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EVIDENCE-BASED PARENTING INTERVENTIONS
Evidence-Based Parenting Interventions: Current Perspectives and Clinical Strategies
David J. Hawes1 & Jennifer Allen2
1University of Sydney
School of Psychology (A18), The University of Sydney, NSW 2006 Australia
Tel: +61 2 93514068 Fax: +61 2 9036 5223 E: david.hawes@sydney.edu.au
2University College London
Department of Psychology and Human Development, UCL Institute of Education
University College London, 20 Bedford Way London WC1H 0AL
Tel: +44 (0)20 7612 6222 Fax: +44 (0)20 7612 6304 E: j.allen@ioe.ac.uk
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Abstract
The effective treatment of child psychopathology is often determined by the effectiveness
with which a clinician is able to facilitate targeted and sustained change in parenting. In this
chapter we provide an overview of evidence-based parenting programmes, and the principles and
strategies that are key to working therapeutically with parents in formulation-based interventions.
We begin by examining the conceptualisation of parenting processes that have informed these
programmes, with a particular focus on child conduct problems and anxiety disorders – the areas
in which the current evidence-base is most established. Attention is then given to key issues in
the planning and delivering of parenting interventions, including strategies for promoting
parental engagement, establishing shared therapeutic goals, and collaborative treatment planning
with parents. A number of the most established programmes are then examined with respect to
key components and ongoing efforts to improve effectiveness.
Key words: parenting interventions, parent-child relationship, parenting practices, discipline,
conduct problems, anxiety
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<h1> Introduction <h1>
The effective treatment of child psychopathology is often determined by the effectiveness
with which a clinician is able to facilitate targeted and sustained change in parenting. The
literature is now replete with evidence-based parenting programmes for a range of problems, in
which parents are cast as the primary agents of therapeutic change. In addition to these
programmes, parenting processes are often core to formulation-driven treatment plans in which
they may be conceptualised and targeted alongside any number of other child and family risk
processes. The benefits of targeting quality of parenting have been demonstrated dramatically in
recent decades, as evidence has grown regarding mechanisms of change and long term outcomes
among children with various disorders. At the same time, such interventions present clinicians
with a range of unique challenges that call for unique theoretical perspectives and process
strategies.
<h1> Theoretical Perspectives on Parenting and Child Psychopathology <h1>
It is now well recognised that competencies related to the self-regulation of emotion,
cognition, and goal-directed behaviour, are shaped through repeated transactions between
children’s biologically-based characteristics and the social contexts in which they development
(Rothbart & Posner, 2006). The earliest and most profound such context is the parent-child
relationship. Parenting practices not only often function as controlling variables for child
behaviour patterns, but may serve to potentiate the expression of biological vulnerabilities, and
in doing so enhance risk that is carried forward across the lifespan (e.g., Hawes et al., 2013;
Dadds et al., in press). At the same time, the very parenting processes that operate on child
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outcomes may themselves arise from child-driven effects associated with child characteristics
(e.g., temperament) and behaviour.
In contrast to the notion that parenting risk factors are unique to specific disorders,
research has emphasised considerable overlap among the parenting processes that are common to
trajectories of both externalising and internalising dysfunction (Levy, Hawes, & Johns, in press).
Indeed, there is now strong evidence that parenting plays a significant role in shaping the self-
regulatory capacities, or executive functions, that are associated with disorders of both kind, as
well as a range of broader developmental and academic outcomes (Fay-Stammbach, Hawes, &
Meredith, 2014). However, as outlined below, the family-based risk models that have received
the strongest empirical support, and have been translated into the most established parenting
interventions, have been those related to disruptive behaviour disorders or conduct problems
(i.e., oppositional defiant disorder and conduct disorder) and childhood anxiety disorders.
<h2> Parenting and Externalising Problems <h2>
The models that have received the strongest empirical support in explaining the
emergence and maintenance of childhood conduct problems are those in which family risk
mechanisms are conceptualised based on social learning (operant) theory (Hawes & Dadds,
2005; Patterson & Fisher, 2002). These conceptualisations attribute the maintenance and
amplification of child conduct problems to escalating cycles of parent-child coercion that
function as interlocking ‘reinforcement traps’. These coercive cycles are maintained by escape-
avoidance mechanisms through which aversive control tactics (e.g., whining, nagging, shouting,
hitting) are rewarded, and positive/warm family interactions extinguished (Dishion & Patterson,
2006). The contingencies supplied by parents in terms of relative rates of reinforcement for
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socially competent versus deviant behaviour are seen to represent the most proximal influences
on child outcomes. Likewise, the same reinforcement mechanisms that operate on child
behaviour are assumed to encompass the alteration and shaping of parenting behaviour.
In addition to specifying the risk processes through which parent-child contingencies play
out on a moment-to-moment time scale, coercion theory also emphasises the longer-term,
developmental time scale across which cascading risk processes are set in train. Often first
initiated by age 2 years, the longer that coercive cycles persist over time, the more rapidly they
are likely to escalate, and the higher they are likely to push the upper amplitudes of family
aggression. As children become increasingly skilled in their use of coercion, discipline becomes
increasingly challenging for parents. Deficits in social competencies expand to other domains of
development, and soon generalise to contexts outside of the home (Dishion & Patterson, 2006).
Parenting processes continue to shape antisocial trajectories across later childhood and
adolescence, however the precise parenting processes of proximal importance in this period shift
from those related to setting limits on behaviour in the home, to those related to the regulation of
children’s peer activities in external settings. As such, evidence-based interventions for
adolescent conduct problems often provide youth with skills training related to self-regulation,
while also targeting parenting practices related to monitoring and supervision (Dishion &
Kavanagh, 2003; Henggeler & Sheidow, 2012).
<h2> Parenting and Internalising Problems <h2>
The critical/rejecting parenting associated with coercion in the families of children with
conduct problems has also been associated with risk for internalising problems – in particular
child and adolescent depression (McLeod, Weisz & Wood, 2007). Alternatively, risk for anxiety
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disorders has been associated most strongly with overprotective/overcontrolling parenting,
wherein parents excessively restrict children’s engagement with situations or behaviours based
on anticipation of potential threat (Rapee, Schniering, & Hudson, 2009). This may extend to
psychological control expressed through intrusive or passive–aggressive parenting behaviours
that inhibit autonomy granting. Such parents may withdraw affection or induce guilt as means of
discipline, creating a family environment in which acceptance is contingent on a child’s
behaviour (Barber, 1996). These parenting behaviours have been proposed to confer risk through
a number of mechanisms, potentially functioning to (a) model anxious responding to innocuous
events, (b) enhance children’s threat interpretations, (c) prevent the habituation of anxious
arousal by limiting children’s exposure to fear-provoking events, and (d) interfere with the
adaptive development of children’s emotion regulation skills (Ollendick, Costa, & Benoit, 2010).
Guided by the conceptualisation of transactional parent-child dynamics emphasised in
models of conduct problems, research has likewise supported the occurrence of transactional
parent-child dynamics in accounts of internalising problems (LaFreniere & Dumas, 1992). In line
with this, Dadds and Roth (2001) proposed an ‘anxious-coercive cycle’, in which fearful children
solicit attention, comfort, and protection from their parents during novel situations, which in turn
functions to reinforce children’s avoidance and dependence on parents. There has since been
considerable support for the notion that child anxiety is maintained by parenting responses that
are in part a product of maladaptive child behaviour (Williams et al., 2012). Such evidence
suggests that interventions for anxiety that ignore parent-child interactions may place children at
risk of reinstating relationship dynamics that contribute to the amplification of anxiety in the
family. At present, evidence based treatments for internalising problems place considerably less
emphasis on parenting targets than those for externalising problems, however growing treatment
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outcome research has emphasised the therapeutic value of training parents in strategies that
emphasise calm and consistent responding, and teaching parents to respond to child anxiety
using cognitive-behavioural strategies such as graded exposure, structured problem solving, and
behavioural experiments (e.g., Cartwright-Hatton et al., 2011).
<h1> Key Issues in the Planning and Delivering of Parenting Interventions <h1>
The clinical assessment of parents and parenting serves a number of key functions. First,
such assessment is essential to formulation-driven clinical practice, informing functional
hypotheses about the controlling variables (e.g., patterns of social rewards and punishment) that
can be targeted to produce child behaviour change. This formulation often benefits from
comprehensive measurement strategies that incorporate parent interviews, self-report inventories,
and structured observational procedures that allow for the assessment of family process variables
that may not otherwise be accessible (see Hawes & Dadds, 2013). Evidence-based models of
childhood disorders such as those already presented provide a means to map out the domains of
parenting that are likely to be of most proximal importance to children and adolescents
characterised by various diagnostic and developmental features. These models specify the
optimal starting points from which to plan the assessment of parenting and family variables, and
guide the interpretation of the resulting data in relation to data on a child’s behaviour and
development. Second, a range of parent and family factors represent potential barriers to
treatment, with data on those factors often needed to guide the effective implementation of
parenting interventions. Such factors include a parent’s resources for change (e.g., self-regulatory
capacities, social support), as well as parents’ readiness for change and motivation for treatment
(Geffken, Keeley, Kellison, Stotch, & Rodrique, 2006). Third, data on parents’ capacities to meet
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children’s current and future developmental needs, and the appropriateness of the demands being
made by the child’s environment, are crucial to making clinical judgements about a child’s
prognostic status – potentially within the context of high-risk scenarios involving neglect or
maltreatment. Finally, the collection of data on parenting throughout an intervention may provide
information of key importance to the evaluation of treatment progress and outcomes. Such data
may allow a therapist faced with poor treatment adherence to understand and address barriers to
change (e.g., parents’ self-defeating cognitions, interference from other family members), and
inform important revisions to problem formulation across therapy.
Although the collection of reliable data on family functioning is essential to planning
effective parenting interventions, such data alone offers no guarantee that an intervention will act
on those dynamics effectively. We assume that the process of therapeutic change is also driven
by the process of consultation, the most important of which concerns the early contacts between
a therapist and family. The effective management of this process is particularly crucial when
working with distressed, multi-problem families (Scott & Dadds, 2009). It is important from the
outset to recognise that the planning and delivery of interventions that address issues related to
parenting and the family is often complicated by the very nature of these domains. By the time
many children and adolescents are referred to clinical services, their parents have suffered a long
history of defeats in their attempts to manage the presenting problem. In addition to the distress
associated with this, many of the family factors implicated in parenting problems (e.g., parent
psychopathology, negative parental attributions and feelings toward the child, marital conflict,
lack of social support) are distressing in their own right. Such factors are likewise associated
with poor engagement in child and adolescent mental health services.
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<h2> Promoting Engagement in Parenting Interventions <h2>
The most valuable strategies for assessing parenting and family domains are those that
support the dual aim of eliciting reliable data while at the same time promoting a strong
therapeutic relationship with parents. Our approach to managing this process (see also Dadds &
Hawes, 2006) draws on a structural model of the family system. According to Minuchin (1974),
a healthy family is characterised by overlapping but independent parent, child and extended
family subsystems, that are organised hierarchically. Most importantly, parents act as an
executive subsystem wherein they maintain a positive relationship independent of the parenting
role and can function cooperatively to solve family problems. While the data to show that
problematic structural dynamics are a direct causal variable for child psychopathology is
complex for methodological reasons , evidence suggests that these dynamics may confer broad
risk for childhood problems. In the families of children with conduct problems, for example, it
has been found that the boundaries between parent and child subsystems often become unclear;
the parents’ relationship becomes conflicted; and extended family get drawn into failed attempts
to manage the child’s behaviour (Green, Loeber, & Lahey, 1992; Shaw Criss, Schonberg, &
Beck, 2004). We assume that the first critical process of therapy is to join with the parental
subsystem of the family to form a therapeutic team, and that it is through this parent-centred
partnership that a therapist is best placed to impact on the broader family system.
In our work we have found that many of the process difficulties encountered by therapists
in engaging parents in family-based interventions stem from a failure to structure initial contacts
that are compatible with this aim (Dadds & Hawes, 2006). The effective management of the
consultation process begins with the first telephone contact, at which point it is important to
clarify who is involved in the parenting of the child, and to take the necessary steps to ensure that
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the relevant members of the parenting subsystem attend the initial assessment session whenever
possible. Many therapists trained in family-systems approaches believe that the first session
should involve all family members so that the system as a whole can be observed. This
opportunity for observation can however come at a significant cost. A therapist’s attempts to
explore issues beyond those directly associated with the child are in many cases rejected by
parents whose experience and perception of the problem has not first been sufficiently validated.
This relies on parents being free to express and explore their experiences in the family, no matter
how distressing or controversial. Complaints about the effect of the child’s behaviour on the
parents’ lives and marriage, catastrophic fears about the child’s future, and hostile feelings
toward the child, are common themes. Parents may withhold such disclosures in the presence of
children, while therapists may be forced to similarly restrict the scope of the interview when such
expressions intensify. We therefore recommend scheduling the initial assessment interview with
parents alone, in order to allow for the full expression and exploration of the issues impacting on
the family, and the planning of future contacts as an adult team. There can be important benefits
to including older children and adolescents in the initial assessment session, however this is
generally most advantageous within a session structure that permits the therapist to build
relationships with the adolescent and his/her parents separately (e.g., dividing the session to
accommodate one-on-one time with respective subsystems). We recommend not proceeding to
more formal assessments of parenting and family dynamics until open and trusting relationships
have been established with relevant parents and caregivers.
<h2> Establishing Shared Therapeutic Goals with Parents <h2>
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Parents who feel forced into a particular intervention, or disagree with the goals upon
which it is focused, will be unlikely to comply with therapist recommendations. Likewise,
parents who do not understand how the goals and components of an intervention relate to the
causes of a child problem will often lack the motivation to work on them. Rather, the therapeutic
goals that are most likely to be achieved in parenting interventions are those that are shared by
therapists and parents, and emerge from a shared perception and conceptualisation of the
problem. The building of such a perception represents a central aim of the consultation models
that is recommended here (see also Sanders & Dadds, 1993; Dadds & Hawes, 2006), and can be
facilitated using a number of strategies.
Clinicians often first explore issues related to parenting and family functioning in the
course of an initial interview that also addresses a range of topics more directly related to the
referred child (e.g., dimensions of the presenting problem, developmental and treatment history,
social and academic functioning). The successful investigation of parent-focused issues in this
interview often relies on effective strategies for managing these respective child and parent foci
in relation to one another. The processes strategies that are most likely to facilitate a shared
perception of the child problem at this stage are those that shift parents away from definitions of
the presenting problem as simply a child issue, toward a perspective that allows this problem to
be considered alongside other issues in the family and their own lives. This is reflected by the
structure of the initial interview recommended by Dadds and Hawes (2006), within which an
initial focus on the child’s presenting problem gradually expands to encompass issues of
importance to the broader family system. As such, careful attention is paid to the order in which
topics are raised, and the management of transitions between these topics.
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The various issues that may be adversely impacting on a family system represent an
essential, yet challenging focus within the parent interview. Included here are issues related to
parents’ mental health and substance use, social support, feelings and attributions about the
parent-child relationship, family history of mental health problems, and distress or violence in
the marital relationship. These issues may be sensitive, highly emotional, or frightening – both to
parents and therapists alike. They can also be the issues that carry the most critical implications
for the planning and delivery of family-based interventions with complex cases. The likelihood
that parents will be receptive to the assessment of these issues can be maximised by a number of
steps taken prior to, and during, this component of the interview. First and foremost, we advise
that inquiries about other problems or stressors in the family are initiated only after parents’
presenting concerns about the child have been adequately addressed. Doing so reflects a basic
respect for those concerns, while at the same time allowing elementary rapport to be established
before more sensitive issues are broached. In our assessment model the focus on these issues is
therefore reserved for the final topic of the interview.
Second, the manner in which this component of the interview is introduced to parents can
be an important factor in their willingness to shift the focus of discussion from the referred child
to their own lives. Parents are often not expecting to be faced with personal questions of this kind
when seeking help for their child, and may react adversely when caught off guard. The smooth
transition to this focus can be facilitated by first summarising the child-focused information
gathered up to this point, and providing a plain-language rationale for turning to issues in the
broader family system (e.g., “With my questions today I’ve been trying to build a complete
picture about Nicholas’ difficulties and his life in general, which is what will allow me to work
out the best way that I can help. As part of this I was also hoping to also ask some standard
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questions about yourselves and family life more generally, so I can really understand the big
picture of what’s important. Is that alright with you?”). We make it a rule to explicitly ask
parents’ permission to proceed at this point – a gesture that should not be underestimated.
Third, by structuring the order in which these issues are raised, it is possible to confront
those more sensitive issues most gradually. Although the specific parent and family issues
addressed in such an interview may vary depending on the nature of the referral and the clinical
setting, we recommend always proceeding from the least to most potentially threatening. The
flow of this discussion can also be facilitated by organising these issues around related domains.
We typically begin with parents’ physical health (e.g., any recent or current illnesses or medical
conditions), which follows naturally onto parent’s mental health (e.g., stress, mood problems,
coping strategies) and in turn social support and quality of life (e.g., availability of social
networks, pleasant events outside of the parenting role). This is typically followed by questions
pertaining to parents’ relationships in the family, beginning with the parent-child relationship.
This can commence with inquiries into how the parent’s time with the child is spent, and the
parent’s role in relation to various caregiver duties, before moving onto the parents’ feelings and
attributions about the child and the presenting problem. Broader relationships in the family may
then be explored, in particular the parents’ own relationship, and the child’s relationships with
significant others. It is important to also invite parents to identify any additional issues that may
qualify as stressors in the family, such as financial strain, problematic work schedules, or
difficulties related to broader social contexts (e.g., interference from relatives, neighbourhood
safety).
Fourth, when exploring these issues in an interview attended by multiple parents or
caregivers, it is important that each is able to respond to these questions without interruption.
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Given the nature of these issues, the comments provided by one parent can at times evoke strong
responses from the other. While the discussion of such responses can be important to the aim of
forming a shared perception of the problem, it is not generally compatible with eliciting
necessary details about these issues. Our strategy for facilitating this questioning is to set up a
process whereby the respective sequence of issues is addressed with each parent in turn. This can
be introduced with a simple rationale and invitation (e.g., “To help me keep track of the things
that may be important for me to know, I would like to ask these next questions first to one of you
and then the other. Who would like to go first?”). Any interruptions from the other parent can
then be dealt with through reminders that they will soon have their chance to comment, and
while appealing for their patience as firmly as necessary.
Unique sensitivities related to the parent-child relationship warrant distinct interviewing
strategies. From a clinical perspective, parents’ cognitive attributions about their child and the
meaning of the presenting problem represent a critical aspect of the parent-child relationship; one
that is associated with risk for both externalising and internalising disorders (e.g., Dadds,
Mullins, McAllister, & Atkinson, 2003; Chen, Johnston, Sheeber & Leve, 2009). These
attributions may include ideas that a child’s behaviour/emotion is intentional and under the
child’s control, is designed to deliberately upset the parent, is a sign of serious mental problems,
is inherited from other (disliked) family members (e.g., an abusive ex-spouse) or is in some way
a punishment that the parent deserves. Parent attributions may be directly incompatible with the
assumptions of the respective treatment model (e.g., expectations that exposure to anxiety-
provoking stimuli will cause the child harm). These attributions may also be associated with
intense emotion, including explosive anger in reaction to provocative child behaviour, and
intense guilt following impulses of rejection and resentment toward the child. The intensity of
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such emotion can easily ‘flood’ a parents’ capacity to manage child behaviour and emotion
effectively, and overwhelm their attempts to initiate and maintain change (Mence et al., 2014;
Snyder et al., 1994).
Therapy may later target such attributions through various means, however the critical
process at the initial assessment stage is often to help parents to make these thoughts explicit.
This can usually be done using a line of questioning that begins with direct, open-ended,
inquiries (e.g., “How would you describe your feelings toward Oscar at the moment?”), and
progresses to close-ended questions oriented toward the parents’ distress (e.g., “How did you feel
the last time he really tried to hurt you?”, “In those moments when you are really struggling with
Oscar’s behaviour, how bad does it get?...What is the worst thought that you have had at that
time?”, “What is your greatest fear about Oscar’s behaviour?”, “In your darkest moments, what
do you think is happening with Oscar?”). The rationale for actively eliciting parent cognitions in
this way does not simply concern the collection of important parenting data, but also the
therapeutic gains associated with expressing these largely unspoken ideas. We advise against
attempts to challenge the irrational cognitions of parents at this point, which may be counter-
therapeutic. It is usually more appropriate that the fears and concerns presented by parents are
simply responded to empathically, normalised, and explored openly. As suggested by Scott and
Dadds (2009) the most appropriate way to conclude a discussion of these attributions may be
with a simple acknowledgement of their importance (e.g., “OK, so let’s keep an eye on how you
are going with these thoughts and feelings).
<h2> Collaborative Formulation and Treatment Planning <h2>
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Many issues of resistance and poor engagement in parenting interventions can be traced
back to a breakdown in the clinical processes that mark the transition from the assessment phase
to the formal commencement of treatment. It is now well recognised that parenting interventions
are most effective when they emphasise therapist-parent collaboration, however this
collaboration can easily be undermined by a failure to empower parents to make their own
decisions about treatment. When clinical recommendations are presented to parents during the
course of initial assessment, or therapists drift from assessment to treatment without
distinguishing between these distinct stages, parents may be denied the opportunity to make an
explicit decision to participate in that treatment. The active and cooperative participation of
parents in the therapeutic process often relies on parents first having a sufficient opportunity to
make such a decision, and doing so based on a clear understanding of assessment findings and
their implications for treatment.
Sanders and Dadds (1993) outlined a guided participation model for communicating
assessment results that is well suited to parenting interventions. The therapist begins by outlining
the specific types of data (e.g., interview, questionnaire, observation) that were gathered from the
various informants involved in the assessment (e.g., mother, father, teacher, child). Each source
of data is then shared, with the therapist checking for the parent’s understanding and reactions
before move on to the next. Care is taken to avoid jargon and technical terms, and to encourage
parents to ask questions and express any concerns about the meaning or integrity of the results. It
is important that adequate attention is also given to the emotional impact of assessment results
that may be distressing for parents to hear. Parents may be most receptive to receiving such
results when they are presented in a sequence that prioritises the information that they
themselves have provided, and addresses the results that are likely to be least unexpected before
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progressing to those that may be more confronting or controversial. The therapist then presents a
concise summary that integrates the overall assessment results, and checks for parent agreement
with the conclusions suggested therein. These simple steps are often highly effective in
promoting a shared conceptualisation of a presenting problem, and facilitating collaborative
treatment planning when implemented following the completion of initial assessment.
<h1> Parenting Programmes and Externalising Problems <h1>
Parenting interventions are recommended as a first line intervention for conduct problems
in children aged 3 to 11 years (NICE, 2013), and numerous such programmes meet the criteria
by which ‘well-established’ interventions are typically defined. These parent training
programmes typically commence with skills-training to increase positive reinforcement of
desirable child behaviour, followed by discipline-focused components in which parents are
trained to use consistent, non-forceful consequences (e.g., time-out) to set limits on negative
behaviour. Research examining the mechanisms through which such interventions operate has
found child outcomes to be accounted for both by reductions in harsh/inconsistent parenting, and
increases in positive parenting practices (e.g., Beauchaine, Webster-Stratton, & Reid, 2005;
Brotman et 2009; Hawes & Dadds, 2006). Three of the most widely disseminated of these are the
Triple P: Positive Parenting Program (Triple P; Sanders, 2012), Incredible Years (Webster-
Stratton & Reid, 2003), and Parent-Child Interaction Therapy (PCIT; Brinkmeyer & Eyberg,
2003; McNeil & Hembree-Kigin, 2010).
Triple P (Sanders, 2012) is a multilevel treatment system comprising five levels of
intensity that correspond to the severity of a child’s conduct problems and the complexity of
family’s needs. Standard Triple P (Level 4), is a parent training programme delivered in group,
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individual, and self-directed formats, in up to 12 sessions by mental health practitioners. Parents
are trained in the use of 17 parenting skills (e.g., talking with children, physical affection,
attention, setting limits, planned ignoring) designed to increase positive child behaviours and
decrease negative child behaviours, as well as strategies (planned activities training) to increase
generalization of treatment effects to a broad range of settings. Enhanced Triple P (Level 5)
builds on this by incorporating additional components that target systemic stressors such as
parent depression and marital problems, and may include home visits to enhance skill
implementation. A major review of treatment outcome data demonstrating durable and
generalised gains resulting from Triple-P was recently reported by Sanders (2012).
The Incredible Years (IY) group format intervention (see Bywater, 2012; Webster-
Stratton & Reid, 2003) utilises a collaborative model of parental engagement to enhance positive
parent–child relationships through the modelling and rehearsal of reward/praise and discipline
techniques (e.g., effective commands, logical consequences, time-out). Parents are also taught
how to teach problem-solving skills to their children. IY comprises three linked programs for
children, parents and teachers, with the parent program’s structured curriculum delivered to small
groups of parents/carers (of children aged 0–12 years) by two facilitators over 4–18 weeks (2
hr/week). Brief videotape vignettes demonstrating social learning and child development
principles are used extensively throughout skills training. Significant long-term reductions in
child conduct problems have been reported in multi-agency randomised controlled trials of the
intervention (e.g., McGilloway et al., 2012; Bywater et al., 2009).
PCIT (Brinkmeyer & Eyberg, 2003; McNeil & Hembree-Kigin, 2010) is another widely
disseminated parent training program for young children (ages 2–7 years) with conduct
problems. Therapists coach the parents via an ear-piece – usually from behind a one-way mirror
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– as they interact with their child during the treatment sessions, teaching them to apply skills in
the clinic until they achieve competency and are deemed ready to implement them on their own.
Families meet for weekly 1-hr sessions for an average of 12 to 16 weeks, during which they are
trained in two basic interaction patterns. These comprise an initial ‘child-directed interaction’
phase in which parents learn specific positive attention skills (e.g., labelled praises), and a
subsequent ‘parent-direction interaction’ phase in which parents learn and practice giving clear
instructions and implementing time-out during in vivo discipline situations. The effectiveness of
PCIT in reducing childhood conduct problems has been characterised by large effect sizes in
meta-analytic research (Thomas & Zimmer-Gembeck, 2007). A number of other evidence-based
programs for use with this younger age group have been widely disseminated and form the basis
for ongoing research into treatment innovations, including the Parent Management Training
Oregon Model (PMTO; Patterson, Reid, Jones, & Conger, 1975), Helping the Noncompliant
Child (McMahon & Forehand, 2003), and Integrated Family Intervention (Dadds & Hawes,
2006).
The most effective interventions for conduct problems in late childhood and adolescence
are those that combine parent training components with child-focused skills training targeting
social-cognitive deficits related to emotion regulation and social problem-solving (e.g.,
Multisystemic Therapy). The effects of such interventions are likewise mediated in part by
changes in parenting practices (e.g., Dekovic et al., 2012), thereby emphasising the importance
of parenting mechanisms to child adjustment across both childhood and adolescence. Three such
treatments that can be considered well-established are Multisystemic Therapy (Henggeler & Lee,
2003), Functional Family Therapy (Sexton & Alexander, 1999), and Multidimensional Treatment
Foster Care (Chamberlain & Smith, 2003).
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<h2> Improving Interventions for Externalising Problems <h2>
Parenting interventions based on coercion theory have been shown to benefit the majority
of children with conduct problems, however the effect sizes associated with these interventions
are often not large. For example, meta-analytic research has indicated that parent training
interventions are associated with a mean effect size of only 0.47 (range from 1.68 to -0.06)
(McCart et al., 2006). Efforts to enhance these benefits have taken various forms, based on the
recognition that multiple theoretical perspectives are needed to account for the synergistic
processes that shape child outcomes within the family. For examples, the unique dynamics that
characterise the attachment system help to explain some child behaviour that social learning
principles cannot, such as why some children seem driven to elicit potentially harmful attention
from parents, and why parent attention is so powerful a reinforcer at particular ages (Greenberg,
Speltz, & Deklyen, 1993). This perspective has informed parent training programs such as that
manualised by Dadds and Hawes (2006), which aims not simply to improve attachment security,
but to act on operant mechanisms in the family using strategies that are compatible with
concurrent attachment dynamics. This includes maximising parents’ use of contingent
reinforcement strategies that emphasise caregiver emotion and proximity, and training them to
implement limit-setting strategies (e.g., time-out) in ways that do not inadvertently threaten
attachment security.
Poor response to parenting interventions for conduct problems has been associated with a
range of social adversity factors that may interfere with families’ implementation of treatment
strategies and engagement with clinical services. These include socioeconomic disadvantage,
minority group status, younger maternal age, and parental psychopathology (e.g., Beauchaine,
20
EVIDENCE-BASED PARENTING INTERVENTIONS
Webster-Stratton, & Reid, 2005; Gardner et al., 2010; Lundahl, Risser, & Lovejoy, 2006; Reyno
& McGrath, 2006). More recently, however, the notion that child characteristics may contribute
to individual differences in treatment response has received growing attention. Most notably,
there is now considerable evidence that poor response to such interventions is more likely to be
seen among children with callous-unemotional (CU) traits (e.g., lack of guilt and empathy),
compared to those without such traits (e.g., Hawes & Dadds, 2005b).
The development of parenting interventions that target the unique needs of children with
conduct problems and CU traits has become a significant focus of emerging research. This work
has been informed by models of the neurocognitive deficits that characterise these children, with
evidence indicating that children with CU traits show deficits in the allocation of attention to
emotional cues including the eyes of attachment figures (Dadds et al., 2012; Dadds et al., 2014).
As outlined by Hawes, Price, and Dadds (2014), a multi-site programme of clinical research is
currently underway to develop and evaluate adjunctive treatment components that target precise
aspects of parent-child emotional engagement (e.g., eye contact) in the families of these children,
and can be delivered alongside core components of social learning based parenting interventions.
<h1> Parenting Interventions for Internalising Problems <h1>
The most established family-based interventions for childhood internalising problems are
for anxiety, and among these, the strongest evidence base can be seen for cognitive behaviour
therapy (CBT) interventions (Connolly & Bernstein, 2007; NICE, 2004). Current CBT
interventions are derived largely from Kendall’s (1994) ‘Coping Cat’ program, and have been
informed by current evidence regarding the role of parent factors and family process in the
development and maintenance of anxiety. The balance of parent and child-focused content differs
21
EVIDENCE-BASED PARENTING INTERVENTIONS
from protocol to protocol, with child-focused, parent-focused and family CBT programs
available. The nature and extent of parental involvement generally reflects the child’s
developmental level, with parent-focused programs directed at young children (2–8 years), and
child-focused programs featuring no or minimal parent involvement directed at older children
and adolescents. The content of CBT programmes for child anxiety varies, but typically includes
psychoeducation covering the nature of anxiety, the framework and rationale for CBT, and
familial processes implicated in the aetiology and maintenance of child anxiety. Parents give
their child support when learning skills (e.g., cognitive restructuring) and concepts (e.g., the link
between thoughts, feelings, physical/somatic symptoms and behaviour), the implementation of
strategies (e.g., graded exposure), completion of homework activities and relapse prevention.
Family-based CBT also includes components that specifically target family factors (see
Wei & Kendall, 2014). Parenting training involves the identification of unhelpful parenting
practices such as over-involvement, rejection and overprotection. Parents are encouraged to
replace these practices with problem-solving, graded exposure and cognitive restructuring to
support their child to develop these same coping skills. Parent modelling of coping emphasises
the importance of modelling effective coping strategies when faced with anxiety-provoking
situations themselves. Contingency management involves explanation of behavioural/learning
theories, emphasising the removal of parent responses that reinforce anxious behaviours, instead
instructing parents to encourage their children to face their fears, often through the use of praise
and rewards. Collaborative problem-solving aims to help parents and children deal with
challenging situations by learning a shared step-by-step process (i.e., defining the problem,
brainstorming solutions, evaluating proposed solutions and selecting the one with the greatest
likelihood of success). Communication skills training involves replacing unhelpful parent
22
EVIDENCE-BASED PARENTING INTERVENTIONS
behaviours such as interrupting and criticising with active listening, praise, and expression of
positive emotions. Finally, parental anxiety management aims to reduce parent anxiety using
CBT strategies (e.g., cognitive restructuring, graded exposure).
The role of the parent may differ somewhat across these programs. Some view the
therapist and parents as forming an expert collaborative team (e.g., Barrett et al., 1996), while
others view parents as ‘co-clients’, with parental difficulties such as parent anxiety addressed
within treatment (Brienholst, Esbjorna, Reinholdt-Dunnea, & Stallard, 2012). Some family-based
programmes place an emphasis on ‘transfer of control’ (Ginsburg et al., 1995), a process that
involves the gradual transfer of knowledge and skills from therapist to parent, and then from
parent to child (e.g., Thirlwall et al., 2013). This is a major benefit of family CBT, as parents can
support their child to successfully implement strategies following the completion of therapy.
Indeed, family-based CBT that aims to change child behaviour via contingency management or
transfer of control appears to offer superior long-term gains (Manassis et al., 2014).
<h2> Improving Interventions for Internalising Problems <h2>
CBT interventions can be regarded as an effective treatment for childhood anxiety
disorders, with an average of 60% of children anxiety diagnosis-free following treatment (James,
James, Cowdrey, Soler, & Choke, 2013). Treatment gains appear to be achieved and maintained
irrespective of the presence of comorbid mood or externalising disorders (Benjamin, Harrison,
Settipani, Brodman & Kendall, 2013). Importantly, however, the parenting processes that
contribute to child anxiety are exacerbated when parents are anxious themselves (see Murray,
Creswell, & Cooper, 2009), and can be problematic for parents’ implementation of CBT
strategies. For example, anxious parents may find it challenging to watch their children face
23
EVIDENCE-BASED PARENTING INTERVENTIONS
feared situations and thus avoid planning and implementing exposure tasks. They may display
anxiety during exposure, reinforcing their child’s belief that the situation is unsafe and he or she
is unable to cope. Not surprisingly, parental anxiety is associated with poor treatment response in
anxious children (Hudson et al., 2014). Interestingly, however, Creswell et al. (2008) found that
the effective treatment of parent anxiety did not modify parenting behaviours known to increase
the risk for anxiety in children. This suggests that even when parent anxiety is successfully
treated, PAM+CBT programs need to specifically target parenting practices characteristic of
anxious parents that serve to maintain child anxiety (e.g., parent over-involvement).
Furthermore, despite a clear rationale for parental involvement, meta-analyses indicate
that studies have failed to demonstrate an advantage of family/parent CBT for child anxiety
compared to child-focused CBT (e.g., Reynolds, Wilson, Austin, & Hooper, 2012). However,
concluding that parental involvement does not produce an added benefit would be pre-emptory
given that programs vary considerably in the nature and extent of parental involvement, program
content and delivery format. When and how to include parents may depend on additional factors,
including child (age, gender, presenting problem) and family/parent factors (parent
psychopathology, parent-child conflict). Parent factors are rarely assessed in trials, making it
difficult to determine if treatment was successful in changing parenting practices, and if so, how
these changes relate to treatment outcomes (Breinholst et al., 2012). Wei and Kendall (2014)
proposed a targeted approach that provides guidance on when, how and under what
circumstances to involve parents in treatment. In this implementation model, parent involvement
is indicated when parent anxiety, maladaptive parenting and/or parent-child conflict is present.
This model serves as a guideline for much needed future research to answer the question of
‘what works best for whom’ with regard to parent involvement in interventions for child anxiety.
24
EVIDENCE-BASED PARENTING INTERVENTIONS
<h1> Conclusions <h1>
Child development and psychopathology are known to be highly embedded in the
dynamics that play out in the parent-child relationship. The interventions that are most likely to
produce durable improvements for children and their families are therefore those that impact on
these dynamics, particularly when delivered early in childhood. Much progress has been made in
the evaluation and dissemination of evidence-based parenting programmes in recent years, most
notably for conduct problems and anxiety disorders. However, the effective care of clinic-
referred families often calls for professional capacities that extend well beyond the immediate
contents of manualised programmes, especially when dealing with highly distressed and multi-
problem families. Indeed, many clinicians working in community settings find that the outcomes
achieved in their own practice fall short of those promised in the literature. In our view, optimal
outcomes often rely not only on access to evidence-based programmes, but on a clinician’s
capacity to formulate child problems according to valid family-based models of
psychopathology, and to apply effective consultation strategies to engage parents in the earliest
stages of assessment and treatment planning (see Hawes & Dadds, 2013). We would argue that
the integration of these aspects of clinical practice should be regarded as a key priority for such
therapists, and for the systems through which these therapists receive professional training and
support.
25
EVIDENCE-BASED PARENTING INTERVENTIONS
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