual versus group format.

Individual Group

Case selectionCan take on special cases unsuitable for groups: shy parents, failed groupparenting programs, high risk/abusive parents

Can take on a variety of cases, can be hard to stop some parents fallingbehind.

Depth of workTherapist can go into greater depth of skills that need to be taught Less detailed due to time constraints and exposure to other parentsCan observe parent interacting with child and pick up styles they areunaware of

Restricted to parents’ accounts of what goes on with the child.

Can adapt the program for particular child needs for example, attachmentproblems, autistic tendencies, learning disabilities, ADHD etc

FlexibilityFlexible order of delivery of program, for example, time out can be givenearly

Fixed order—for example, Limit-setting and time-out have to wait till end

Flexible timing to attend to suit parent Groups held at a fixed time when parent may be busyCan easily be delivered in the home context, Parents have to come to clinic or community venueNo need to set up a crèche for child May need to set up a crèche

Support from other parentsNo support from other parents Other parents can provide validation for their efforts; normalize having a

child with problems; enable parents to learn from and support each other

Therapists skills and supportCan work as a solo therapist Requires a second group leader plus group management skills

Duration and cost-effectivenessTypical program takes around 8 sessions, more complex 10-12 Triple P level 4 has 4 group sessions plus 4 phone sessions; IY minimum 14

sessions, 18–22 recommended for clinical casesCost will vary, typically £2000/€2200/$2500 Costs typically lower per case, £1200/€1350/$1800

parental mental health and found it improved by 0.36 sd.Positive parenting and harsh practices improved, assessed byboth parent report and independent observation. It is less clearhow the effects are sustainable in the long term: many trials haveused waiting list control groups that are offered the intervention6 months later. As a result, no long-term randomized compari-son can be made (e.g., Gardner et al., 2006; Bywater et al., 2009).A small number of trials based on selective prevention sampleshave retained their randomized control group and show goodlong-term outcomes (Forgatch et al., 2009). In summary, thereis convincing evidence that parenting programs substantiallyimprove parenting practices, parental mental health, and childantisocial behavior, and importantly that behavior change isreported both by parent report and independent observations.The evidence for longer-term effects is less conclusive.

Comparison with nonbehavioral programsThere have been rather few head-to-head comparisons ofsocial learning theory parenting programs with nonbehavioral,humanistic approaches. For children with severe conductproblems, the classic paper by Bank et al. (1991) found thatbehavioral parent management training was effective whereasusual family therapy was ineffective on objective measures,despite favorable reports from parents. Most other studieshave found that the humanistic approach usually had no effect

whereas the more behavioral programs changed child outcomes(Scott, 2008). A trial of a parenting program based primar-ily on emotional communication (the Parenting Puzzle) formild-to-moderate antisocial behavior found no effects (Simkisset al., 2013). It would appear that for child behavior problems,programs with a practical slant and strong focus on parentalbehavior change are more effective.

Programs for infants

Most programs draw on attachment theory and in the last 20years or so, several interventions have been developed andvalidated (Chapter 6). The more effective interventions forinfants typically last 8–20 sessions and videotape parent–infantinteractions and then replay them to the parent. The greatstrength of this approach is that (i) it allows parents to get anaccurate picture of what is actually happening (rather thanjust talking about their perception of their relationship withtheir infant, as in traditional parent–infant psychotherapies);(ii) it enables them to observe for themselves that when theychange their behavior, this impacts on their infant (iii) it allowssimultaneous exploration of the mother’s mental state, so thatmental blocks to more sensitive responding can be explored andoften overcome. The Leiden group has tested video feedbackprograms in RCTs (Velderman et al., 2006).


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The Attachment and Biobehavioral Catch-up (Dozier et al.,2012) is another well-proven intervention. It targets three issuesknown to affect children’s attachment and self-regulation. First,parents are helped to behave in nurturing ways when childrenare distressed. Second, similarly to social learning approaches,parents are helped to follow children’s lead, to enable childrento better regulate their emotions. Third, parents are helped toreduce frightening behavior as it is associated with disorganizedattachment.These issues are targeted through 10 sessions imple-mented in families’ homes with parents and children present.Other attachment-based programs are discussed in Chapter 6.Some interventions for infants do not use video-feedback.

They include more lengthy and intensive psychodynamic ones,for example, Slade et al. (2005). Olds (2006), By contrast, devel-oped a home visiting programdelivered by nurses (Nurse FamilyPartnership), based not on attachment theory but on systematicevaluation of, and evidence-based interventions for, risk factorsfrom pregnancy to age 2 years. Thus parents are encouragedto reduce smoking and alcohol in pregnancy through under-standing the effects on their babies; once the baby is born,parent–child interaction is coached, including how to stimulatethe baby appropriately, and wider issues such as partner violenceand general education for the mother are addressed.

EffectivenessA meta-analysis by Bakermans-Kranenburg et al. (2003) found81 studies, with over 7000 parent–infant pairs. Overall, theyimproved parental sensitivity by 0.33 sd and attachment secu-rity by 0.20 sd. The most effective interventions were relativelyshort (under 26 sessions) and started later (after the infant was6 months). Both of these findings go against cherished notionsthat early intervention must be better, and that more effortshould lead to more change (mean effect size for long interven-tions was −0.03). Recently, an RCT of the ABC interventionshowed that as well as enhancing child attachment security, itimproved diurnal cortisol production, executive functioning,and emotional regulation (Chapter 6).For programs that do not rely on attachment theory, those

that focus on specified risk factors appear to fare better. Thusthe Nurse–Family Partnership approach has been evaluated inthree RCTs involving over 1000 mother–infant pairs. This hasshown benefits for the child in terms of improved cognitiveand emotional development and fewer accidents and injuries,and for the mothers in terms of less harmful health behaviors(e.g., smoking) and higher take-up of further education, lessuse of public handouts, and a longer interval until subsequentpregnancy (Olds, 2006). By contrast, programs that draw upon amore general notion that if the parents are supported, then theyin turn will relate better to their infants appear less effective.For example, in a trial of a home visiting program with 97 hface-to-face contact with mothers, none of the many motheror child variables measured changed (Barnes et al., 2006); a

similar lack of effectiveness was found for the OxfordshireHome Visiting project (Barlow et al., 2007).

Father involvement in parenting programs

Most literature refers to “parenting” as if it made no differencewhether fathers or mothers were involved. While in the greatmajority of cultures it is more often mothers who spend mosttime looking after younger children, fathers have a particularrole, which often increases as children become older (Lamb,2004). When it comes to parenting programs, it should notnecessarily be assumed that evidence about effectiveness appliesequally to mothers and fathers. In practice, however, it is mainlymothers who attend parenting programs and participate inresearch evaluations. The under-representation of fathers inthese interventions is perhaps surprising, given that in manycountries their role now reflects greater equality of genderroles and increased sharing of parenting (Maughan & Gardner,2010). Furthermore, there is considerable research suggestingthat amount and quality of father involvement in parenting isbeneficial to children’s mental health and development, overand above the level of the mother’s involvement (Lamb, 2004;Ramchandani et al., 2013). A systematic review by Lundahlet al. (2008) suggested that if intervention trials involve fathers,they produce stronger effects on child behavior. Some interven-tions have been designed to engage couples and fathers, withimproved outcomes when couples attend (Cowan et al., 2009).However, as it would be very difficult to randomize to one versustwo parents attending a program (but see Besnard et al., 2013),it is unclear if father attendance per se causes these changes, orwhether outcomes are better in families with two parents (asfound by Gardner et al., 2009), and in families where the couplerelationship is healthier (Cowan et al., 2009), so fathers are morelikely to attend. Irrespective of trial data, it is highly desirablethat interventions should involve both parents. Studies of fathersviews (Stahlschmidt et al., 2013) suggest a number of barriers(and potential solutions), including time of day of the interven-tion, and that many interventions are run by women, who mayfind it easier to communicate with mothers than fathers. Thiseffect can be pronounced in group-based interventions wherefathers may feel out of place if they are in a minority.

Application of programs to specificpopulations

Although designed for conduct problems, these programs canimprove other clinical outcomes, evenwhenunadapted; they canreduce children’s anxiety disorders (Cartwright-Hatton et al.,2011), ADHD (Jones et al., 2008; Charach et al., 2013); obesity(Brotman et al., 2012), and parental depression (Hutchings



et al. 2007; Barlow et al., 2012). However, adaptation and exten-sion of these parenting programs is now increasingly occurringfor a range of child psychiatric problems and parental contexts.

Programs for particular child issues and contextsDepression, anxiety, and other emotional problemsEvidence supporting a link between quality of parent–childrelationships and depression, anxiety, and other emotionalproblems (e.g., somatic complaints and social withdrawal) isclear, although smaller than that found for disruptive outcomes(Dadds et al., 1996; Wood et al., 2003). Low warmth and con-flict are both linked with depression and anxiety; however,the influence of control strategies is generally much weaker.Additionally, emotional symptoms in children are linked withover-protectiveness (e.g., Dadds et al., 1996). The elements ofparenting programs aimed primarily at conduct problems arelikely to be helpful for children showing emotional symptoms,but generally an individual-based intervention should probablybe added, although Cartwright-Hatton et al. (2011) testedthe effects of a group-based parenting program for diagnosedclinically anxious children (aged 3–9) and found strong effectson reducing anxiety disorders. The majority of sessions focusedon components of traditional social learning theory-based par-ent management skills (e.g., child-centered play, rewards, andlimit setting), with about one third of the sessions focusing oncomponents specifically aimed at dealing with anxious children(e.g., anxiety education; fear hierarchies).

ADHDA number of parenting programs designed for conduct prob-lems have shown improvements in ADHD symptoms as well(Scott et al. 2001, 2010b; Webster-Stratton, 2011; Charach et al.,2013). Additionally, parenting interventions have been devel-oped and specifically for children with ADHD, for example,The New Forest program in the UK, which showed good effectson ADHD symptoms in preschoolers in a clinic-based trial,but not in routine services (Sonuga-Barke et al., 2001). Recentsystematic reviews conclude that behavioral parenting interven-tions are effective for younger children with ADHD, more sothan methylphenidate (Charach et al., 2013), and are probablyeffective for older children (Zwi et al., 2011). European and UK(NICE) guidelines, both recommend parenting programs as thefirst line treatment for ADHD. However, Sonuga-Barke et al.(2013) found that while effects were good on parent-report,they were negligible using direct observation.

Callous unemotional traitsDespite the common belief that children with conduct problemswho also show callous unemotional traits are insensitive toparenting, and to parenting interventions, Waller et al. (2013)found little evidence to support this belief, either from lon-gitudinal studies or from randomized trials. Nevertheless,

specific programs are being developed for them (Daddset al., 2013).

Programs for particular parent issuesand contextsSpecific parental issues and contextsThere is some promising evidence that social learning theorybased programs, with some adaptation and extension, can beeffective for parents who maltreat their children (MacMillanet al., 2009; Ch 30). For drug misusing parents, the program“Parents under Pressure” has shown promising results (Dawe &Harnett, 2007). For children in the foster care system, some trialssuggest that parenting interventions aimed at foster-caregivers,can be effective in reducing problem behavior in this oftenvery troubled group of young people (Briskman & Scott, 2013),although other trials have been more disappointing (MacDon-ald & Turner, 2005; Turner et al., 2007), perhaps where theinterventions have been less intensive.

Transportability of parenting programs to differentcultures and countriesParenting programs appear to transport well across cultures,despite different parenting norms and values. A systematicreview of programs developed in the USA and Australia foundcomparable effect sizes in recipient countries, including Europeand Asia (Gardner et al., 2013). Surprisingly perhaps, in manycases, “imported” programs were more effective in culturallyvery different settings (for example, Hong Kong).These findingsare consistent with studies of effects in ethnic minority groupswithin one country. For example, Reid et al. (2001), in a largestudy of low income families in the USA found no ethnicdifferences in outcomes, engagement, or satisfaction across fourethnic groups, and Scott et al. (2010a) found a similar lack ofethnic differences in outcomes in London.Given the high levels of international concern about youth

crime and violence in developing countries (WHO, 2013), andthe loss of children’s developmental potential due to povertyand conflict, it is important to know if parenting programswork in low and middle-income countries (LAMICs). A recentsystematic review (Knerr et al., 2013) found promising evidencefrom randomized trials that parenting programs can be effectivein LAMICs for improving harsh parenting, and potentially forreducing conduct problems. Broader parenting interventionsthat also target early cognitive stimulation can also be effectivefor improving parenting skills and children’s developmentalpotential (Engle et al., 2007; Rahman et al., 2009). WHO (2013)have begun an important initiative to develop, adapt, andtest through RCTs programs in LAMICs, where home-basedparenting interventions have already shown good results forinfants (Cooper et al., 2009; Knerr et al., 2013). There are manyother examples of promising practice in developing coun-tries, but very few have been tested in rigorous trials (Knerr


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et al., 2013), as recommended by WHO, and sustainability willbe challenging.

What makes parenting programs work?

Predictors and moderators of outcomeIn a controlled trial, if a characteristic of the participants (e.g.,child age or symptom severity) predicts outcome in both theintervention and control groups, then it is a predictor. If, how-ever, there is an interaction with treatment, so that one subgroup(say younger children) does better than another (older children)in the intervention group only, then the characteristic is operat-ing as a moderator. Until recently, analyses have mainly been atthe level of predictors only, with one or two exceptions. It is cru-cial that treatment and policy decisions are based on evidencefrom moderator, rather than predictor analyses. Without thesecomparisons between intervention and control group, it is notpossible to tell if a group that appears to benefit to a greater extentfrom treatment (e.g., girls or younger children), would not havedone equally well untreated.

Child age and genderClinicians often gain the impression that boys and olderchildren, especially adolescents, perform worse, and Banket al. (1991) found a smaller effect size with adolescentsthan with younger children at the same institution. However,meta-analyses of interventions for antisocial behavior aremixed. For example, the Cochrane reviews of parenting inter-ventions for antisocial behavior found an effect size of 0.56SDin teenagers (Woolfenden et al., 2001), 0.53SD in middle child-hood (Furlong et al., 2012) and 0.25SD in early childhood(Barlow et al., 2010), thus showing smaller effects in youngerchildren. Within the middle childhood age range, Furlong et al.(2012) found no effect of age on outcome. Teenagers may appearless tractable for a number of reasons. Firstly, many studies onadolescents include the most severe cases (Lipsey, 2003; Leijtenet al., 2013). Often, when severity is controlled for, there is noage effect—across a wide age range (2–16 years), Ruma et al.(1996) found that the adolescent group did slightly less well, butthe difference disappeared after taking into account initial sever-ity. Within prepubertal children, there also do not appear to beage effects when using direct observation (Dishion & Patterson,1992; Beauchaine et al., 2005). By contrast, the meta-analysis bySerketich and Dumas (1996) found that across (not within) 36studies ranging from 3 to 10 years of effectiveness was greaterin older children. In summary, it appears that age is not a cleardeterminant of outcome. Likewise, boys are as likely to improveas girls (e.g., see Beauchaine et al., 2005; Scott, 2005). Therefore,there is room for some optimism when treating adolescents.

Child psychopathologyThe meta-analysis by Reyno and McGrath (2006) foundthat more severe initial antisocial behavior predicted (not

moderated) less change, but this was a bivariate associationwith no controlling for other factors. By contrast, taking otherfactors into account, Scott (2005) found the opposite, namelythat higher initial levels of antisocial behavior predicted morechange. Most recent reviews and meta-analyses tend to concur.Although Furlong et al.’s (2012) Cochrane review found nodifference by conduct problem severity (coded at the trial level),Shelleby & Shaw’s (2013) narrative review, andmeta-analyses byLundahl et al. (2006) and Leijten et al. (2013) found larger effectsizes with higher initial severity. Future studies need to addressthis issue using multivariate statistics and larger pooled sam-ples. Child ADHD predicts a less good response in some studies(MTA, 1999; Scott, 2005) but not others (Beauchaine et al., 2005;Ollendick et al., 2008). In the MTA study, direct observations inthe psychological treatment-only arm showed that parents hadchanged their behavior, whereas child ADHD symptoms hadnot (Wells et al., 2006).This suggests that it is the characteristicsof the children with ADHD that make them less sensitive tochange, rather than parents not implementing more effectiveparenting practices. By contrast, when studied, comorbid anx-iety appears to predict better treatment response for childrenwith behavior problems (Beauchaine et al., 2005). A broadreview by Ollendick et al. (2008) concluded that for conductproblem interventions, comorbidity did not affect outcomes.

Family factorsDemographic predictors of outcome such as single parenthood,lower maternal education, poverty, and larger family size havetraditionally been found in meta-analyses to have a small butnegative effect on outcomes (Lundahl et al., 2006; Reyno &McGrath, 2006). However, a recent systematic review (Leijtenet al., 2013) that controlled for confounders, especially initialchild problem severity, found no diminished effects of parentinginterventions in low SES families, consistent with moderatoranalyses in recent trials of more flexible interventions (Dishionet al., 2008; Gardner et al., 2009, 2010).Similarly, reviews have traditionally found that parental psy-

chopathology, especially maternal depression, predicts worseoutcomes, as do life events and harsher initial parenting prac-tices (Reyno & McGrath, 2006). However, Gardner et al. (2010)found larger child improvement with depressed parents. Formothers with the most negative beliefs about their children,Doolan (2006) found no change in child behavior at all. Overall,these conflicting subgroup findings from small trials suggestthat the field would benefit frompooling individual patient-leveldata from multiple randomized trials (Brown et al., 2013).

Mediators of changeIn recent years, researchers have begun to investigate whatmediates outcome, as recommended by Rutter (2005). To medi-ate treatment outcome, the treatment has to (i) change outcome(ii) change the mediator (iii) the mediator has to correlate withoutcome, and (iv) the effect of treatment on outcome has toreduce or disappear after controlling for the mediator (Kraemer



et al., 2002). It would seem likely that for parenting programsto change child behavior, some aspect of parenting would firsthave to change. This is worth testing as it might not be thecase—for example, the parenting program could make a couplerealize that they should , for example, stop arguing in front oftheir child, but still use the same disciplinary strategies.Beauchaine et al. (2005) and Tein et al. (2004) found that

changes in critical and ineffective parenting mediated childchange in antisocial behavior, whereas several studies havefound that positive parenting mediated change (Gardner et al.,2006, 2010; Dishion et al., 2008). Gardner et al. (2006) testedcompeting mediators, finding that it was change in positive par-enting skill, rather than confidence in parenting, that predictedchange in child problem behavior. In adolescents, Eddy andChamberlain (2000) found for parenting, quality of supervisionand discipline, and a positive adult–youth relationship all medi-ated change, as did time spent with deviant peers and the degreeof their influence. Taken together, these four factors accountedfor a substantial 32% of variance in subsequent antisocialbehavior. Similarly, Huey et al. (2000) in a trial of MultiSystemicTherapy for delinquency showed that a positive relationshipand firm discipline mediated outcome and good supervisionmediated deviant peer association which in turn mediatedsubsequent antisocial behavior. These studies indicate whichvariables need to change for a good outcome and have led tochanges in programs, for example, there is now a much strongeremphasis on preventing deviant peer association—the OSLCTreatment Fostercare program penalizes youth for every minutethat they cannot verifiably account for their whereabouts.

Implementation and dissemination

ImplementationMost of the trials cited earlier were carried out using (i) spe-cially recruited cases rather than clinical referrals, (ii) speciallytrained research therapists rather than regular clinicians (iii)university rather than clinical settings; indeed Weisz’s studiesshow that fewer than 5% of psychosocial child mental healthtrials meet all three “real-life” criteria (Chapter 36). There istherefore considerable concern whether the good effects seenin trials will be replicated in everyday life, where cases havea high degree of comorbid conditions and most therapists donot use evidence-based approaches and do not get skill-specificsupervision. Trials that compared evidence-based approachesin real-life with usual services nonetheless get a clear advantage,by 0.3 SDs (Chapter 36). The challenge is therefore to dissem-inate best practice more widely and to ensure that it is wellimplemented (Fixsen et al., 2011)

Therapist effectsTherapist performance can be divided into three elements. (i)the alliance, which includes how well client and therapist geton together and agree shared goals. A meta-analysis of youth

studies of the alliance found it contributed on average an effectsize of 0.21 sd to outcome (Shirk & Karver, 2003). (ii) fidelityor adherence to specific components of a model that concernsthe extent to which the therapist follows the actions prescribedin the manual. In a large real-life study of the implementationof a family program for antisocial youths, Sexton and Turner(2011) found that therapists who were highly adherent to themodel obtained good results, with a larger effect size on moresevere cases, whereas low adherent therapists actually obtainedpoorer results than the control group, implying that they mighthave perpetrated harm. (iii) the skill or competence with whichthe therapist carries out the tasks, that is, how well the thera-pist performs the actions. Skill can include aspects of the allianceand fidelity. Both Forgatch et al. (2005) and Eames et al. (2009)found that therapist skill significantly predicted change in inde-pendently observed parenting. In summary, there is good evi-dence that therapist variables make a crucial difference to par-enting programs for antisocial behavior.

DisseminationAlthough formal surveys are lacking in most countries, fromthe paucity of professionals trained in evidence-based pro-grams, we can conclude that the vast majority of childrenwith conduct problems or insecure attachment are not offeredproven approaches. There are examples of initiatives to addressthis. Norway has set up a national training center to roll-outand support a portfolio of parenting programs. In England,the National Academy for Parenting Practitioners was setup in 2007 and by 2010 had trained 4000 practitioners in asmall number of carefully chosen evidence-based programs,estimated to have benefited 150,000 children (Scott, 2010).This was accompanied by a sizeable research program and adetailed evaluation of over 100 parenting progras, with theresults posted on a searchable site for parents and commis-sioners (www.education.gov.uk/commissioning-toolkit). Forclinically referred cases, the Children and Young People’sIncreasing Access to Psychological Therapies (CYP-IAPT)initiative is training up 5 staff from each local health authorityin England in either parent training for conduct problems orcognitive behavioral therapy (CBT) for depression and anx-iety. The training is intense, 3 days a week over a year, withclose supervision of skills. A further element likely to leadto effectiveness is insistence on session-by-session outcomemonitoring (http://www.iapt.nhs.uk/cyp-iapt). More is nowknown about how to achieve successful dissemination, includ-ing training managers as well as clinicians, educating both thatregular supervision is necessary, and making the case for thecost-effectiveness of parenting programs.

Prevention

In an ideal public health preventive strategy, all parents wouldlearn effective parenting skills, which would help to improve


474 Chapter 37

parent–child relationships and child well-being, and reducethe population rate of harsh and abusive parenting. Therewould be a tiered set of interventions available in primary andthen in increasingly specialist levels of care, to help those withcontinuing difficulties. This vision has been well articulatedby Sanders (1999) and appropriate programs developed by hisgroup for each level. It is clear that we have good evidence forthe effectiveness of parenting interventions for selective andindicated prevention and for treatment of conduct problems.However, it is less clear whether universal prevention parentingprograms work: there have been many successful trials, but alsomany unsuccessful ones (Malti et al., 2011; Simkiss et al., 2013).Further studies need to understand under which conditionsand using which delivery mechanisms, universal parentingprograms can be helpful; if they are not, then the conclusionmight be that targeted programs are more useful. Prevention iscovered in more detail in Chapter 17.

Conclusions

Parenting programs have developed considerably in recentyears. Findings from scores of randomized trials present a posi-tive view of their effectiveness, with widespread implementationin many countries. Recent moderator analyses suggest that formany groups considered as hard-to-treat, for reasons of socialdisadvantage or psychopathology, parenting interventions canimprove child behavior. For families with very complex needs,such as those in the child protection system, the evidence ispromising. Future developments need to include evaluationof the long-term effects of programs and the mechanisms thatmediate changes in parenting behavior. As parenting programstend to have small effects on children’s behavior in school,further evidence on school-based programs is warranted.Finally, future studies need to investigate which families canimprove with minimal intervention such as computer-basedself-instruction.

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