Meta-analysis: Which Components of Parent Training Work for Children With Attention-Deficit/Hyperactivity Disorder?

Abstract

Objective:
Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components are most effective. This meta-regression analysis investigated which specific behavioral techniques that parents learn in parent training are associated with effects on parental outcomes.

Method:
We searched for randomized controlled trials on parent training for children with ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-child relation quality, and/or parental mental health as outcome measures. After screening 23,026 publications, 29 studies contributing 138 effect sizes were included (N=2345). For each study, the dosage of 39 behavioral techniques was derived from intervention manuals, and meta-regression determined which techniques were related to outcomes.

Results:
Parent training had robust small-to-medium-sized positive effects on all parental outcomes relative to control conditions, both for unblinded and probably blinded measures. A higher dosage of techniques focusing on the manipulation of antecedents of behavior was associated with better outcomes on parenting sense of competence and parental mental health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was related to larger decreases in negative parenting. Higher dosages of psycho-education were negatively related to parental outcomes.

Conclusion:
Although techniques were not investigated in isolation, our results suggested that the manipulation of antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.

Full text

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Meta-analysis: Which Components of Parent Training Work for Children With
Attention-Deficit/Hyperactivity Disorder?
Tycho J. Dekkers, PhD, Rianne Hornstra, MSc, Saskia van der Oord, PhD, Marjolein
Luman, PhD, Pieter J. Hoekstra, MD, PhD, Annabeth P. Groenman, PhD, Barbara J.
van den Hoofdakker, PhD
PII: S0890-8567(21)00420-2
DOI: https://doi.org/10.1016/j.jaac.2021.06.015
Reference: JAAC 3469
To appear in: Journal of the American Academy of Child & Adolescent
Psychiatry
Received Date: 26 October 2020
Revised Date: 2 June 2021
Accepted Date: 2 June 2021
Please cite this article as: Dekkers TJ, Hornstra R, van der Oord S, Luman M, Hoekstra PJ, Groenman
AP, van den Hoofdakker BJ, Meta-analysis: Which Components of Parent Training Work for Children
With Attention-Deficit/Hyperactivity Disorder?, Journal of the American Academy of Child & Adolescent
Psychiatry (2021), doi: https://doi.org/10.1016/j.jaac.2021.06.015.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
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© 2021 Published by Elsevier Inc. on behalf of the American Academy of Child and Adolescent
Psychiatry.

Meta-analysis: Which Components of Parent Training Work for Children With Attention-
Deficit/Hyperactivity Disorder?
RH = Working Elements in ADHD Parent Training
Tycho J. Dekkers, PhD, Rianne Hornstra, MSc, Saskia van der Oord, PhD, Marjolein Luman,
PhD, Pieter J. Hoekstra, MD, PhD, Annabeth P. Groenman, PhD, Barbara J. van den
Hoofdakker, PhD
Drs. Groenman, and van den Hoofdakker shared senior authorship of this work.
Supplemental Material
Accepted June 25, 2021
Drs. Dekkers, Hornstra, Hoekstra, Groenman, and van den Hoofdakker are with the
University of Groningen, the Netherlands. Drs. Dekkers, Groenman, and van der Oord are
with the University of Amsterdam, the Netherlands. Drs. Dekkers and Luman are with
Levvel, Academic Center for Child- and Adolescent Psychiatry and Specialized Youthcare,
Amsterdam, the Netherlands. Dr. Dekkers is also with Amsterdam University Medical
Center, the Netherlands. Dr. van der Oord is also with KU Leuven, Research Group Clinical
Psychology, Belgium. Dr. Luman is also with Vrije Universiteit Amsterdam, the Netherlands.
This research was funded by the Dutch Organization for Health Research and Development
(ZonMw) under grant number 729300013 to Barbara J. van den Hoofdakker. The funder had
no role in the design of this protocol, the collection of data, the data analysis, or the
interpretation or publication of the study results.
This article is part of a special series devoted to the subject of child and adolescent attention-
deficit/hyperactivity disorder (ADHD). The series covers a range of topics in the area
including genetics, neuroimaging, treatment, and others. The series was edited by Guest
Editor Jonathan Posner, MD along with Deputy Editor Samuele Cortese, MD, PhD.
This work has been prospectively registered:
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018096768
Author Contributions
Conceptualization: van der Oord, Groenman, van den Hoofdakker
Formal analysis: Groenman
Funding acquisition: van der Oord, Luman, Hoekstra, van den Hoofdakker
Methodology: Groenman
Project administration: Dekkers, Hornstra, Groenman
Supervision: van der Oord, Groenman, van den Hoofdakker
Writing – original draft: Dekkers
Writing – review and editing: Dekkers, van der Oord, Luman, Hoekstra, Groenman, van den
Hoofdakker
ORCID
Tycho J. Dekkers, PhD: https://orcid.org/0000-0001-8572-5606
Rianne Hornstra, MSc: https://orcid.org/0000-0001-8797-8973
Saskia van der Oord, PhD: https://orcid.org/0000-0003-2771-0187
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Marjolein Luman, PhD: https://orcid.org/0000-0002-1539-2831
Pieter J. Hoekstra, MD, PhD: https://orcid.org/0000-0003-1018-9954
Annabeth P. Groenman, PhD: https://orcid.org/0000-0002-8394-6605
Barbara J. van den Hoofdakker, PhD: https://orcid.org/0000-0001-9570-9976
The authors would like to thank Lieke Bruinsma, MSc and Simone Breider, PhD student, of
the University of Groningen, for assistance in scoring the manuals, and gratefully
acknowledge all authors who provided their data. The authors thank Nico Flierman, PhD
student, of the University of Amsterdam, for assistance with the figures.
Disclosure: Dr. van der Oord has co-developed a planning-focused and solution-
focused treatment, and other behavioral treatments, but has no financial interest in any of
these. She has received research grants from ZonMw (The Netherlands Organization for
Health Research and Development) and the FWO (The Flemish Organization for Scientific
Research); she was an advisor of the Dutch ADHD guideline groups and is a member of a
working group on ADHD of the health counsel of Belgium. Dr. Luman has co-developed a
self-help teacher training, without financial interests. She has received research grants from
ZonMw and was an advisor of the Dutch ADHD guideline groups. Dr. van den Hoofdakker
has received royalties as one of the editors of “Sociaal Onhandig” (published by Van
Gorcum), a Dutch book for parents that can be used in parent training. She has been involved
in the development and evaluation of several parent and teacher training programs, without
financial interests; she has been a member of Dutch ADHD guideline and practice standard
groups. Drs. Dekkers, Hoekstra, Groenman and Ms. Hornstra have reported no biomedical
financial interests or potential conflicts of interest.
Correspondence to Tycho J. Dekkers, PhD, University Medical Center Groningen,
Department of Child and Adolescent Psychiatry, Lübeckweg 2, 9723 HE, Groningen, the
Netherlands; e-mail: t.dekkers@accare.nl
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Abstract
Objective: Behavioral parent training is an evidence-based intervention for children with
attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components
are most effective. This meta-regression analysis investigated which specific behavioral
techniques that parents learn in parent training are associated with effects on parental
outcomes.
Method: We searched for randomized controlled trials on parent training for children with
ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-
child relation quality, and/or parental mental health as outcome measures. After screening
23,026 publications, 29 studies contributing 138 effect sizes were included (N=2345). For
each study, the dosage of 39 behavioral techniques was derived from intervention manuals,
and meta-regression determined which techniques were related to outcomes.
Results: Parent training had robust small-to-medium-sized positive effects on all parental
outcomes relative to control conditions, both for unblinded and probably blinded measures. A
higher dosage of techniques focusing on the manipulation of antecedents of behavior was
associated with better outcomes on parenting sense of competence and parental mental
health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was
related to larger decreases in negative parenting. Higher dosages of psycho-education were
negatively related to parental outcomes.
Conclusion: Although techniques were not investigated in isolation, our results suggested
that the manipulation of antecedents of behavior and reinforcement techniques are key
components of parent training for children with ADHD in relation to parental outcomes.
These exploratory findings may help to strengthen and tailor parent training interventions for
children with ADHD.
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Key words: attention-deficit/hyperactivity disorder (ADHD), Behavioral Parent Training,
parenting, meta-analysis, children
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Introduction
Behavioral parent training is recommended as evidence-based intervention for children
with attention-deficit/hyperactivity disorder (ADHD) in clinical practice guidelines (e.g.,1,2).
The presumed working mechanism of behavioral parent training is to alter the child’s
behavior via parenting behaviors3. Several meta-analyses demonstrated effects of parent
training on several parental outcomes (see 4 for a review of these meta-analyses), with largest
and most robust effects on positive and negative parenting, smaller improvements in
parenting sense of competence, but no effects on parental mental health5. Behavioral parent
training consists of many different behavioral techniques that are being taught to parents, and
it is yet unknown which of these techniques are most effective. In the current study, we
investigated which behavioral techniques contribute to the effects of parent training on
parental outcomes.
Several studies show that improvements in parenting behaviors mediate improvements in
the behavior of children with ADHD. There is consistent evidence that parent training for
children with ADHD is less likely to improve the child’s behavior when negative parenting
practices such as harsh and inconsistent discipline do not decrease6–8. Furthermore, increased
parenting sense of competence and decreased parenting stress after parent training has
repeatedly been found to be associated with behavioral improvements of children with
ADHD9,10.
Although the effectiveness of parent training on parenting outcomes is recognized by all
major clinical practice guidelines on ADHD1,2,11, there is surprisingly little research about
which specific behavioral techniques that are being used in parent training contribute (most)
to changes in parenting behaviors. Some examples of behavioral techniques are restructuring
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situations, offering rewards, and time-out procedures12,13. Most behavioral parent training
programs are rooted in social learning theories14, and the overarching aim of these programs
is teaching parents to prevent and manage their child’s behavior15. The content of existing
behavioral parent training programs, however, differs substantially: some mainly consist of
psycho-education (e.g., Sunshine Program for ADHD16,17), whereas others emphasize
disciplinary communication (e.g., Helping the Noncompliant Child18), observation and
monitoring (e.g., Family-School Success-Early Elementary19), or positive reinforcement (e.g.,
Incredible Years20).
Knowing which specific behavioral techniques are effective components of parent
training is crucial as it could guide the development, improvement, and tailoring of
interventions, and thereby benefits the well-being of children with ADHD and their
families21. The current study is the first meta-analysis that disentangled the effects of these
specific behavioral techniques of parent training for ADHD on parenting outcomes.
Two earlier endeavors examining the effectiveness of specific behavioral techniques of
parent training are worth mentioning. First, for children with disruptive behavior disorders,
the use of positive reinforcement (particularly praise) and natural/logical consequences was
associated with stronger effects on disruptive child behavior22. Second, a meta-analysis
including a broad range of parenting programs23 suggested that techniques focusing on
positive parent–child interactions and emotional communication skills, time-out, parenting
consistency, and practicing skills during the sessions were associated with larger
effectiveness, as measured by child and parenting outcomes. Despite the valuable
contribution of these studies, their conclusions were limited for several reasons: (1) in Leijten
et al.22, only child outcomes were assessed, whereas the presumed working mechanism of
parent training is to change parenting behaviors; (2) both studies only scored the presence or
absence of specific behavioral techniques, which ignores crucial and more nuanced
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information about the dosage of these techniques; (3) both studies only used information
about the components of parent training that was provided in papers and supplements, which
may be less detailed relative to information derived from treatment manuals; (4) both studies
did not focus specifically on children with ADHD, and therefore the implications of these
studies for children with ADHD are yet unclear, particularly as children with ADHD are
suggested to have specific underlying instrumental learning deficits which potentially should
be targeted with specific behavioral techniques12. Unique problems in intra-individual
variability in responding (i.e., increased number of lapses of attention24) as well as aberrant
motivational processes are documented for children with ADHD relative to children with
disruptive behavior disorders25–27. Specifically, alterations in reward and punishment
sensitivity may provide targets for behavioral parent training in this population (see 12 for a
review on specific instrumental learning deficits in ADHD and the link with behavioral
parent training).
The current meta-analysis took these limitations into account, by including only
randomized controlled trials with samples in which all children were diagnosed with ADHD,
and by scoring the dosage of behavioral techniques (i.e., the number and percentage of
sessions in which a specific technique is being taught to parents). More specifically, we
scored the behavioral techniques of all behavioral parent training manuals that were used in
the included trials using a taxonomy consisting of 39 different behavioral techniques,
grouped in 8 main categories (see Supplement 1, available online, for details).
In addition to the effects of the dosage of different techniques, we exploratively
investigated whether other characteristics of the intervention (setting, delivery method,
format, duration, collaboration with school, allowance of concurrent medication, and
checking treatment integrity) or characteristics of the child (age, sex, comorbid disorders)
were associated with the effectiveness of the intervention. So far, evidence for the possible
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moderating effect of these characteristics is mixed. One meta-analysis showed that individual
parent training was more effective than group training on parenting outcomes28, whereas a
meta-analysis on parent training in preschoolers with ADHD did not observe this effect29.
Another meta-analysis on parent training in preschoolers with ADHD reported no moderation
of age (within preschoolers) and duration of the intervention30, but a meta-analytic review on
behavioral interventions for children with a wider age range demonstrated larger effects on
positive parenting for younger children5. Meta-analytic evidence for other moderator effects
is scarce, but highly needed to establish who benefits most from behavioral parent training31.
The primary aim of the current study was to investigate whether the behavioral
techniques that were included in our taxonomy were associated with the effects of behavioral
parent training for parents of children with ADHD on five different parental domains, i.e.,
positive parenting, negative parenting, parenting sense of competence, quality of the parent-
child relationship, and parental mental health. A secondary aim was to investigate whether
intervention and child characteristics influenced the training effects.
Method
Protocol and registration
This meta-analysis was preregistered at PROSPERO
(https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018096768), and
PRISMA guidelines32 were followed (see Supplement 2, available online, for the PRISMA
checklist). Note that the preregistration also covers child outcomes, which is described in a
separate article by the same research group (Hornstra et al., under review). Also, for this
reason, some of the wording in the method sections of these articles may overlap.
In- and exclusion criteria
Randomized controlled trials were included when (i) behavioral parent training or a
multimodal intervention (the latter only if >50% of intervention time was spent with the
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parent) was compared to a control condition; (ii) the control condition consisted of (a) an
active control treatment, (b) treatment as usual, or (c) no treatment/waitlist, and in case of
multiple control conditions, the one with the highest quality was selected (a>b>c); (iii)
participants were (on average) below 18 years old; (iv) participants met criteria for ADHD,
either established by meeting DSM (any edition) criteria for ADHD measured by diagnostic
interviews, or scoring above clinical cut-offs on questionnaires measuring ADHD. Studies
were excluded if medication was used as control condition, or if medication was prescribed
as part of the intervention. Behavioral parent training was defined as an intervention that
teaches parents techniques to manipulate the antecedents of their child’s behavior (i.e.,
stimulus control techniques) and/or techniques to manipulate behavioral contingencies (i.e.,
contingency management techniques), making children more likely to increase desired
behaviors and to decrease unwanted behaviors15.
Outcome variables
Five domains of outcome variables were selected: positive parenting, negative parenting,
parenting sense of competence, parent-child relation, and parental mental health. Positive
parenting includes parenting behavior such as reinforcement, monitoring, stimulating, and
guiding the child. Negative parenting refers to behavior such as corporal punishment, harsh
discipline, inconsistent parenting, and poor monitoring. Parenting sense of competence is
defined as the extent to which parents perceive themselves as competent or efficacious when
raising their child. Outcomes were classified as measuring the quality of the parent-child
relation when measuring display of affect, support, sensitivity, and/or responsiveness. For
parental mental health, measures included parenting stress and several indices of parental
psychopathology (e.g., depression, anxiety, ADHD). Note that we performed a sensitivity
analysis without parental ADHD symptoms as measure of parental mental health, as
improvements in parental ADHD symptoms after parent training may be smaller than in other
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domains of parental mental health. The categorization of all instruments can be found in
Table 1. When one measure tapped multiple outcome domains, we assigned this measure to
the outcome domain which was reflected by most items of the measure. Measures were coded
as either unblinded (parent-rated) or probably blinded (rated by independent coders).
Literature search
Literature was searched up to May 13th, 2020 (see Figure 1 for the PRISMA flowchart,
Supplement 3, available online, for specific search terms per database). Selection and
screening of the articles was performed by two authors (out of three: TJD, APG, RH) using
Rayyan software33. Disagreement was solved by debate or by consulting the other authors
(SvdO, BJvdH).
INSERT FIGURE 1 HERE
Data extraction
Included studies were independently rated by two out of three authors (TJD, APG, RH),
disagreement was solved by debate or by consulting the other authors. Our taxonomy, which
was based on several influential reviews23,34–36, included eight categories (shaping
knowledge; observation and monitoring; manipulating antecedents; positive consequences;
negative consequences; combined techniques; practicing, generalization and maintenance;
relationship building and communication skills). These categories cover a total of 39
behavioral techniques (for details on the taxonomy, see Supplement 1, available online; for
operational definitions of other extracted variables, see Supplement 4, available online). For
each technique, we established the dosage of these techniques by scoring the number and the
percentage of sessions in which this technique was used. If not publicly available, the
manuals of the interventions used in the included studies were requested from the authors.
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The manual was unavailable for three studies37–39, which were therefore excluded from the
analyses on the effects of the dosage of behavioral techniques. Note that for 37, the manual of
the traditional Behavioral Parent Training was unavailable. The same study also compares the
STEPP (Strategies to Enhance Positive Parenting) program with a waitlist control, and this
comparison is included in the analyses.
Risk of bias
We used GRADE (Grading of Recommendations Assessment, Development and
Evaluation40) to assess the quality of the included studies, which was performed
independently by two authors (APG and RH). GRADE uses six criteria to assess selection,
detection, attrition, and reporting bias: random sequence generation, allocation concealment,
blinding of outcome assessment, incomplete outcome data, vested interest, and selective
outcome reporting. All studies were scored individually on these criteria.
Data-analytic approach
Effect sizes of every outcome were calculated in terms of standardized mean differences
(Hedges’ g), based on pre-post intervention differences standardized by the post-intervention
standard deviation, using Comprehensive Meta-Analysis software41 and, if applicable,
recoded to ensure that positive effect sizes on that outcome indicate beneficial effects of the
intervention relative to the control condition (i.e., increases in positive parenting, parenting
sense of competence and parent-child relation quality, and decreases in negative parenting
and parental mental health problems). The metafor and dmetar packages in R were used
for further analyses42,43. Main effects of each outcome were calculated using multilevel meta-
analyses. After main effects were estimated, a random effects meta-regression analysis was
performed for each of the five outcome domains. Because several studies contributed
multiple effect sizes, the analysis concerned three levels (i.e., participants, effect sizes, and
studies; see 44 for background on multilevel meta-regression). This approach thereby
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accounted for dependency between effect sizes within studies (e.g., when two different
measures for positive parenting were used in one study, or when a study reported scores from
two informants on one measure). Five studies compared two intervention arms with one
control condition, we performed a sensitivity analysis to assess the potential influence of the
dependency between these arms (see Supplement 5, available online). For meta-regression
analyses we report
̂ coefficients, with
̂1 indicating the change in the standardized mean
difference when the moderating variable increases with one unit, and
̂0 indicating the
intercept, which is equal to the standardized mean difference for a specific value of the
reference category of the moderator45.
Potential differences between probably blinded and unblinded measures were investigated
in a categorical moderation analysis (probably blinded vs. unblinded), and differences based
on the type of control condition were assessed with a similar analysis (active vs. waitlist
control). Publication bias was assessed using Egger’s test for funnel plot asymmetry46, and
Trim-and-Fill analyses were performed to estimate the number of studies that are needed to
counter potential funnel plot asymmetry47. P-Curves were calculated to estimate evidential
value and potential flexibility in data-analysis48, and leave-one-out analyses were performed
to assess the potential influence of single studies. For all analyses, I2 statistics were used as
indication of heterogeneity, separated for between-variables and between-studies
heterogeneity (level 2 and 3, respectively). To estimate main effects and for continuous
moderation analyses at least 10 effect sizes were required, and subgroups required at least 4
effect sizes for categorical moderation analyses49.
For our primary aim, we assessed associations between behavioral techniques and
outcomes using meta-regression analyses. To limit the number of analyses, we first tested
whether the eight overall categories of behavioral techniques were associated with outcomes
in two ways: by assessing the influence of (1) the percentage of sessions in which at least one
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technique from a category occurs and (2) the number of sessions in which at least one of the
techniques from a specific category occurs. If the percentage of sessions in which at least one
technique from a category occurs was (borderline-)significantly (p<.10) related to an outcome
domain, we conducted follow-up analyses for all specific techniques within that category.
The same procedure was adopted when the number of sessions in which a certain category of
techniques was represented was associated with the outcome.
For our secondary aim, we assessed the influence of the following factors on treatment
effects on parenting outcomes: setting (home, clinic, school), delivery method (individual,
group, mixed), format (parent training only versus parent training as part of multimodal
treatment), the presence of home-school collaboration (yes/no), medication use at study entry
(allowed versus not allowed) and the presence of integrity checks (yes/no) as
intervention/study characteristics, and age (both continuously and categorical), sex
(percentage boys), and comorbid externalizing disorders as child characteristics.
For all analyses, we did not control for multiple testing, as the analyses were hypothesis-
generating, and not confirming.
Results
Study selection
In total, 29 studies with 35 interventions and 138 relevant effect sizes were included (see
Figure 1). Study characteristics can be found in Table 1. The mean and the range of the
dosage of all scored techniques are provided in Supplement 6, available online.
Risk of bias
Risk-of-bias analyses can be found in Supplement 7, available online (interrater
reliability κ = .96). Few studies included blinded measures, most studies reported complete
outcome data. Overall, the information in the published manuscripts of many studies was not
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sufficient to determine the risk of bias for the categories random sequence generation,
allocation concealment, vested interest, and selective outcome reporting.
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Main effects
Significant small-to-medium-sized main effects (ranging from .41 to .60, all p’s < .001) favoring parent training over control conditions
were found for all outcome categories (see Table 2 and Figure 2).
Effect sizes were not significantly different for probably blinded and unblinded measures on positive parenting (
̂1 = .05, p = .82), negative
parenting (
̂1 = -.15, p = .52) and parent-child relation (
̂1 = .02, p = .95) (see Table 2 for effect sizes). None or too few blinded measures were
available for parenting sense of competence and parental mental health.
Visual inspection of the forest plot (Figure 2) depicted one outlying study with particularly high effect sizes on the outcome domain of
parental mental health 50. As noted in Table 2, the effect size decreased and the heterogeneity between studies dropped considerably after
removing that study. For the forthcoming analyses on the parental mental health domain, we therefore decided to exclude that study from further
analyses (analyses including this study were also performed and are described in Supplement 8, available online). A sensitivity check excluding
one study measuring parental ADHD revealed highly similar results (see Supplement 9, available online).
A sensitivity check comparing studies with active control conditions and studies with waitlist control conditions demonstrated that—as
expected—effect sizes for most of the outcome domains were smaller when parent training was compared to an active control condition than
when it was compared to a waitlist. However, this difference in effect sizes was only significant for negative parenting (see Supplement 10,
available online, for detailed results).
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INSERT FIGURE 2 HERE
Robustness analyses
Egger’s test46 indicated signs of funnel plot asymmetry (which potentially indicates publication bias) on negative parenting (t = 2.57, p =
.02), parenting sense of competence (t = 2.17, p = .04), and parent-child relation (t = 2.46, p = .03), but not on positive parenting (t = 1.83, p =
.08) and parental mental health (t = .55, p = .59). Note that Egger’s test and trim-and-fill analyses were performed without modeling for
dependency between effect sizes, as this is currently not possible.
Trim-and-fill analyses52 demonstrated that, on the left side of the funnel plot, 9 studies were missing for negative parenting, 4 studies were
missing for parental mental health, 4 for parent-child relation, 3 for positive parenting, and 1 for parenting sense of competence (see Supplement
11, Figure S1, available online, for funnel plots with estimated missing effect sizes). After taking into account these missing studies, the effect
size slightly decreased (but remained significant) for positive parenting, negative parenting, parent-child relation, and parental mental health and
remained similar for parenting sense of competence (effect sizes ranged between .29 and .54, all p’s < .05; see Table 2).
P-curves48 were created for all outcome categories. In all cases, p-curves were right-skewed and indicated evidential value (all p-values for
the half p-curve < .05). See Supplement 11, Figures S2-S6, available online, for p-curves.
Sensitivity analyses (i.e., leave-one-out) indicated that effect sizes were not heavily dependent on single studies, as the minimum and
maximum effect size calculated by the leave-one-out analyses did not differ substantially for all outcome domains, and all were within the range
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of the confidence intervals of the main effects: for positive parenting (minimum SMD = .53, p < .001; maximum SMD = .64, p < .001), for
negative parenting (minimum SMD = .53, p < .001; maximum SMD = .63, p < .001), for parenting sense of competence (minimum SMD = .49,
p < .001; maximum SMD = .57, p < .001), for parent-child relation quality (minimum SMD = .45, p < .001; maximum SMD = .58, p < .001),
and for parental mental health (minimum SMD = .32, p < .001; maximum SMD = .37, p < .001).
Additional sensitivity analyses were performed to assess the influence of dependency in studies that compared two intervention arms with
one control condition. The influence was minimal (see Supplement 5, available online, for details).
In sum, although some analyses indicate the presence of publication bias (Egger’s test, trim-fill analyses), the main effects are robust given
the results of the trim-fill corrected analyses, p-curves and leave-one-out analyses.
Primary analyses: Does the dosage of behavioral techniques influence the effects of parent training?
All results regarding the association between the overall effect size and the dosage of technique categories or specific techniques (measured
by both the percentage and the number of sessions in which a technique from a certain category/a specific technique occurs) can be found in
Supplement 12, available online.
In Table 3, we summarized those categories/techniques that were significantly associated with outcomes. We found that (1) the dosage of
psycho-education was negatively associated with treatment effects on positive parenting and the quality of the parent-child relation; (2) the
dosage of teaching parents to manipulate antecedents, and in particular to anticipate misbehaviors, was positively associated with treatment
effects on parenting sense of competence and parental mental health; (3) the dosage of teaching parents to work with positive consequences was
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associated with larger treatment effects on negative parenting; (4) the dosage of practicing/generalization techniques was negatively associated
with the effect of treatment on the parent-child relation. Dosage was established by either the number or the percentage of sessions in which the
techniques occur (see Table 3 for specific results). Most of the analyses, however, were not significant (see Supplement 12, available online).
Secondary analyses: Moderation by intervention and participant characteristics
Intervention characteristics
Secondary analyses of intervention characteristics on all outcomes were all non-significant except for two findings. First, on negative
parenting, parent training only was associated with a larger effect than parent training as part of multimodal treatment. Second, interventions
without integrity checks (although only 2 studies containing 6 effect sizes) were more effective than interventions with integrity checks on
positive and negative parenting. See Table 3 for significant findings, see Supplement 13, Table S1-3, available online, for all results.
Child characteristics
Effects of parent training on negative parenting were higher when the child was younger, and effects on positive parenting were higher for
preschoolers than for school-age children (the latter were more pronounced when two studies on adolescents were excluded, see Supplement 14,
available online, for details on these sensitivity analyses). Sex of the child moderated the effect on negative parenting: the higher the percentage
of boys in the sample, the higher the effects. Finally, the percentage of comorbid externalizing disorders in the sample did not moderate any
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outcomes. All analyses containing moderation by participant characteristics can be found in Supplement 13, Table S3, significant findings are
also in Table 3.
Discussion
Behavioral parent training for children with ADHD consists of many different techniques that are being taught to parents. To enhance the
development of more effective future parent training interventions, the primary aim of the current study was to investigate which behavioral
techniques were associated with better or worse parental outcomes.
We found that higher dosages of behavioral techniques teaching parents to manipulate the antecedents of behavior (i.e., stimulus control
techniques), in particular by explicitly anticipating potential misbehavior of the child (e.g., thinking ahead, prepare a plan before entering a
problematic situation), were associated with positive effects on parenting sense of competence and parental mental health. Stimulus control
techniques may be particularly relevant for children with ADHD, with their noted disorganization and executive functioning deficits12,53–55.
These intervention components are (relative to for example techniques focusing on relationship building and teaching communication skills)
relatively straightforward for parents and focus on the prevention of non-adaptive behavior, which may provide a sense of control. This may give
parents immediate mastery of these skills. Also, it may well be that children respond quickly to these techniques and thereby reinforce parents,
altogether leading to an increased sense of competence and a decrease of stress.
Additionally, stimulus control techniques such as applying more structure and clear rules may also be beneficial for parents themselves, as a
significant proportion of the parents of children with ADHD has impairing ADHD symptoms56. This may well explain our finding that a higher
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dosage of stimulus control techniques was associated with improved parental mental health. This is an important finding, as parental ADHD
symptoms have been found to attenuate effects of behavioral parent training6,57.
Second, higher dosages of behavioral techniques teaching parents to provide children with positive consequences after showing desired
behavior, in particular offering social rewards and responding in a consistent way, were associated with decreased negative parenting. The
importance of the effects on negative parenting is emphasized by previous studies that consistently demonstrated that decreases in negative
parenting mediated behavioral improvements in children: Decreases in negative parenting practices predicted improvements in child outcomes in
the Multimodal Treatment of ADHD (MTA) study8, and a recent telephone-assisted self-help parent training study found that changes in
negative parenting mediated effects on children’s ADHD symptoms7. Also, in response to behavioral parent training, changes in negative
parenting mediated the link between maternal ADHD symptoms and the child’s behavioral problems after parent training6, and improved
discipline techniques by parents predicted decreased disruptive behavior by the child58. This suggests that changing negative parenting is pivotal
to ultimately improve the child’s behavior.
Third, higher dosages of psycho-education were associated with lower effects on positive parenting and the quality of the parent-child
relation. This seemingly surprising finding does not necessarily imply that psycho-education is ineffective, but suggests that other behavioral
techniques such as manipulating antecedents and providing positive consequences deserve a higher dosage, given the limited time that is often
available for behavioral parent training (usually between 8 and 12 sessions). On average, psycho-education occurred in 7 sessions, and in 69% of
the total number of sessions, which was substantial. A limitation of the current approach, however, is that the content of the psycho-education
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was not scored. This could be relevant, as deterministic, biologically-based psycho-education potentially increases the perceived burden of the
disorder by caregivers59. This could lead to more parental awareness of their child’s problems and potentially also results in discouragement
about the influence of parents on the problems of their children, ultimately resulting in lower effects of interventions. Future research should
disentangle which specific forms of psycho-education are, and are not, useful in parent training for ADHD.
Fourth, higher dosages of techniques aimed at practicing, generalization and maintenance of learned skills (e.g., problem-solving
techniques) were associated with lower effects on the quality of the parent-child relation, but there also was a trend towards a positive
association between these techniques and positive parenting. Implications of these mixed findings with regard to practicing, generalization and
maintenance techniques are not straightforward. Techniques from this category occurred in almost 90% of the sessions, with homework
assignments as specific technique that was most frequently included in interventions (78% of the sessions). Potentially, the generally high rates
of these techniques observed across studies may have obscured their effects. Earlier studies point towards the importance of these techniques, as
assigning homework, for example, was associated with higher efficacy of behavioral treatment for ADHD60.
Directly studying which techniques are related to the core mechanism of change of behavioral parent training—parenting—is the ultimate
way of advancing our psychological treatments61. The main findings of our study therefore provide directions to better tailor behavioral parent
training for children with ADHD, and to improve current interventions. This, however, does not imply that parent training in its current form is
not effective: in correspondence with previous meta-analyses and reviews4,5, we observed robust medium-sized effect sizes of parent training on
all five outcome domains related to parenting. Effect sizes were lower when parent training was compared with active control conditions relative
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to waitlists, but only the effect size for negative parenting dropped to non-significant when only including studies with active control conditions.
A reassuring finding was that effect sizes on positive parenting, negative parenting, and the parent-child relation did not differ between probably
blinded and unblinded measures, indicating that effects are not merely attributable to parents’ investment affecting their assessment of outcome
measures. This corresponds with an earlier meta-analysis of behavioral interventions for ADHD, which reported medium-sized effects on both
positive and negative parenting, as measured by probably blinded assessments5. These robust effects of behavioral parent training on parenting
outcomes are imperative, as improvements in parenting are a prerequisite to ultimately lead to improvements in child functioning, as these are
the core mediators of change6,8,9.
The secondary aim of this study was to investigate whether several child and intervention characteristics were associated with parenting
outcomes. The most relevant finding was that effects of parent training on both positive and negative parenting were higher when children were
younger, which is consistent with a previous meta-analysis on psychosocial interventions for ADHD 5. Potentially, at an early age, not only the
child’s but also parenting behavior is less engrained and more prone to change relative to later ages. Together with observations that early onset
of ADHD is associated with more severe long-term outcomes29, these findings emphasize the need for early psychosocial interventions for
children with ADHD62. Other secondary findings were more surprising. First, studies without integrity checks had higher effect sizes on positive
and negative parenting than studies with integrity checks. The large majority of studies included integrity checks, and our findings on this
variable were likely driven by two old studies38,39 that did not report such checks and obtained medium-to-large effects on positive and negative
parenting. Second, studies investigating parent training only had higher effect sizes on the reduction of negative parenting relative to studies on
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multimodal treatment. A likely explanation is that multimodal interventions focused less specifically on parenting (e.g., many of the multimodal
interventions included in our study also involved school consultations), which could limit the impact of such interventions on parenting skills.
Third, a higher proportion of boys was associated with stronger effects on negative parenting. A very tentative explanation for this finding could
be that there is some evidence of higher (baseline) levels of negative parenting for boys relative to girls63,64, which potentially leaves more room
for improvement of negative parenting in parents of boys.
Although the current investigation has several strong aspects, including thorough investigation of the dosage of 39 behavioral techniques by
scoring all original treatment manuals, inclusion of a large number of studies, and the use of state-of-the-art multilevel meta-regression analyses,
a few limitations warrant mentioning. First, by using the current method we could not examine the effects of separate techniques, as these were
not investigated in isolation. Therefore, potential effects of combinations of techniques, or sequencing of techniques, could not be ruled out and
could have confounded the results. Correlations between dosages of different techniques (see Supplement 6, Table S2, available online, for the
correlation matrix) further underline this issue: especially the dosage of positive consequences was associated with the dosage of several other
techniques. Multicollinearity was not a problem as none of the correlations between technique categories was above .8.
Second, the current investigation should be primarily regarded as hypothesis-generating instead of confirming. For hypothesis-generating
studies, correcting for multiple testing is not advised65,66. This implies that results should be interpreted with caution, and should be confirmed,
or falsified, by future empirical studies.
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A third limitation is that only effects at the end of the intervention were taken into account. Potentially, some behavioral techniques are
more effective on the longer term. For example, there were no direct post-treatment effects in a study particularly focusing on psycho-education,
but substantial effects of psycho-education were observed after six months16. Similar mechanisms may apply for generalization techniques, as
transfer of skills from therapy to daily life logically takes time.
Fourth, although our technique categories showed substantial variation, some of the separate techniques only occurred in a small number of
studies (Supplement 6, Table S1, available online). This may have limited the power of our analyses on these techniques.
Fifth, we did not compute inter-rater reliability statistics about the coding of the intervention manuals. However, we do not believe this
limitation affects our findings, as all manuals were independently scored by two raters, and senior authors were consulted in rare cases of
disagreement.
Sixth, we scored the dosage of techniques in terms of number and percentage of sessions, but not the total amount of time spent on specific
techniques within sessions. The latter may yield more definitive information for intervention optimization (e.g., how to best balance the time
spent during sessions between homework review vs teaching a new skill).
Future studies are needed to test the hypothesis based on our current results that focusing on teaching parents to manipulate antecedents of
behavior and to provide positive consequences for desired behavior is particularly effective to change child behavior in ADHD samples. Two
recent micro-trials (one for parents and one for teachers) provided evidence in this direction: when provided in isolation, both stimulus control
and contingency management techniques were found effective on improving the child’s behavior67,68. Future studies should further test whether
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the current findings also apply for child outcomes, as the ultimate goal of parent training is to change the child’s behavior via parental behavior.
These studies could also investigate associations between changes in parental outcomes and child outcomes.
The current study has several implications for clinical practice. First, the robust small-to-medium-sized main effects of parent training on all
domains of parenting and parental well-being add to the evidence-base regarding parent training as an effective intervention for children with
ADHD4,5,15. Second, this evidence, combined with our finding that parent training was particularly effective in ameliorating parenting for
preschool-age children with ADHD, suggests that parent training should be delivered early in the potential chain of mental healthcare for
children with ADHD (also see69,70). Third, although techniques were not investigated in isolation, our results suggest that the manipulation of
antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental
outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.
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Table 1. Study Characteristics
Study
Intervention
(N)
Control
(N)
Positive
Parenting
Negative
Parenting
Parenting
Sense of
Competence
Parent-Child
Relation
Parental
Mental Health
Setting/
Format/
Delivery
Duration
in
minutes
Age
(cat.)
%
Boys
%
Ext.
dis.
Home-
school
coll.
Med.
All.
Integr.
checks
Abikoff et al.
2015 18
HNC (63)
WL
(34)
PPI-Total
(N)
N/A
N/A
GIPCI-R-Total
(Y), PSI-R &
PPES Sum (N)
N/A
C/PT/I
480
3.6
(P)
74
42
N
N
Y
NFPP (67)
PPI-Total
(N)
N/A
N/A
GIPCI-R-Total
(Y), PSI-R &
PPES Sum (N)
N/A
H/PT/I
600
3.6
(P)
74
42
N
N
Y
Aghebati et
al. 2014 50
Triple P (14)
WL
(13)
N/A
PS (N)
N/A
PBI-Care,
Overprot. (N)
DASS-42-Anx.,
Depr., Stress
(N)
C/PT/G
667,5
8.0
(S)
59
N/A
N
Y
N/A
Au et al.
2014 71
Triple P (8)
WL (9)
N/A
N/A
PSOC Eff., Sat.
(N)
N/A
SNQ-Stress (N)
M/PT/M
975
7.7
(S)
94
N/A
N
N
Y
Chacko et al.
2009 37
BPT (40)
WL
(40)
DPICS-PP
(Y)
DPICS-NP
(Y)
N/A
IRS-Par. (N)
BDI (N), PSI
(N)
C/MM/G
1350
7.9
(S)
71
71
N
Y
Y
STEPP (40)
DPICS-PP
(Y)
DPICS-NP
(Y)
N/A
IRS-Par. (N)
BDI (N), PSI
(N)
C/MM/G
1350
7.9
(S)
71
70
Y
Y
Y
Daley et al.
2013 72
NFPP SH
(24)
WL
(19)
GIPCI-
Parent (Y)
N/A
PSOC Eff., Sat.
(N)
N/A
GHQ (N)
H/PT/I
330
7.3
(S)
81
NA
Y
N
Y
DuPaul et al.
2018 73
F2F BPT
(16)
WL
(16)
N/A
N/A
PSI-SF-Dysf.
Int. (N)
N/A
PSI-SF-Distress
(N)
C/PT/G
900
4.4
(P)
64
60
Y
N/A
Y
Online BPT
(15)
N/A
N/A
PSI-SF-Dysf.
Int. (N)
N/A
PSI-SF-Distress
(N)
H/PT/I
900
4.4
(P)
64
60
Y
N/A
Y
Fabiano et al.
2012 74
Coaches (28)
WL
(27)
DPICS-Total
Praise (N)
DPICS-Total
Com., Neg.
Talk (N)
N/A
N/A
N/A
C/PT/G
960
8.5
(S)
87
69
N
Y
Y
Ferrin et al.
2014 17
Ps.-Ed. (43)
AC (37)
N/A
N/A
N/A
N/A
PSI-SF (N)
C/PT/G
1080
10.7
(S)
80
30
Y
Y
Y
Ferrin et al.
2016 16
Ps.-Ed. (35)
TAU
(34)
N/A
N/A
N/A
N/A
PSI Total (N)
C/PT/G
720
10.7
(S)
87
97
Y
Y
Y
Franke et al.
2016 75
TPOL (27)
WL
(26)
N/A
PS-Laxness,
Overreact.,
Verb. (N)
PSOC Eff., Sat.
(N)
PSDQ-Auth.
(N)
DASS-21-Anx.,
Depr., Stress
(N)
H/PT/I
480
4.0
(P)
72
N/A
N
N/A
Y
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Herbert et al.
2013 76
BPT (17)
WL
(14)
CCNES-
Supp. (N),
Audiotape-
Comm.
Qual. (Y)
CCNES-
Unsupp. (N),
PS-Laxness,
Overreact.,
Verb. (N)
N/A
Audiotape-
Neg. Aff., Pos.
Par. (Y)
Audiotape-
Distress (Y)
C/PT/G
1260
4.6
(P)
74
N/A
N
Y
Y
Hoath et al.
2002 77
EGTP (9)
WL
(11)
N/A
PS-Laxness,
Overreact.,
Verb. (N)
PSBC (N)
N/A
DASS-Anx.,
Depr., Stress
(N)
S/PT/G
574
7.7
(S)
80
NA
N
Y
Y
Jiang et al.
2018 78
CLAS (74)
TAU
(51)
APQ/PCRQ-
Pos. (N)
APQ/PCRQ-
Neg. (N)
PSOC, PCEQ
(N)
N/A
N/A
M/MM/M
1260
8.6
(S)
54
5
Y
Y
Y
PFT (74)
APQ/PCRQ-
Pos. (N)
APQ/PCRQ-
Neg. (N)
PSOC, PCEQ
(N)
N/A
N/A
C/PT/M
1080
8.6
(S)
62
6
N
Y
Y
Lange et al.
2018 79
NFPP (86)
TAU
(75)
GIPCI (Y)
N/A
PSOC Eff., Sat.
(N)
N/A
N/A
M/PT/I
600
5.1
(P)
73
8
N
N
Y
Matos et al.
2009 80
PCIT (20)
WL
(12)
PPI (N)
N/A
N/A
N/A
BDI-S (N)
C/PT/I
1305
5.0
(P)
NA
98
N
N
Y
Mautone et
al. 2012 19
FSS-EE (24)
CARE
(29)
FIQ (N),
DPICS-CU-
DO (Y),
DPICS-CP-
DO (Y)
PCRS (N),
DPICS-CU-
DON’T (Y),
DPICS-CP-
DON’T (Y)
PES (N)
N/A
N/A
C/MM/M
980
NA
(P)
72
30
Y
Y
Y
Mikami et al.
2010 81
PFC (28)
No tr.
(29)
Observation-
Praise (Y)
Observation-
Crit. (Y)
N/A
Observation-
Warmth (Y)
N/A
C/PT/G
720
8.3
(S)
68
32
Y
Y
Y
Pisterman et
al. 1989 38
BPT (23)
WL
(23)
% Alpha
comm. (Y),
% Pos. (Y),
Freq. Alpha
(Y)
% Dir. (Y),
% Neg. (Y),
Freq. Beta
(Y)
N/A
N/A
N/A
C/PT/M
720
4.2
(P)
80
NA
N
Y
N
Pisterman et
al. 1992a 39
BPT (23)
WL
(22)
% Alpha
comm. (Y),
% Pos. (Y),
% Reinf. (Y)
% Dir. (Y),
% Neg. (Y),
Freq. Dir.
(Y), Freq.
Neg. Fb. (Y)
N/A
N/A
N/A
C/PT/G
720
4.1
(P)
84
NA
N
Y
N
Pisterman et
al. 1992b 82
BPT (46)
WL
(45)
N/A
N/A
PSCS-S, PSCS-
V (N)
N/A
PSI-PD (N_
C/PT/M
720
4.2
(P)
82
NA
N
Y
N
Power et al.
2012 83
FSS (92)
CARE
(96)
N/A
PCRQ-N/ID
(N)
PES (N)
PCRQ-PI (N)
N/A
M/MM/M
980
NA
(S)
68
27
Y
Y
Y
Shimabukuro
et al. 2020 84
WPJ (28)
WL
(24)
N/A
PS-Laxness,
Overreact.,
(N)
PSOC Eff., Sat.
(N), PLOC-
Resp., Control
(N)
Pasta Task-
Pos., Neg. (Y)
PSI (N), BDI
(N)
C/PT/G
1560
8.4
(S)
83
NA
N
Y
N
Sibley et al.
2013 85
STAND (18)
TAU
(18)
N/A
N/A
N/A
CBQ (N)
CSQ (N)
C/MM/M
740
12.4
(S)
72
78
Y
Y
Y
Sibley et al.
2016 86
STAND (67)
TAU
(61)
PAMS-
Contr.,
Privil. (N)
N/A
N/A
CBQ (N)
CSQ (N)
C/MM/I
740
12.7
(S)
65
58
Y
Y
Y
Sonuga-B. et
al. 2001 87
BPT (30)
PC&S
(28)
N/A
N/A
PSOC Eff., Sat.
(N),
N/A
GHQ (N)
H/PT/I
480
3.5
(P)
62
NA
N
N
Y
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Sonuga-B. et
al. 2004 88
BPT (59)
WL
(30)
N/A
N/A
PSOC Eff., Sat.
(N),
N/A
GHQ (N)
H/PT/I
480
3.5
(P)
NA
NA
N
N
Y
Sonuga-B. et
al. 2018 20
IY (131)
TAU
(42)
GIPCI (Y)
N/A
N/A
N/A
GHQ (N)
C/PT/G
1620
3.5
(P)
71
73
N
N
Y
NFPP (133)
GIPCI (Y)
N/A
N/A
N/A
GHQ (N)
H/PT/I
1080
3.6
(P)
75
74
N
N
Y
Thompson et
al. 2009 89
NFPP (17)
TAU
(13)
GIPCI (Y)
N/A
N/A
PFMSS-Neg.,
Pos., Gl. (Y)
GHQ (N),
AARS (N)
H/PT/I
600
4.5
(P)
76
NA
N
N
Y
van den
Hoofdakker
et al. 2007 90
BPT (47)
RCC
(47)
N/A
N/A
N/A
N/A
PSI-PD (N)
C/PT/I
1440
7.4
(S)
76
76
N
Y
Y
Note: Intervention: BPT = Behavioral Parent Training, CLAS = Child Life and Attention Skills, EGTP = Enhanced Group Triple P, F2F BPT = Face-to-face Behavioral Parent Training, FSS-EE = Family School
Success Early Elementary, HNC = Helping the Noncompliant Child, IY = Incredible Years, NFPP = New Forest Parenting Program, NFPP-SH = New Forest Parenting Program Self Help, PCIT = Parent-Child
Interaction Therapy, PFC = Parental Friendship Coaching, PFT = Parent Focused Treatment, Ps.-Ed. = Psycho-Education, STAND = Supporting Teens’ Academic Needs Daily, TPOL = Triple P Online, WPJ = Well
Parent Japan,. Control: AC = Active Control, , CARE = Coping With ADHD Through Relationships and Education, No tr. = No treatment, PC&S = Parent Counselling and Support, RCC = Routine Clinical Care, TAU
= Treatment as Usual, WL = Waitlist. Outcomes (Positive Parenting, Negative Parenting, Parenting Sense of Competence, Parent-Child Relation, Parental Mental Health; in parentheses: probably blinded or not [Y/N]):
AARS = Adult ADHD Rating Scale, APQ = Alabama Parenting Questionnaire, BDI = Beck Depression Inventory, CBQ = Conflict Behavior Questionnaire, CCNES = Coping with Children’s Negative Emotion Scale,
Comm. = Commands, Comm. Qual. = Command Quality, Contr. = Contracting, CP = child-led play, CSQ = Caregiver Strain Questionnaire, CU = clean-up, DASS = Depression Anxiety Stress Scale, Dir. = Directive,
DPICS = Dyadic Parent–Child Interaction Coding System, Dysf. Int. = Dysfunctional Interactions, FIQ = Family Involvement Questionnaire, Freq. Neg. Fb. = Frequency of Negative Feedback, GHQ = General Health
Questionnaire, GIPCI-R = Global Impressions of Parent-Child Interactions-Revised, Gl. = Global, IRS = Impairment Rating Scale, Neg. Aff. = Negative Affect, N/ID = Negative/Ineffective Discipline, NP = Negative
Parenting, Overreact. = Overreactivity, PAMS = Parent Academic Management Scale, PBI = Parental Bounding Instrument, PCEQ = Parent Cognitive Error Questionnaire, PCRQ = Parent-Child Relationship
Questionnaire, PES = Parent as Educator Scale, PFMSS = Pre-school Five Minute Speech Sample, PI = Positive Involvement, PLOC = Parental Locus of Control Scale, PP = Positive Parenting, PPES = Parent
Perceptions of Parents Efficacy scale, PPI = Parenting Practice Interview, Priv. = Privileges, PSDQ-Auth. = Parenting Styles and Dimensions Questionnaire – Authoritative Parenting, PS = Parenting Scale, PSCS-S =
Parenting Sense of Competence Scale - Skills, PSCS-V = Parenting Sense of Competence Scale - Valuing, PSI-PD = Parenting Stress Index – Parent Domain, PSI-R = Parenting Stress Index-Revised, PSI-SF = Parent
Stress Index-Short Form, PSOC = Parenting Sense of Competence scale [Eff. = Efficacy (subscale), Resp. = Responsibility, Sat. = Satisfaction (subscale)], SNQ = Service Needs Questionnaire, Supp. = Supportive,
Unsupp. = Unsupportive, Verb. = Verbosity,. Setting: C = Clinic, H = Home, M = Mixed, S = School,. Format: MM = Multimodal, PT = Parent Training,. Delivery: G = Group, I = Individual, M = Mixed. Duration:
total duration of the intervention in minutes. Age: mean age of the children in the intervention condition in years. Age category: P = Preschool, S = School-age. % boys: Percentage of boys in the intervention condition.
% ext. dis.: percentage of children with comorbid externalizing disorder in the intervention condition. Home-school coll.: Collaboration between home and school was actively encouraged in the intervention (Y= Yes,
N = No). Med. all.: whether medication was allowed next to the intervention (Yes/No). Integr. checks: whether integrity checks were performed in the study (Yes/No). N/A = Not Available.
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Table 2. Main Effects per Outcome Domain
k (n_es)
SMD
95% CI
I2 (level 2, %)
I2 (level 3, %)
Positive parenting
19 (27)
.60***
.39;.81
72.9
5.3
probably blinded
12 (17)
.58***
.30;.86
71.3
7.8
unblinded
9 (10)
.63**
.28;.98
71.3
7.8
after trim-fill correction
22 (30)
.49***
.24;.73
81.2
Negative parenting
15 (31)
.59***
.36;.82
56.3
18.1
probably blinded
6 (12)
.68***
.32;1.04
59.2
15.6
unblinded
10 (19)
.54***
.25;.83
59.2
15.6
after trim-fill correction
24 (40)
.35**
.12;.59
81.9
Parenting s/of competence
17 (29)
.54***
.35;.73
0.0
64.8
after trim-fill correction
18 (30)
.54***
.36;.72
63.1
Parent-child relation
13 (18)
.53***
.29;.77
44.5
19.6
probably blinded
6 (10)
.53**
.17;.88
43.8
23.5
Unblinded
7(8)
.54**
.18;.90
43.8
23.5
after trim-fill correction
17 (22)
.37*
.07;.67
72.2
Parental mental health
23 (33)
.41***
.20;.61
0.0
69.2
after trim-fill correction
29 (39)
.30*
.03;.57
75.1
without Aghebati study
22 (30)
.34***
.22;.45
3.1
16.6
without Aghebati study &
after trim-fill correction
26 (34)
.29***
.17;.41
32.8
Note: Table presents overall main effects, main effects on probably blinded and unblinded measures separately, main effects after trim-fill correction. k represents the number
of studies, with the number of effect sizes (n_es) in parentheses. The trim-fill correction calculates the effect size after correcting for funnel plot asymmetry. CI = confidence
interval; I2 represents “the proportion of variation in study estimates that is due to heterogeneity” 51, separately for heterogeneity between variables (level 2) and between
studies (level 3); s/of = sense of; SMD = standardized mean difference in terms of Hedges’ g.
* p < .05, ** p < .01, *** p < .001.
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Table 3. Significant Effects of Primary and Secondary Analyses
Primary analyses
k (n_es)
̂1 (95% CI)
I2 (2,3, %)
Positive Parenting
1. Shaping knowledge (#sessions)
16 (20)
-.05 (-.11;.01)****
69.2, 0.0
1. Shaping knowledge (%sessions)
16 (20)
-.01 (-.01;-.00)*
66.5, 0.0
1a. Psycho-education parent (%sessions)
16 (20)
-.01 (-.01;-.00)*
66.7, 0.0
7. Practicing/generalization/maintenance (%sessions)
16 (20)
.04 (-.00;.09)****
66.9, 0.0
Negative Parenting
4. Positive consequences (%sessions)
12 (23)
.01 (-.00;.02) ****
65.4, 0.0
4d. Social reward (%sessions)
12 (23)
.01 (.00;.02)*
63.2, 0.0
4j. Consistent responding (%sessions)
12 (23)
.01 (.00;.03)*
64.6, 0.0
Parenting Sense of Competence
3. Manipulating antecedents (%sessions)
16 (27)
.01 (.00;.03)*
5.7, 53.2
Parent-Child Relation
1. Shaping knowledge (#sessions)
12 (17)
-.08 (-.15;-.00)*
54.8, 0.0
1a. Psycho-education parent (#sessions)
12 (17)
-.08 (-.16;-.00)*
54.8, 0.0
7. Practicing/generalization/maintenance (#sessions)
12 (17)
-.09 (-.17;-.01)*
52.8, 0.0
Parental Mental Health
3. Manipulating antecedents (#sessions)
20 (27)
.05 (.01;.09)*
0.0, 7.2
3b. Plan misbehavior (#sessions)
20 (27)
.03 (.00;.06)*
0.0, 11.8
3. Manipulating antecedents (%sessions)
20 (27)
.01 (.00;.01)*
4.8, 0.0
3b. Plan misbehavior (%sessions)
20 (27)
.00 (.00;.01)*
0.2, 10.1
Secondary analyses
k (n_es)
̂1 (95% CI)
I2 (2,3)
Positive Parenting
Age (categorical): preschool vs school-age
19(27)
-.42 (-.84;-.01)*
75.4, 0.0
Integrity checked vs not checked
19(27)
.58 (.10;1.07)*
73.9, 0.0
Negative Parenting
Age (continuous)
13(27)
-.12 (-.22;-.01)*
62.0, 5.5
Sex (% boys)
15(31)
.03 (.00;.05)*
62.6, 6.8
Parent Training vs Multimodal
15(31)
-.46 (-.91;-.00)*
67.2, 4.2
Integrity checked vs not checked
14(30)
.59 (.17;1.00)**
68.7, 0.0
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Note: Significant effects of dosage of categories of behavioral techniques and specific techniques (primary analyses; upper panel) and significant effects of intervention and
participant characteristics (secondary analyses; lower panels). k represents the number of studies, with the number of effect sizes (n_es) in parentheses.
̂1 denotes the change
in standardized mean difference (in terms of Hedges’ g) when the moderator increases with one unit (95% confidence intervals are depicted in parentheses). I2 represents “the
proportion of variation in study estimates that is due to heterogeneity” 51, separately for heterogeneity between variables (level 2) and between studies (level 3). Category
numbers (and specific techniques within categories with numbers and letters) correspond with the taxonomy (see Supplement 1, available online).
* p < .05; ** p < .01; *** p < .001; **** p < .10.
Figure 1. PRISMA Flowchart
Figure 2. Forest Plots With all Effect Sizes Sorted per Outcome Domain
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40
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Screening
Included
Eligibility
Identification
Additional records identified through
other sources
(n = 3)
Records after duplicates removed
(n = 13,053)
Records screened
(n = 13,053)
Records excluded
(n = 12,723)
Full-text articles assessed for
eligibility
(n = 330)
Full-text articles excluded:
Other publication type (n = 72)
No RCT/ wrong design (n = 52)
Other intervention (n = 48)
Re-analysis (n = 38)
Other population (n = 29)
Foreign language (n = 14)
Medication (n = 20)
Other control group (n = 10)
Other outcome (n = 18)
Studies included in
qualitative synthesis
(n = 29)
Studies included in
quantitative synthesis (meta-
analysis)
(n = 29)
Records identified through database
searching
(n = 23,023)
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