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Original Investigation
April 2016

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

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

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.