Features

A lifeline for struggling parents

11 April 2019

Carole Sutton looks at the evidence on parent training programmes delivered by phone and internet to support troubled young children.

I remember clearly the first occasion when I worked with a parent of a troubled child using only the telephone to communicate. I had not – and never would – meet her face to face. To my delight, after a series of eight weekly phone calls, and drawing upon a set of booklets that I had written sent weekly by post, she reported that her little boy was becoming more manageable. She wrote to me, and I have her letter, dated 1 August 1983, in front of me as I write. It reads:

‘Thank you very much for all the help you have given us with R… the difference is amazing. A lot of people have noticed a change in him for the better. After reading your booklets we realised that we were not praising him enough. We were doing a lot of what you say but only the negative things e.g. time out*. We have always put him in the hall when he was very difficult but only until he stopped crying then he was allowed back.’

This mother was one of the parents in a pilot study for a much larger piece of work in which I explored two hypotheses: first, that many parents of troubled pre-school children, who had been screened by health visitors and then referred to me, could be helped using social learning/behavioural theory; and second, that the principles could be taught by eight weekly telephone calls based on the booklets which I had written. When, several years later, I had completed the main study, I found that there was evidence to support both hypotheses (Sutton, 1992).

Other researchers used the telephone as the medium of contact; later, of course, the internet was used to develop a variety of ways of communicating with parents. Since then, an array of technological interventions has helped numerous children with many complex health conditions. This article aims first to explore ways in which the telephone and the internet have been employed to help parents; and second, to highlight lessons drawn from research that may be helpful to current practitioners. As the field is so large, I shall focus primarily on pre-school children with behaviour difficulties.

How soon should we be worried?

Moffitt and Scott (2008) confirm that conduct problems are the most common disorder in child and adolescent mental health. The early work of Robins (1966) showed that children displaying difficult behaviour at a young age often went on to display the same patterns of behaviour in adolescence and young adulthood, while Stevenson and Goodman (2001) confirmed the association between seriously troublesome behaviour in three-year-olds and subsequent criminality. However, it was the seminal work of Moffitt and Caspi (2001) into the origins of antisocial behaviour that drew the attention of researchers worldwide to the evidence distinguishing two groups of young people who display antisocial behaviour: those with an onset of serious behaviour difficulties in early childhood and who may well become ‘life-course persistent offenders’, and those with an adolescent onset of misbehaviour and among whom serious behaviour difficulties are more likely, over time, to become less frequent or less harmful.

This taxonomy has been questioned, but is widely accepted. It draws attention to the large numbers of pre-school children whose parents are seeking help in managing their behaviour. For example, Rolon-Arroyo et al (2014) reported that approximately 3% to 7% of pre-school children display behaviour that meets criteria for conduct disorder, and they highlight the ‘predictive utility of conduct disorder symptoms in pre-school children’, confirming that children with these early symptoms often go on to display the same patterns of behaviour as they grow older.

Social learning theory and troubled children

There was an explosion of research addressing children’s mental health in the second half of the 20th century. The findings have been very important and have contributed much towards the reduction of human suffering. Because the field is so enormous, I shall concentrate on those approaches based on social learning theory, a body of concepts that has been found particularly fruitful. Following the pioneering work of Patterson (1975), researchers such as Pisterman et al (1992) have shown how training in principles of social learning theory can not only help parents gain skills in dealing with conditions in their children such as aggressiveness and hyperactivity, but also reduce parents’ levels of stress and feelings of incompetence. Interventions based on principles of social learning theory have also been accompanied by evidence of enhanced attachment between child and parent (Sutton, 2001).

Parents can gain skills in dealing with conditions in their children such as aggressiveness and hyperactivity

During the 1990s, one of the earliest and most successful researchers to employ these principles was Carolyn Webster-Stratton, whose collaboration with parents and teachers via The Incredible Years programmes (1992) showed that parents could be trained in the necessary approaches for managing children with major conduct problems and defiant behaviour. This programme originated in the US, and practitioners trained by this team are now working with parents worldwide. In the same decade, the Triple P Positive Parenting Programme (Sanders, 1999), originating in Australia, was published and is now enjoying widespread use.


What is social learning?

The term ‘social learning theory’ is often used rather loosely: it may refer to the notion that children imitate the patterns of behaviour which they observe in those who care for them; it may also be used to refer to the specific concepts of ‘learning theory’: these suggest that how a parent or caregiver responds to a child, for example by rewarding or penalising a child’s behaviour, will affect the probability of the child behaving in the same way again. These ‘behavioural’ principles have been shown to be extremely important both in understanding situations and how, if need be, to go about changing them.


Telephone initiatives

The telephone is the obvious means of developing support for parents living in rural or isolated settings

The telephone is the obvious means of developing support for parents living in rural or isolated settings. Notably, Lefever et al (2017) showed that it was possible to use the telephone to work successfully with families where parents were at risk of maltreating their child. Using the parent-child interactions approach (Eyberg, 1988), this team was able first to enhance the emotional links between parent and child, and second to help parents teach the child compliance and discipline. They also used mobile phones to maintain contact with the participants. Overall, the intervention had three beneficial outcomes: it improved long-term parenting practices, reduced maternal depression and reduced children’s aggression. The use of the phone also promoted long-term retention of participants in the programme.

Use of digitally-based/online programmes

In parallel with these developments, the internet arose as a means of working with parents of children with major behavioural difficulties. A review by Breitenstein et al (2014) examined nine methods of delivering digitally-based parenting programmes and found that four of the nine that measured an impact upon children’s behaviour all reported encouraging positive effects for both parents and children.

A particularly important approach has been that of Sourander et al (2016) in developing a ‘whole country’ approach in Finland. In the first study, of a total population of 4656 four-year-olds, 730 (15.67%) were found to demonstrate high levels of disruptive behaviour, as measured by the Child Behaviour Checklist (Achenbach and Rescorla, 2001). Aggression, callous-unemotional tendencies, anxiety and parental stress were also measured. Families were then offered help via the Strongest Families parenting programme (Lingley-Pottie et al, 2016), a feature of the Canadian Mental Health Association; this offered help via 11 internet-based programmes, supplemented by telephone calls to individual families. A randomised controlled trial was carried out with 464 families, with half receiving help via the Strongest Families website and the other half participating in an education control group. At follow-up 12 months later, the improvements in the group helped by the Strongest Families approach were significantly greater than those in the educational group, with disruptive behaviour markedly reduced; there were also statistically significant improvements among these children in their aggression, anxiety levels and sleeping patterns and in their scores on the Inventory of Callous and Unemotional Traits (Frick and White, 2008). Moreover, parents of children in this group self-reported their parenting skills to be significantly improved.

In a follow-up study (Sourander et al, 2018), 24 months after the first, the Strongest Families group had maintained their improvement, both in reductions of disruptive behaviour and in secondary syndromes, while parents continued to report improved parenting skills. The researchers suggest that their results demonstrate the value of identifying families in need of support early and that the use of the internet and telephone can assist in parent training at the level of whole populations.

Major review of online parental training

A review of studies of online parental training by Baumel et al (2017) examined 14 studies of training that delivered the service primarily via the internet. Several studies used videos to illustrate key concepts and others made additional telephone coaching available.

The authors concluded: ‘Online parental training led to reasonable improvements in behaviour problems in children and young people, compared to no training’ (NIHR Signal, 2017).

They went on to report: ‘There was no clear difference in outcomes when comparing online training with a face-to-face therapist-led programme or interactive versus non-interactive programmes. However, […] two studies suggested that enhancing online training with telephone calls or other “check-ins” may help to improve participation and increase the effectiveness of training programmes’ (NIHR Signal, 2017).

Commenting on this review, Professor Stephen Scott, director of the National Academy for Parenting Research, noted that ‘given the huge prevalence of conduct problems (the commonest disorder in child and adolescent mental health), there will never be enough face-to-face provision of parenting programmes, so an online service must surely be part of service provision’ (NIHR Digital, 2017).


Implications for CPs

  • Practitioners such as HVs, who are ideally placed to offer support to parents seeking help for their troublesome young children, need ongoing training/supervision with one of the established parent training programmes. They need to achieve a level of competence based on a sound theoretical understanding, and if the programmes themselves do not offer a means of validating that competence, practitioners should provide evidence to their managers that their competence has been demonstrated by work with at least, I suggest, 10 families.
  • Practitioners should familiarise themselves with the Strengths and Difficulties Questionnaire (Goodman, 1997), now accepted internationally as a validated pre- and post- assessment tool for a range of child and adolescent emotional and behavioural difficulties. This excellent resource can be downloaded in several versions, appropriate for different age groups, from bit.ly/SDQ_tool
  • Practitioners should work with concerned parents as early as possible, should discuss with them how the work is progressing, so that achievements or deterioration in child and/or family functioning can be noted and future plans made in the light of these developments.
  • Once a recognised level of competence has been demonstrated in face-to-face work, practitioners can begin to practise working with the parents of difficult pre-school children by telephone and via the internet.
  • Practitioners should seek supervision of their practice from either a worker with specific training or skills or from a group of experienced colleagues. Practitioners can offer help to thousands of parents in preventing children from becoming involved in careers of antisocial behaviour. But they themselves also need support.

The therapeutic alliance

The therapeutic alliance, usually achieved during face-to-face meetings, is often considered a prerequisite for building successful and trusting work between practitioner and client. In view of the increasing number of papers reporting effective outcomes for services offered primarily by telephone and the internet, this issue has been explored more fully. A useful tool has been the Working Alliance Inventory (Munder et al, 2010). Lingley-Pottie et al (2016) described working with 64 families using the Strongest Families approach; training was given via the internet and telephone, and the evidence showed that both children and parents developed a strong therapeutic alliance with their coach despite not meeting face to face.

We may conclude, first, that technology is being increasingly used successfully for supporting the parents of pre-school children with behaviour difficulties; second, that there is evidence that many families can be helped either by telephone with or without the use of the internet; and third, that the results obtained via the telephone and the internet, without face-to-face contact, are as effective as those in which parent and therapist actually meet.

* Time out needs to be administered with great care as parents can misunderstand and abuse it. This is particularly so for children with complex needs.

Carole Sutton is visiting senior research fellow at the School of Health and Life Sciences at De Montfort University.

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References

Achenbach TM, Rescorla LA. (2001) Manual for the ASEBA school-age forms and profiles: an integrated system of multi-informant assessment. University of Vermont: Burlington VT.

Baumel A, Pawar A, Mathur N, Kane JM, Correll CU. (2017) Technology-assisted parent training programs for children: a systematic review. Journal of Clinical Psychiatry 78(8): e957-e969.

Breitenstein SM, Gross D, Christophersen R. (2014) Digital delivery methods of parenting training interventions: a systematic review. Worldviews on Evidence-Based Nursing. 11(3): 168-76.

Eyberg S. (1988). Parent-child interaction therapy: integration of traditional and behavioral concerns. Child and Family Behavior Therapy 10: 33-46.

Frick PJ, White SF. (2008) Research review: the importance of callous-unemotional traits for developmental models of aggressive and antisocial behaviour. Journal of Child Psychology and Psychiatry 49(4): 359-75.

Goodman R. (1997) The strengths and difficulties questionnaire: a research note. Journal of Child Psychology and Psychiatry 38(5): 581-6.

Lefever J, Bigelow KM, Carta JJ, Borkowski JG, Grandfield E, McCune L, Irvin DW, Warren SF. (2017) Long-term impact of a cell phone-enhanced parenting intervention. Child Maltreatment 22(4): 305-14.

Lingley-Pottie P, McGrath P. (2016) Imagine a mental health service that builds stronger families. Paediatric Child Health 21(5): 247-8.

Moffitt TE, Scott S. (2008) Conduct disorders of childhood and adolescence In: Rutter M, Bishop DVM, Pine DS, Scott S, Stevenson J, Taylor E, Thapar A (eds) Rutter’s child and adolescent psychiatry. (5th edition) Blackwell Publishing: Oxford.

Moffitt TE, Caspi A. (2001) Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Development and Psychopathology 13(2): 355-75.

Munder T, Wilmers F, Leonhart R, Linster HW, Barth J. (2010) Working Alliance Inventory-Short Revised (WAI-SR): psychometric properties in outpatients and inpatients. Clinical Psychology and Psychotherapy 17(3): 231-9.

NIHR Signal (2017). Online parental training may help to improve behaviour in children. See: https://discover.dc.nihr.ac.uk/content/signal-000458/online-parental-training-may-help-to-improve-behaviour-in-children (accessed 18 March 2019).

Patterson G. (1975) Families: applications of social learning to family life. Research Press: Champaign IN.

Pisterman S, Firestone P, McGrath P, Goodman JT, Mallory R, Coffin B. (1992) The effects of parent training on parenting stress and sense of competence. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement 24(1): 41-58.

Robins LN. (1966) Deviant children grown up: a sociologial and psychiatric study of sociopathic personality. Williams and Wilkins: Baltimore, MD.

Rolon-Arroyo B, Arnold DH, Harvey E. (2014) The predictive utility of conduct disorder symptoms in preschool children: a 3-year follow up study. Child Psychiatry and Human Development 45(3): 329-37.

Sanders, MR, (1999) Triple P-positive parenting programme. Clinical Child and Family Psychology Review 2(2): 71-90.

Sourander A, McGrath PJ, Ristkari T, Cunningham C, Huttunen J. Hinkka-Yli-Salomäki S, Kurki M, Lingley-Pottie P. (2018) Two-year follow-up of internet and telephone assisted parent training for disruptive behavior at age 4. Journal of American Academy of Child and Adolescent Psychiatry 57(9): 658-68.

Sourander A, McGrath, PJ, Riskari T, Cunningham C, Huttenen J, Lingley-Pottie, P, Hinkka-Yli-Salomaki S, Kinnunen M, Vuorio J, Sinokkia A, Fossum S, Unruh A. (2016) Internet-assisted parent training intervention for disruptive behaviour in 4-year-old children: a randomized clinical trial. Journal of American Academy of Child and Adolescent Psychiatry 73(4): 378-87.

Stevenson J, Goodman R. (2001) Association between behaviour at age 3 years and adult criminality. British Journal of Psychiatry 179(3): 197-202.

Sutton C. (2001) Resurgence of attachment (behaviours) within a cognitive behavioural intervention: evidence from research. Behavioural and Cognitive Psychotherapy 29(3): 357-66.

Sutton C. (1992) Training parents to manage difficult children: a comparison of methods. Behavioural and Cognitive Psychotherapy 20(2): 115-39.

Webster-Stratton C. (1992) The incredible years. Umbrella Press: Toronto.

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