By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Summary Points
- A randomized controlled trial involving 300 young children with behavioral problems found that Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD), in addition to usual care, resulted in a significant reduction in behavioral problem scores compared to usual care alone.
- The VIPP-SD intervention, which involved filming in-home parent-child interactions and providing feedback geared toward a positive, emotionally aware, and consistent parenting and discipline style, was delivered every other week for six weeks within family homes.
- After a five-month follow-up, the VIPP-SD group showed a significant reduction in behavioral problem scores compared to the usual care group, particularly for conduct problems, with P-values of 0.04 and 0.007, respectively.
SYNOPSIS: This randomized trial of an in-home parenting intervention consisting of review of video interactions and feedback promoting positive parenting was associated with reduced behavioral problems in high-risk children (ages 1 to 3 years) compared with usual care.
SOURCE: O’Farrelly C, Watt H, Babalis D, et al. A brief home-based parenting intervention to reduce behavior problems in young children: A pragmatic randomized clinical trial. JAMA Pediatr 2021;175:567-576.
Young children often have behavioral problems. These can manifest in various ways, including fearfulness or shyness, extreme aggression, destructive actions, poor sleep regulation, and hyperactivity/impulsiveness.
Although some mental health disorders may be identified by age 2 or 3 years (but more commonly after 4 years of age), the rapid developmental changes of infancy and toddlerhood, as well as difficulty with expressive language, make certainty in diagnosis unlikely at younger ages.1,2
However, multiple investigations have confirmed that behavioral problems outside the norm for a child’s developmental age are a risk factor for later psychopathology. Early intervention via parenting programs may help mitigate this risk. Most of the studies in this arena involve pre-school or school-aged children, but less is known about the effectiveness of parenting programs during infancy and toddler years.2-4
O’Farrelly et al conducted a randomized trial across six sites in the United Kingdom involving children aged 1 to 3 years who had attended a routine healthcare visit and had scored at or above the 80th percentile on the Strength and Difficulties Questionnaire (SDQ), a standardized tool that measures childhood behavioral problems.5 The SDQ, completed by a parent or guardian, assesses behaviors such as temper tantrums, sharing habits, fearfulness, and argumentativeness.
Exclusion criteria included sensory and language impairments as well as diagnosed learning disabilities in the child or parent.
Out of more than 2,000 potential candidates for this study, 300 eligible families (one or two adult participants were required) consented, enrolled, and were randomized into the usual care (UC) arm or the intervention arm, which used Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) in addition to UC.
VIPP-SD consisted of six home-based one- to two-hour sessions, during which filmed video of parent/guardian-child interactions are reviewed with the adults and feedback is given regarding emotional sensitivity and consistent discipline. Interveners in this study predominately were public health nurses.
UC ranged from minimal intervention to referral to parenting support groups or mental health services.
At baseline and five months after the start of the study, researchers assessed the behavior of the participants. All researchers were blinded to treatment arm during each assessment. The primary tool used to evaluate the degree of behavioral difficulty was the Preschool Parental Account of Children’s Symptoms (PPACS). The PPACS is a semi-structured interview conducted with the guardian or parent by a researcher.
During the interview, the researcher obtained information (including detailed examples) about the child’s typical behavior over a specified time, then rated the severity and frequency according to standard criteria. Lower scores on the PPACS indicate less severe and less frequent behavioral problems.
The PPACS has two primary subscales: problems with behaviors related to conduct (such as destructive outbursts and defiance) and problems with behaviors related to attention-deficit disorder (such as impulsivity and hyperactivity).
RESULTS
Scores were fully adjusted to account for factors such as treatment center, length of follow-up, age of child, and number of caregivers participating in the study.
The PPACS scores at baseline and five-month follow-up are shown in Table 1, while Table 2 displays the mean difference in scores between the control group (UC) and the intervention group along with the effect size or Cohen’s d. Cohen’s d often is used in social sciences to determine the magnitude or practical significance of an intervention, especially when there are multiple variables or outcomes. Cohen’s d is found by calculating the standardized difference between two means: (mean of group A − mean of group B) ÷ pooled standard deviation). In general, effect sizes are defined as:6
- small effect: 0.2;
- medium effect: 0.5;
- large effect: 0.8.
Table 1. Review of Results at Baseline and Five-Month Follow-Up |
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| VIPP-SD + UC | UC (Control) | |
PPACS total baseline |
33.5 (SD 9.0) |
32.4 (SD 10.6) |
PPACS total at five-month follow-up |
28.8 (SD 9.2) |
30.3 (SD 9.9) |
PPACS conduct behaviors at baseline |
16.0 (SD 5.8) |
15.5 (SD 6.4) |
PPACS conduct behaviors at five-month follow-up |
14.8 (SD 5.1) |
15.8 (SD 5.4) |
PPACS ADHD behaviors at baseline |
17.5 (SD 5.8) |
16.9 (SD 6.6) |
PPACS ADHD behaviors at five-month follow-up |
14.0 (SD 6.1) |
14.5 (SD 6.2) |
n = 151 baseline for the VIPP-SD + UC group and 140 at five-month follow-up. n = 149 baseline for the UC group (control) and 146 at five-month follow-up. VIPP-SD: Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline; UC: usual care; PPACS = Preschool Parental Account of Children’s Symptoms; SD: standard deviation; ADHD: attention-deficit/hyperactivity disorder |
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Table 2. Mean Difference and Effect Size Between Intervention and Control Group at Five-Month Follow-Up |
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| Mean Difference <at Five-Month Follow-Up | P Value | Effect Size (Cohen’s d) | |
PPACS total |
2.03 (95% CI, 0.06-4.01) |
0.04* |
0.20 (95% CI, 0.01-0.40); small effect size* |
PPACS conduct scale |
1.61 (95% CI, 0.44-2.78) |
0.007* |
0.30 (95% CI, 0.08-0.51); small-medium effect size* |
PPACS ADHD scale |
0.29 (95% CI, -1.06 to 1.25) |
0.67 |
0.05 (95% CI, -0.17 to 0.27); no effect size |
n = 151 baseline for the VIPP-SD + UC group and 140 at five-month follow-up. n = 149 baseline for the UC group (control) and 146 at five-month follow-up. *Statistically significant values PPACS = Preschool Parental Account of Children’s Symptoms; CI: confidence interval; ADHD: attention-deficit/hyperactivity disorder |
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Effect size and statistical significance differ. One way to think about this is to consider that effect size reflects the importance or clinical relevance of the result (for example, a medium effect size is a result that should be visible to “the naked eye”) while statistical significance or P value indicates the likelihood of the result occurring by chance.6
COMMENTARY
This interesting study of a parenting intervention designed to address behavior problems in 1- to 3-year-old children adds much-needed data to a field lacking in evidence-based treatment. There is far too little known about changing or adjusting parenting techniques for children in this age group to modify behavior. However, modifying caregiver behavior is one of the most practical interventions to have clinical utility for this age.3,4 Specifically, this study found that the families receiving VIPP-SD had a significant decrease in child behavior problems at the five-month follow up, and that this was most evident when looking at behaviors involving conduct as opposed to behaviors linked to attention-deficit/hyperactivity disorder (ADHD).
One of the more striking findings from this study is the high level of commitment and follow-through from the participants in both the control and intervention groups. In part, this may be a direct reflection of the degree of parental distress regarding these challenging behaviors in young children.
While the PPACS numbers significantly decreased in total and in the conduct subscale at five months in the intervention group, the Cohen’s d value or effect size initially looked less impressive at small to moderate. To this point, O’Farrelly et al explained that a two-point difference in the PPACS score for tantrums (equating to a 0.2 Cohen’s d or small effect size) indicated a decrease in tantrum frequency from daily at baseline to one to two tantrums weekly at follow-up or from breaking objects at baseline to shouting at follow-up. While this technically is equivalent to a small effect size, the effect on family life may be much more substantial.
While the reasons for the better response of conduct-related behavior problems compared to ADHD-related behaviors is not entirely clear, O’Farrelly et al speculated that the intervention’s focus on sensitive and consistent discipline may be more effective for addressing problematic behaviors involving conduct. This is a clear area for further research and investigation.
Other necessary areas for future research include identification of target groups and characteristics of families most likely to accept and respond to VIPP-SD. The long-term effect of this intervention, the need for periodic “boosters” or refreshers, and other such factors likewise will be important to generalize using this intervention. Results of the study strictly measured levels of behavior problems in the children but did not investigate any changes in parenting style or techniques during the intervention period. The act of filming parent-child interactions itself may have played a role in behavioral improvement (for example, by drawing more focused attention to such interactions). The mechanism of action of VIPP-SD is unclear; this remains a crucial area to explore to continue making progress in this field.
This study can serve as a reminder to integrative providers of the challenges many patients face regarding unwanted and disruptive child behavior. Being sensitive to such matters and empowering parents to seek out specialized techniques to deal with challenging behaviors in children can be useful, even when the children are very young.
REFERENCES
- Ogundele MO. Behavioural and emotional disorders in childhood: A brief overview for paediatricians. World J Clin Pediatr 2018;7:9-26.
- Bagner DM, Rodríguez GM, Blake CA, et al. Assessment of behavioral and emotional problems in infancy: a systematic review. Clin Child Fam Psychol Rev 2012;15:113-128.
- Nixon RDV. Treatment of behavior problems in preschoolers: a review of parent training programs. Clin Psychol Rev 2002;22:525-546.
- Mingebach T, Kamp-Becker I, Christiansen H, Weber L. Meta-meta-analysis on the effectiveness of parent-based interventions for the treatment of child externalizing behavior problems. PLoS One 2018;13:e0202855.
- youthinmind. What is the SDQ? Updated Aug. 16, 2022. https://www.sdqinfo.org/a0.html
- Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs. Front Psychol 2013;4:863.
This randomized trial of an in-home parenting intervention consisting of review of video interactions and feedback promoting positive parenting was associated with fewer behavioral problems in high-risk children (ages 1 to 3 years) compared with usual care.
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