Positive Parenting and Early Childhood Cognition: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

This review examines the effectiveness of positive parenting interventions aimed at improving sensitivity, responsiveness, and/or non-harsh discipline on children’s early cognitive skills, in four meta-analyses addressing general mental abilities, language, executive functioning, and pre-academics. The objectives are to assess the magnitude of intervention effectiveness and identify moderators of effectiveness. We include randomized controlled trials of interventions targeting positive parenting to improve cognition in children < 6 years. Studies that include children with neurodevelopmental and/or hearing disorders were excluded. MEDLINE, PsycINFO, ERIC, and ProQuest Dissertations & Theses (October 2021) and citation chaining identified relevant records. Five reviewers completed screening/assessments, extraction, and risk of bias. Pooled analysis in Comprehensive Meta-Analysis (Version 3) used random effects modeling, with moderation via Q-statistics and meta-regression. Positive parenting interventions led to significant improvements in mental abilities (g = 0.46, N = 5746; k = 33) and language (g = 0.25, N = 6428; k = 30). Effect sizes were smaller and nonsignificant for executive functioning (g = 0.07, N = 3628; k = 14) and pre-academics (g = 0.16, N = 2365; k = 7). Robust moderators emerged for language and cognition. For cognition, studies with higher risk of bias scores yielded larger intervention effects. For language, studies with younger children had larger effect sizes. Studies mitigated selection and detection bias, though greater transparency of reporting is needed. Interventions that promote parental sensitivity, responsiveness, and non-harsh discipline improve early mental abilities and language. Studies examining executive functioning and pre-academics are needed to examine moderators of intervention effectiveness.
Trial registration Systematic review PROSPERO registration. CRD42020222143

Full text

Vol.:(0123456789)
1 3
Clinical Child and Family Psychology Review
https://doi.org/10.1007/s10567-022-00423-2
Positive Parenting andEarly Childhood Cognition: ASystematic
Review andMeta‑Analysis ofRandomized Controlled Trials
HeatherPrime1,2 · KrystaAndrews3· AlexandraMarkwell1,2· AndreaGonzalez3· MagdalenaJanus3·
AndreaC.Tricco4,5,6· TeresaBennett3· LeslieAtkinson7
Accepted: 30 December 2022
© The Author(s) 2023
Abstract
This review examines the effectiveness of positive parenting interventions aimed at improving sensitivity, responsiveness,
and/or non-harsh discipline on children’s early cognitive skills, in four meta-analyses addressing general mental abilities,
language, executive functioning, and pre-academics. The objectives are to assess the magnitude of intervention effective-
ness and identify moderators of effectiveness. We include randomized controlled trials of interventions targeting positive
parenting to improve cognition in children < 6years. Studies that include children with neurodevelopmental and/or hearing
disorders were excluded. MEDLINE, PsycINFO, ERIC, and ProQuest Dissertations & Theses (October 2021) and citation
chaining identified relevant records. Five reviewers completed screening/assessments, extraction, and risk of bias. Pooled
analysis in Comprehensive Meta-Analysis (Version 3) used random effects modeling, with moderation via Q-statistics and
meta-regression. Positive parenting interventions led to significant improvements in mental abilities (g = 0.46, N = 5746;
k = 33) and language (g = 0.25, N = 6428; k = 30). Effect sizes were smaller and nonsignificant for executive functioning
(g = 0.07, N = 3628; k = 14) and pre-academics (g = 0.16, N = 2365; k = 7). Robust moderators emerged for language and
cognition. For cognition, studies with higher risk of bias scores yielded larger intervention effects. For language, studies
with younger children had larger effect sizes. Studies mitigated selection and detection bias, though greater transparency of
reporting is needed. Interventions that promote parental sensitivity, responsiveness, and non-harsh discipline improve early
mental abilities and language. Studies examining executive functioning and pre-academics are needed to examine modera-
tors of intervention effectiveness.
Trial registration Systematic review PROSPERO registration. CRD42020222143
Keywords Positive parenting· Early childhood cognition· Randomized controlled trials· Systematic review· Meta-
analysis
* Heather Prime
hprime@yorku.ca
Krysta Andrews
andrek1@mcmaster.ca
Alexandra Markwell
alexmark@my.yorku.ca
Andrea Gonzalez
gonzal@mcmaster.ca
Magdalena Janus
janusm@mcmaster.ca
Andrea C. Tricco
Andrea.Tricco@unityhealth.to
Teresa Bennett
bennett@hhsc.ca
Leslie Atkinson
leslie.atkinson@ryerson.ca
1 Department ofPsychology, York University, Toronto,
Canada
2 LaMarsh Centre forChild & Youth Research, York
University, Toronto, Canada
3 Offord Centre forChild Studies, Department ofPsychiatry
andBehavioural Neurosciences, McMaster University,
Hamilton, Canada
4 Knowledge Translation Program, Li Ka Shing Knowledge
Institute, St. Michaels Hospital, Unity Health Toronto,
Toronto, Canada
5 Epidemiology Division andInstitute ofHealth Policy,
Management, andEvaluation, Dalla Lana School ofPublic
Health, University ofToronto, Toronto, Canada
6 Queen’s Collaboration forHealth Care Quality Joanna Briggs
Institute Centre ofExcellence, Queen’s University, Kingston, Canada
7 Department ofPsychology, Toronto Metropolitan University,
Toronto, Canada
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Clinical Child and Family Psychology Review
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Children’s early cognitive skills lay the foundation for life-
long learning and well-being. Individual differences in men-
tal abilities, language, executive control, and early literacy
are linked to preschool and school-age learning, as well as
adulthood achievement, educational, and occupational out-
comes (Ahmed etal., 2019; Johnson etal., 2010; Scarbor-
ough etal., 2009; Wade etal., 2018). Furthermore, early
cognitive systems underlie general risk for psychopathology
(Michelini etal., 2021; Morris & Cuthbert, 2012). Thus,
early cognitive skills represent transdiagnostic risk markers
for a host of short- and long-term clinical, school, and fam-
ily outcomes. Identifying modifiable contributors to early
cognition is essential to policy and programming designed
to reduce early disparities in development.
Children’s developing competencies are, in part, con-
structed within cooperative social exchanges (Carpendale
& Lewis, 2004). The mutually responsive stance between
a child and their parent(s) is built within a positive par-
ent–child relationship. That is, a parent who is sensitive to
their child’s subtle and overt cues promotes an eager, will-
ing stance in the child, who then reciprocates the exchange
within and across interactions over time (Kochanska etal.,
2015). This dynamic creates fertile grounds for the parent
learning about the needs of the child and tailoring their
input accordingly, while also motivating the child to engage
and commit to learning in their social environments—both
within the parent–child relationship and beyond. The mutu-
ally responsive stance is also important in the disciplinary
context; for instance, a strong relational foundation between
a parent and a child may lead a child to accept parents’ bids
for power and control, rather than interpreting such acts as
hostile or threatening (and thus responding in an opposi-
tional manner; Kochanska etal., 2009).
The current paper examines a collection of unique though
overlapping parenting behaviours that are considered benefi-
cial to young children including sensitivity, responsiveness,
and non-harsh discipline (i.e., positive behavioural manage-
ment). There is not a unified definition of these parenting
behaviours, though they are commonly targeted together
(Landry etal., 2008), and they have previously been referred
to as positive parenting (Juffer etal., 2008; Madigan etal.,
2019; Sanders etal., 2014). As such, we will refer to this
collection of parenting behaviours as positive parenting,
hereafter. Though this general term has the advantage of
referring to varied yet related parenting behaviours, it has
the disadvantage of lacking specificity.
Positive parenting takes different forms based on the
currently activated relationship between parent and child
(Grusec, 2011). Traditionally conceptualized within an
attachment framework, positive parenting behaviours can be
characterized by sensitivity, warmth, acceptance, and nurtur-
ance (Ainsworth, 1979), as well as consideration of infants’
intentions, thoughts, and emotions (i.e., mind-mindedness;
Laranjo etal., 2008). Relatedly, positive parenting can be
understood within a sociocultural framework, wherein par-
ents respond promptly and contingently to infants’ explora-
tory and communicative actions, serving to expand their
individual learning through an interpersonal exchange
(Bernier etal., 2010; Tamis-Lemonda etal., 2014). Thus,
both cognitively and affectively responsive behaviours char-
acterize positive parenting in infancy and throughout early
childhood (Landry etal., 2008). As infants enter their sec-
ond year, their cognitive, linguistic, and physical develop-
ment leads to aggression and active resistance to parental
control (Alink etal., 2006; Côté etal., 2006). As a result,
what is considered positive parenting expands to include
non-harsh discipline, appropriate limit-setting, and moni-
toring of child behaviour, within the realm of social learn-
ing and operant conditioning frameworks. Thus, positive
parenting behaviours vary as a function of context (e.g.,
cooperative exchanges such as play; hierarchical exchanges
such as teaching, protecting, or limit-setting) and/or child
needs based on age, neurodevelopmental and/or tempera-
mental characteristics (Grusec, 2011). Cutting across these
positive parenting behaviours is a motivation and capacity to
attend to the internal states of the child, reasonably respect
their needs for autonomy, and cultivate a warm relationship.
Evidence for the predictive power of positive parenting
in relation to children’s early cognition comes primarily
from naturalistic, longitudinal study designs. For instance,
Browne etal. (2018) demonstrated that the relationship
between socioeconomic, neighbourhood, and household
risk (child age 2months) and children’s pre-academic
skills, vocabulary, executive function, and theory of mind
(4.5years), operated, in part, through parental responsive-
ness (18months), after accounting for family material
investments. Furthermore, executive functioning has been
longitudinally associated with early positive parenting, such
as sensitivity, positive regard, and stimulation (Towe-Good-
man etal., 2014), and serves as a link between these early
parenting behaviours and children’s later behavioural prob-
lems (Sulik etal., 2015). Importantly, children whose moth-
ers show more responsive behaviours in infancy and toddler-
hood demonstrate enhanced cognitive and language skills,
as compared to those whose mothers show more responsive
behaviours in only infancy or early childhood (Landry etal.,
2001). Robust support for associations between positive par-
enting and early cognition comes from reviews and meta-
analyses, for instance in children’s language and mental
abilities (Madigan etal., 2019; Neel etal., 2018), academic
achievement (Pinquart, 2016), and executive functioning
(Valcan etal., 2017).
Although there is robust correlational evidence that
positive parenting behaviours are linked to early childhood
cognition, study designs that can establish causal processes
are needed. Behavioural genetic studies demonstrate that
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Clinical Child and Family Psychology Review
1 3
early cognitive development is, in part, genetically medi-
ated (Friedman etal., 2008; Hayiou-Thomas etal., 2006;
Polderman etal., 2015; van Bergen etal., 2018). Moreover,
putative environmental effects are confounded by genetics
by way of evocative gene-environment correlations (e.g.,
parental warmth is significantly influenced by children’s
genetic propensities; Klahr & Burt, 2014) and passive gene-
environment correlations (e.g., reading ability is primarily
transmitted from parent to child through genes rather than
the home-literacy environment; van Bergen etal., 2017).
As such, observed associations between parenting and early
development are, in part, confounded by genetic factors.
Furthermore, even in well-controlled observational designs,
associations between environmental and child outcomes are
at risk of confounding by unmeasured environmental factors
(e.g., family functioning; see Daniel etal., 2018 for an exam-
ple). Given these confounds, researchers and consumers of
research may make erroneous conclusions that the home
environment and children’s outcomes are causally linked
without sufficient evidence (Haber etal., 2018, 2021; Hart
etal., 2021).
Randomized controlled trials (RCTs) confer a high prob-
ability for establishing causal mechanisms, with differences
in outcomes across intervention and control groups attrib-
uted to the effects of the intervention (Cook etal., 2002).
A growing number of RCTs have examined positive par-
enting interventions in relation to early cognitive develop-
ment, including language (Bagner etal., 2016; Guttentag
etal., 2014), mental abilities (Dubois-Comtois etal., 2017;
Roggman etal., 2009), executive functioning (Cassidy
etal., 2017; Lunkenheimer etal., 2008), and literacy and
numeracy skills (Landry etal., 2021; Sheridan etal., 2011).
Studies yield variable estimates when it comes to the direc-
tion and magnitude of intervention effects, and there are
considerable differences in study design in terms of par-
ticipant, intervention, and outcome characteristics (Bernard
etal., 2017; Boivin etal., 2017; Cassidy etal., 2017; Colditz
etal., 2019; Hutchings etal., 2017; Pontoppidan etal., 2020;
Tachibana etal., 2012). Thus, although there is growing sup-
port for the effectiveness of positive parenting interventions
in enhancing children’s early cognition, several questions
remain, which are best addressed with a systematic review
and meta-analysis.
The current study is a systematic review and meta-anal-
ysis designed to illustrate the state of knowledge regarding
the effectiveness of positive parenting interventions, based
on RCT designs, for enhancing children’s early cognition.
In a recent systematic review and meta-analysis, Jeong etal.
(2021) examined 102 unique RCTs of a range of parenting
interventions delivered during the first three years of life. All
studies had an evaluation of an early childhood development
outcome, among which included cognitive and/or language
development. Parenting interventions that included content
to promote responsive parenting behaviours (i.e., prompt,
consistent, contingent, and developmentally appropriate to
the child’s cues, signals, and needs) were more effective at
enhancing child cognitive development as compared to par-
enting interventions without a focus on promoting respon-
sive parent–child interactions. Thus, content that focuses
on positive parent–child interactions may be necessary to
optimize the effectiveness of parenting interventions in the
first 3years of life. However, it is unclear whether positive
parenting interventions, in isolation, are effective in enhanc-
ing children’s early cognitive development, as several stud-
ies in the review had additional intervention targets (e.g.,
the provision of early play and learning materials, caregiver
awareness of developmental milestones). The current study
aim is to shed light on the utility of single-focused interven-
tions (i.e., is positive parenting content sufficient?), while
also informing developmental theory on child cognition and
the parenting environment.
Furthermore, the current study extends Jeong etal. (2021)
review by including children up to and including six years of
age. This has several advantages, including greater sensitiv-
ity to detect potential age effects, the inclusion of interven-
tion strategies designed to address the needs of preschool
children or a wider range of children (e.g., behavioural guid-
ance), and the assessment of skills that develop later in early
childhood such as executive functioning and pre-academics.
Potential Moderators
Child Characteristics
Child-specific characteristics, such as age, sex, and early
risk factors, may impact the effectiveness of positive par-
enting interventions. Whereas there is some meta-analytic
evidence for greater effects of positive parenting interven-
tions for younger children as compared with older children
when examining socio-emotional and behavioural outcomes
(Gardner etal., 2010; Sanders etal., 2014), other meta-anal-
yses do not support this claim (Gardner etal., 2019b; Van
Aar etal., 2017). Findings in relation to positive parenting
interventions and cognitive development are similarly mixed
(Baudry etal., 2017; Jeong etal., 2021). Timing effects may
depend on the age range of the samples included and/or the
developmental outcome examined (Maughan & Barker,
2019).
There is evidence for differences in male versus female
children in cognitive development, positive parenting, and
the relations between positive parenting and children's
outcomes (Barnett & Scaramella, 2013; Else-Quest etal.,
2006; Leaper & Smith, 2004). Previous reviews are mixed
with respect to whether child sex moderates the effective-
ness of positive parenting interventions, with evidence for
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Clinical Child and Family Psychology Review
1 3
stronger intervention effects in male children (Gardner etal.,
2017), and no differences between male and female children
(Nowak & Heinrichs, 2008).
Finally, early infant/childhood risk factors such as peri-/
postnatal problems (e.g., low birth weight, prematurity)
and/or socio-emotional/behavioural problems may impact
intervention effectiveness. Stronger effect sizes have been
observed in parenting interventions targeted towards higher
risk children in relation to behavioural outcomes, such as
those with developmental needs and those with higher dis-
tress at baseline (Gardner etal., 2017; Sanders etal., 2014).
There is alternative evidence that children with peri-/post-
natal risk may not make the same cognitive gains as those
without such risks following parent intervention (Landry
etal., 2008; Vanderveen etal., 2009). However, this ques-
tion has not be examined meta-analytically in relation to
cognitive outcomes.
Contextual Characteristics
Social disadvantage is consistently related to children’s early
cognitive development, partially explained by family factors
such as parenting; this has been robustly demonstrated for
both socioeconomic status (Borairi etal., 2021; Letourneau
etal., 2013) and maternal depression (Ahun & Côté, 2019;
Liu etal., 2017). It is important to understand whether par-
enting interventions focused on promoting positive parent-
ing behaviours, without additional program components, are
effective for families experiencing multiple stressors. The
effectiveness of the Incredible Years parenting program,
designed to support children’s behavioural functioning,
is not reduced for disadvantaged families (Gardner etal.,
2019a, 2019b), and indeed confers greater effects for some
higher risk families such as those with depressed parents
(Gardner etal., 2017). However, such findings cannot be
directly applied to children’s cognitive development, where
there is contradictory evidence for the effectiveness of posi-
tive parenting programs with high-risk families (Baudry
etal., 2017; Rayce etal., 2020).
Intervention Characteristics
Both parental affective- and cognitive responsiveness have
been linked to gains in children’s cognitive development
following parent training (Landry etal., 2008). However,
distinctions between specific positive parenting behaviours
(e.g., warmth and contingent responding, respectively) are
evident, in terms of the strength of their prediction of child
development (Borairi etal., 2021; Madigan etal., 2019; Neel
etal., 2018). Thus, we will examine whether there is an
association between parenting behaviour targeted and inter-
vention effect size. Intervention format is relevant, too; inter-
ventions that have fewer sessions and those that are shorter
in duration have been shown to be more effective for inciting
change in parent and child outcomes (Bakermans-Kranen-
burg etal., 2003; Baudry etal., 2017; Harris etal., 2020;
Jeong etal., 2021). Finally, given that fathers are frequently
overlooked in research on child psychopathology (Parent
etal., 2017), one goal of the current study is to systemati-
cally examine how frequently fathers are included in posi-
tive parenting interventions designed to enhance children’s
cognitive development, and to examine whether inclusion
influences differences in intervention effects.
Methodological Characteristics
Several methodological characteristics influence between-
study variability in effect sizes, including year of publica-
tion, risk of bias/methodological quality, and publication
status (Baudry etal., 2017; Nowak & Heinrichs, 2008; Pin-
quart, 2016, 2017). In addition, the method of child outcome
assessment (e.g., parent-report vs. direct assessment) can
influence the strength of effects, as seen in both in individual
studies and meta-analyses (Andrews etal., 2021; Landry
etal., 2017; Madigan etal., 2013; Nowak & Heinrichs,
2008).
Current Study
The current study is a systematic review and meta-analysis
that includes primary studies of positive parenting interven-
tions in the infancy and early childhood period. All primary
studies in the review include RCT designs and an evalua-
tion of one or more of mental abilities, language, executive
functioning and/or pre-academics. The goal of the review is
to obtain a pooled estimate of the magnitude of the effect
of positive parenting programs for promoting positive gains
in early child cognition, and to identify moderating factors
associated with intervention effect sizes.
All included studies evaluate single-focused interventions
in that they have a primary focus on positive parenting with
only minimal, if any, additional intervention components.
Notably, interventions that target positive parenting behav-
iour draw on several theoretical models including attach-
ment, social learning, sociocultural, and biobehavioural
frameworks (Prime etal., 2020). The current review uses a
comprehensive definition of positive parenting that includes
emotional responsiveness and sensitivity (e.g., responding to
distress, affection/warmth), cognitive responsiveness (e.g.,
maintaining children’s focus of attention, responding to
infants’ exploratory and communicative actions), and posi-
tive behavioural guidance/management. We do not include
parenting interventions that are specifically literacy-based or
focused solely on enhancing parental language input.
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Clinical Child and Family Psychology Review
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We use early cognitive skills as a broad umbrella term for
four categories of foundational early learning: mental abili-
ties, language, executive functioning, and pre-academics.
Mental abilities are typically represented by developmen-
tal/intelligence quotients, and/or cognition scores, based on
assessments of a variety of skills such as visuo-spatial, motor,
quantitative, and verbal/non-verbal reasoning skills. Language
refers to children’s verbal abilities, including communication,
receptive (i.e., understanding) and expressive (i.e., produc-
tion) vocabulary, and speech production. Executive function-
ing refers to children’s developing abilities for inhibition, cog-
nitive flexibility/set-shifting, effortful control, and working
memory. Finally, pre-academics represents acquired knowl-
edge in the domains of achievement, early literacy (e.g., print
knowledge), numeracy (e.g., counting), and related skills (e.g.,
shapes and colours). There is significant interdependence
among this subset of early skills, in early childhood and into
the elementary school years (Fitzpatrick etal., 2014; Spiegel
etal., 2021), making it useful to examine in a unified project
(Prime etal., 2020; Rodrigues etal., 2021). At the same time,
there are differential effects of early psychosocial interven-
tions across early cognitive skills, for instance, with some evi-
dence of stronger benefits to broad developmental, language,
and pre-academic skills, as compared to executive function-
ing (Bick etal., 2018; Landry etal., 2017; McDermott etal.,
2012). The current study examines these four domains of
early child cognition, independently, to assess whether there
are differential patterns of effectiveness of positive parenting
interventions and/or moderating factors.
First, we systematically review studies to draw themes in
study, participant, and intervention characteristics, while also
providing a critical assessment of the strengths and weak-
nesses of the extant literature through a risk of bias assess-
ment. Second, we examine outcomes independently in four
separate meta-analyses, with accompanying outcome-specific
moderator analyses. Several substantive and methodologi-
cal moderators are examined as potential explanations for
between-study heterogeneity of effect sizes, including child
characteristics (age, sex, early risk factors), contextual char-
acteristics (income, education, parental age, parental mental
health), intervention characteristics (parenting target, inten-
sity, duration, father involvement), and methodological char-
acteristics (publication year, publication status, sample size,
risk of bias, outcome assessment approach).
Methods
Study Inclusion Criteria
Eligibility criteria are based on population, interven-
tion, comparators, outcomes, and study design (PICOS)
characteristics and include: (i) a study population of chil-
dren less than or equal to 6years of age; (ii) an interven-
tion with a primary focus on improving positive parenting
behaviours, as defined as one or more of the following:
emotional responsiveness (e.g., sensitivity, warmth, con-
tingent responding, acceptance), cognitive responsiveness
(e.g., rich verbal input, following attention, verbal scaf-
folding), and/or positive behavioural guidance (e.g., incen-
tives, limit-setting and non-harsh discipline, reinforcement/
praise)1; (iii) a comparison group utilizing passive control,
treatment-as-usual, and/or waitlist controls (but not active
controls that receive a comparable standard treatment.);
(iv) an assessment of children’s cognitive development at
less than or equal to six years of age, as defined by mental
abilities (e.g., cognition, developmental/intelligence quo-
tient, reasoning/problem-solving, performance), language
(e.g., verbal abilities, communication, receptive/expressive
vocabulary, speech production), executive functioning (e.g.,
inhibition, cognitive flexibility/set-shifting, effortful control,
working memory), and/or pre-academics (e.g., print knowl-
edge, school readiness, achievement); and (v) a randomized
controlled trial study design. Only articles written in Eng-
lish were included. Published and unpublished records were
considered. Exclusion criteria included studies with samples
of parents/children with intellectual disabilities, deafness/
hearing loss, blindness, and brain injuries.
Information Source andSearch Strategy
The search strategy was developed and executed by the first
author, in consultation with an experienced librarian, experts
in knowledge synthesis research methods, and the research
team (remaining authors). First, a database search of MED-
LINE (Ovid), PsycINFO (Ovid), ERIC, and ProQuest Dis-
sertations & Theses Global was executed in September 2020
(from inception to date of the search) and updated in October
2021. The search strategy went through multiple rounds of
pilot testing (Hayman, 2015). The final strategy included a
combination of subject terms/headings and keywords tailored
to individual databases indexing: parenting, intervention,
early childhood, and cognition (see Supplemental File 1 for
the entire database search strategy). Eligible studies identified
at the full-text phase were put through backward (reference
lists) and forward (cited by lists) searching procedures to iden-
tify additional records for screening (Boland etal., 2017).
1 Primary reasons for exclusion included interventions that provided
content directly teaching children skills or focused solely on enhanc-
ing parental language input (e.g., shared book reading or literacy
interventions) and/or those with significant program components
unrelated to positive parenting (e.g., maternal well-being, child health
and safety). Minor additional program components were admissible if
the primary focus for all participants in the treatment group was posi-
tive parenting.
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Clinical Child and Family Psychology Review
1 3
Study Records
Data Management
Records identified in the search strategy were imported into
Covidence (Covidence, 2017), and duplicates removed.
Abstract/title screen, full-text assessment, data extraction
of study characteristics, and risk of bias assessment were
conducted in Covidence, and extraction of effect sizes was
executed in Microsoft Excel.
Selection Process
Standardized manuals were developed by the first author
and piloted by the research team for abstract screening (50
records) and full-text assessments (40 full-texts). Interrater
agreement was established prior to independently screening/
assessing records and full-texts (Percent agreement ≥ 0.80;
Kappa ≥ 0.60). The abstract screening was completed by four
members of the research team, with each abstract screened
by two independent reviewers, and discrepancies resolved
by the first author. Full-text assessments were similarly exe-
cuted by two members of the research team, with discrepan-
cies resolved by the first author.
Data Collection Process
Data extraction forms were developed by the first author.
The data extraction forms went through piloting on five
articles, with multiple iterations, to enhance clarity and
inter-rater agreement. Teams of two completed extraction
of either study characteristics, effect size extraction, or risk
of bias assessments. Discrepancies were resolved by a third
senior reviewer or through discussion and consensus (for
effect size extraction). Subsequently, all data extraction
was reviewed by the first author. First and senior authors of
primary studies were contacted for three primary reasons:
(i) to request full-text articles that were not readily avail-
able online or through library services; (ii) to request data
required to compute an effect size (including means/standard
deviations and/or pre-post correlations, as described below
in Meta-Analysis); and (iii) to request missing data related
to study characteristics.
Data Items
Data items were selected based on the Cochrane Handbook,
study objectives, and norms of the child development and
parenting literature. Participant characteristics included
child age (in months) at baseline and at the time of outcome
assessment, and % of male children. Most risk indicators
were dichotomized as present or absent in a sample based
on whether ≥ 30% of the sample was deemed to have the
risk present. An exception to this was for parental income
and education, which were considered present if ≥ 50% of
the sample was deemed to have the risk.2 Child-related
risks were coded as peri/post-natal risks (e.g., low birth
weight, prematurity) and/or social-emotional/behavioural
risks (as indicated, for example, by elevated scores on a
screener measure). Parental risks included low education
(≤ a high school education; or low education as defined by
authors) and/or low income (equivalent to ≤ $40,000 USD;
or low income as defined by authors). Additional risk fac-
tors included whether the sample was made up of adoles-
cent parents and the presence of parental mental health dif-
ficulties. We were able to code the mean parental age (in
years) continuously. Intervention characteristics included
the intervention name, intensity (16 + sessions vs. < 16;
Bakermans-Kranenburg etal., 2003), duration (12 + months
vs. < 12months; Jeong etal., 2021), % mothers participating,
father involvement (1 = any indication of involvement; 0 = no
indication of father involvement), who the intervention was
delivered by, intervention setting (e.g., home, community,
hospital), and the nature of the comparison group. The spe-
cific target of positive parenting was coded as affective-emo-
tional responsiveness, cognitive responsiveness, behavioural
guidance, or mixed (1 + of the preceding targets). Methodo-
logical characteristics included year of publication, type of
record (journal article, dissertation, book chapter, report),
country of origin, the sample size (analytic sample), and the
outcome measurement approach (i.e., standardized assess-
ment, parent-reported, or behavioural observation).
Outcomes
The four primary outcomes for the systematic review and
meta-analysis were:
(i) Mental abilities (e.g., cognition, developmental/intel-
ligence quotient, reasoning/problem-solving, perfor-
mance);
(ii) Language (e.g., verbal abilities, communication,
receptive/expressive vocabulary, speech production);
(iii) Executive functioning (e.g., inhibition, cognitive
flexibility/set-shifting, effortful control, working
memory) and/or;
(iv) Pre-academics (e.g., print knowledge, school readi-
ness, achievement).
2 This is only a cursory categorization. Though efforts were made
to extract measures of risk using a continuous scale (e.g., number of
years of education, % of families with low income), primary studies
typically did not report this information. Thus, cut-offs were selected
based on commonly available information.
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Clinical Child and Family Psychology Review
1 3
Moderators
Moderators that were examined to explain between-study
variation in effect sizes include outcome, child, contextual,
intervention, and methodological characteristics, as listed
in Table6.
Risk ofBias inIndividual Studies
A risk of bias assessment was conducted for included studies
using the modified Cochrane risk of bias tool for randomized
trials, developed by the CLARITY Group at McMaster
University (CLARITY Group, 2021). The Clarity tool
was selected as it provides variability in the classification
system based on available information (e.g., probably yes
and/or probably no, in addition to definitely yes/definitely
no options). Furthermore, it provides specific instructions
for addressing unclearly reported masking status in rand-
omized controlled trials (Akl etal., 2012). These modifica-
tions allow for a nuanced assessment of risk of bias when a
literature has variability in the quality of reporting, as was
expected in the current review.
Studies were evaluated based on the following criteria:
adequacy of random sequence generation, adequacy of
allocation concealment, masking to group allocation (data
collectors, participants, interventionists, data analysts), fre-
quency of missing outcome data, selective outcome report-
ing, and other biases (e.g., baseline differences). Additional
questions were added to the assessment after consultation
with the tool developer including the use of a power analy-
sis, sample power, and trial registration. For each criterion,
studies were rated as either: (1) definitely high-risk of bias;
(2) probably/mostly high-risk of bias; (3) probably/mostly
low risk of bias, or (4) definitely low risk of bias. Following
piloting and adjustment of the assessment with 11 articles,
each study was assessed by two independent coders and dis-
agreements resolved by the second author. For multiple stud-
ies pulling from the same sample, ratings were compared for
each criterion and where discrepancies emerged (k = 6), the
higher rating was selected. Finally, total scores were gener-
ated for each study by assigning a value of 1 for “Definitely
Yes” or “Probably Yes”, and 0 for “Definitely No, Probably
No or Not Reported”, and then summing across all risk of
bias items. Scores could range from 0 to 12 with higher
scores indicating lower risk of bias.
Data Synthesis
Description ofStudies
Descriptive tables are presented with individual-study data,
including participant, intervention, and methodological char-
acteristics, respectively. Frequencies (and percentages) and
means/standard deviations are used to summarize descrip-
tive information across studies, when applicable. Risk of
bias assessment is summarized with frequencies and per-
centages, and a visual depiction of individual-level data by
study is presented.
Quantitative Analyses
All studies with sufficient data to compute an effect size
were included in the meta-analysis. Authors were con-
tacted to request data when sufficient data were not read-
ily available. Studies with insufficient data to compute an
effect size were excluded from the meta-analysis (though
retained in the qualitative synthesis); however, sensitiv-
ity analyses were used to examine the impact of inclusion/
exclusion of these studies on the pooled effect sizes, with
an effect of 0.0 substituted for missing data. Comprehensive
Meta-Analysis Version 3 software (Borenstein etal., 2013)
was used to calculate individual effect sizes as Hedge’s g
(Hedges, 1981) and, subsequently, to pool effects across
studies. We included the pre- and post means and standard
deviations of intervention and control groups, respectively,
and correlations between pre- and post-test scores, to obtain
standardized difference scores (Borenstein etal., 2021).
Pre-post score correlations were requested from authors
when not reported. When not available, pre-post score cor-
relations were imputed at 0.7 (with sensitivity analyses at
0.5; Rosenthal, 1991). When pre/post means and standard
deviations were not available, other methods were used to
obtain an effect size (e.g., post-test score comparison, cor-
relations between group and post-test outcome, sample size
and p-value, etc.). Four meta-analyses were conducted using
random effects modeling and independent samples: one for
each of mental abilities, language, executive functioning,
and pre-academics, respectively, including outcome-spe-
cific moderation analyses. These four meta-analyses were
not independent (i.e., samples between meta-analyses were
overlapping).
Publication bias was examined for each meta-analysis
using the trim-and-fill approach to assess degree of possible
test bias, if any (Duval & Tweedie, 2000). In the event of
evidence of publication bias, Rosenthal's (1986) Fail-safe N
was examined, as an additional indicator of potential publi-
cation bias, to estimate the number of unpublished studies
with null results that would deem the effect size nonsignifi-
cant. Publication bias could not be examined via moderation
analyses due to small cell sizes within each meta-analysis
(i.e., < 5 unpublished studies in all relevant cells).
Effect Size Selection
Several studies drew from overlapping samples. We screened
for overlapping samples based on first/senior authorship and/
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Clinical Child and Family Psychology Review
1 3
or intervention names (e.g., Incredible Years, Family Check-
Up), and confirmed overlap by comparing study character-
istics. In addition, several studies had multiple outcomes of
interest either across outcomes (e.g., language and executive
functioning), within outcomes over time (language at post-
intervention and follow-up), or both. To ensure each sample
was only represented in each meta-analysis once, the follow-
ing steps were taken prior to data analysis:
(i) The broadest level of measurement was typically
retained (e.g., an executive functioning compos-
ite of three subscales was selected over any single
executive functioning subscale). The exception was
when the broadest level of measurement included
two domains of cognitive development (e.g., mental
abilities and language), in which case we retained
outcomes across domains, as these outcomes were
analyzed in independent meta-analyses.
(ii) The measurement approach that most robustly pro-
tected against risk of bias was retained (standard-
ized assessment > observations > parent-report).
Outcomes that used the same measurement approach
(e.g., both parent-report) were combined. To com-
bine two or more effect sizes into a single effect size,
an estimate of the correlations among outcomes is
required (Borenstein etal., 2021). As these were typi-
cally not available, a plausible range of correlations
was used, wherein we imputed a correlation between
variables of 0.2 (and sensitivity analyses were con-
ducted with an assumed correlation of 0.7).
(iii) We selected the earliest assessment point (most often
the post-intervention assessment but sometimes only
a follow-up was available). Sensitivity analyses com-
pared this selection to one where we selected the lat-
est assessment point; that is, we used the effect size
from the follow-up instead of post-intervention.
Moderation Analyses
Heterogeneity of effect sizes (or, dispersion) was assessed
using the Q statistic, and true dispersion was assessed based
on the I2 statistic. In the presence of significant heterogene-
ity (i.e., significant Q statistic), moderation analyses were
conducted (see Table6 for a list of all moderators). For
categorical moderators, moderation was examined using
subgroup analyses and significance was assessed via Q-sta-
tistics. Planned comparisons with two cells were not con-
ducted if one cell included fewer than five samples. Where
planned comparisons involved more than two cells, cells
with fewer than five samples were excluded from the analy-
sis. Independent meta-regressions were conducted for each
continuous moderator, separately (Borenstein etal., 2017,
2021). Subsequently, for each meta-analysis, all significant
categorical and continuous moderators were simultaneously
entered into a meta-regression to examine the unique vari-
ance of each, and their combined linear prediction capacity.
Transparency andOpenness
The systematic review and meta-analysis that follow are
guided by the Cochrane Handbook, and reporting complies
with the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses(PRISMA) statement (Page etal., 2021).
The protocol was published (Prime etal. 2021) and it was
preregistered with the International Prospective Register of
Systematic Reviews (PROSPERO; CRD42020222143). All
data and research materials (amendments from the study
protocol;screening, full-text assessment, and data extrac-
tion manuals) will be made available at APA’s repository
on the open science framework (OSF). Data were modeled
using Comprehensive Meta-Analysis Version 3; code/syntax
is not applicable.
Results
Study Selection
Figure1 presents the PRISMA flow diagram. After removal
of duplicates, there were 11,972 abstract/titles of records
screened, with 570 moving to the full-text assessment.3
Primary reasons for exclusion from the review were: not
an RCT, not a positive parenting intervention, no cognition
outcome assessment, and exclusionary intervention criteria
(i.e., primary focus on a target other than positive parenting).
This resulted in 69 eligible papers. Backward and forward
chaining of these papers resulted in screening an additional
402 records, with 96 assessed at the full-text stage, and an
additional 10 papers for inclusion (to make 79 total). Papers
were examined for overlapping samples, resulting in 61 inde-
pendent samples across 79 papers.
Description ofStudies
Outcome Characteristics
Table1 provides study-level outcome and participant char-
acteristics. Studies included the following child outcome
assessments (not mutually exclusive): mental abilities
(k = 39, 63.9% of studies), language (k = 34, 55.7%), execu-
tive functioning (k = 14, 23%), and/or pre-academics (k = 8,
13.1%). Of these, 35 studies (57.4%) examined one outcome
3 There were 12 full-texts that could not be located through tradi-
tional methods. We attempted to contact authors to request full-texts,
and we were successful in obtaining three.
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Clinical Child and Family Psychology Review
1 3
domain only, 20 studies (32.8%) two outcome domains,
four studies (6.6%) three outcome domains, and two studies
(3.3%) examined all four outcome domains.
Child andContextual Characteristics
At baseline, the median age of children was 14.6months
(IQR 1.0–32.1months), with a range from 0 to 61.6months
old. At the time of outcome assessment, the median child age
was 36months (IQR 18.0–50.1months), with a range from
6 to 67.6months old. The mean proportion of male children
was 51.8% (range from 38.9 to 78.0%). Several studies had
children with early risk factors: eight studies included chil-
dren with socio-emotional or behavioural problems and 17
studies included children with perinatal or postnatal com-
plications. Around half of studies included parents with less
than or equal to high school education (k = 31; 50.8%), and
many studies included samples of families designated as low
income (k = 38, 62.3%). Three studies (4.9%) included ado-
lescent parents. Average parent age was 29.3years (range
from 17.5 to 43.2years). Ten studies (16.4%) included sam-
ples of parents reporting mental health difficulties.
Intervention Characteristics
As shown in Table2, there was overlap across studies in the
interventions implemented (Mother–Child Home Program,
k = 5; Play and Learning Strategies, k = 4; Mother-Infant
Transaction Program, k = 4; Mediational Intervention for
Sensitizing Caregivers, k = 3; Incredible Years Parenting
Program, k = 2; Family Check-Up, k = 2). The exact nature
of comparison groups is listed in Table2. In terms of inten-
sity, 24 studies (39.3%) included interventions with 16 + ses-
sions (with the remainder having < 16 sessions). For dura-
tion, 20 studies (32.8%) included interventions that lasted
12months or more (with the remainder being under a year).
Interventions targeted emotional responsiveness (k = 25,
41%), cognitive responsiveness (k = 12, 19.7%), behav-
ioural guidance (k = 6, 9.8%) and/or a combination of two
or more targets (k = 18, 29.5%). Mothers were included in
all studies (with a median of 100 %and inter-quartile range
of 99.4% to 100%). In contrast, 11 studies (18%) reported
father involvement. Interventions were delivered by trained
interventionists (k = 18, 29.5%; e.g., coaches), clinical health
workers (k = 13, 21.3%; e.g., physical therapists), mental
health professionals (k = 10, 16.4%; e.g., psychologists),
research staff (k = 8, 13.1%), community volunteers (k = 4,
6.6%; e.g., peers), educators (k = 3, 4.9%; e.g., teachers), or
were not classified (k = 5, 8.2%).
Methodological Characteristics
Methodological characteristics are presented in Table3.
Studies spanned from 1979 to 2021. Including studies from
Fig. 1 PRISMA 2020 flow diagram for new systematic reviews (Page etal., 2021)
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Clinical Child and Family Psychology Review
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Table 1 Child and contextual characteristics
Study Child outcomes Child age, months
(Baseline)a
Child age, months
(Outcome)a
Child, % male Child,
birth risk
Child, socio-
emotional risk
Context, low
education
Context, low
income
Context,
parent age
Context, parent
mental health
MA L EF PA
Sample A (2 papers)bX X 43.05 61.05 51.20 X 29.44
Sample B (4 papers)bX X X X 0.68 48.00 53.75 X X X 28.20
Sample D (5 papers)bX X X 29.90 36.00 51.00 X X X 26.90
Sample E (2 papers)bX X 4.00 56.00 54.00 X 27.50
Sample F (2 papers)bX X 8.93 13.93 53.70 X X – X
Sample G (3 papers)bX 13.47 15.47 55.00 X X X 29.57
Sample H (2 papers)bX X 0.00 60.00 52.94 X 30.21
Sample I
(3 papers)b
X X X 0.00 44.00 50.31 X 34.20
Sample J (5 papers)bX 0.00 6.00 50.00 X 27.05
Sample K (2 papers)bX X 22.00 41.00 43.37 X X 24.35
Abikoff etal. (2015) X 42.84 44.84 73.80 X –
Aboud and Akhter (2011) X 14.16 22.16 46.67 X X 23.45
Alvarenga etal. (2020) X 1.00 12.00 61.36 X X 27.66
Bernard etal. (2017) X 14.80 39.52 44.00 43.20
Boivin etal. (2013a) X 33.60 45.60 53.78 X X –
Boivin etal. (2013b) X 43.80 55.80 54.20 – X –
Boivin etal. (2017) X X 34.44 46.44 56.56 X X 35.00
Cameron etal. (2021) X X 4.00 36.00 38.89 X 30.60
Cassidy etal. (2017) X 48.60 50.90 41.80 X X 29.55
Cicchetti etal. (2000) X X 20.47 36.00 51.20 31.62 X
Colditz etal. (2019) X X 0.00 24.00 58.85 X 30.60
Cooper etal. (2015) X 0.00 18.00 48.48 28.30 X
Dubois-Comtois etal. (2017) X 17.76 20.06 51.20 X X 24.20
Elizur etal. (2017) X 48.63 52.08 78.00 X X X 34.97
Feeley etal. (2012) X X 1.08 6.00 48.96 X 30.69 X
Feil etal. (2020) X 4.41 10.41 44.20 X 27.23 X
Fewell and Wheeden (1998) X 14.56 17.56 51.61 X X 17.47
Flierman etal. (2016) X X 18.00 24.00 50.00 X 31.00
Fong etal. (2019) X 17.40 18.40 52.00 X X 25.75
Francis and Baker-Henningham, (2021) X 48.48 50.32 50.70 X X X 31.88
Guttentag etal. (2014) X 0.00 30.00 – X X 20.49
Hutchings etal. (2017) X 21.33 27.33 58.40 X 28.97
Jensen etal. (2021) X X 21.42 36.42 49.72 X X X 36.00
Jin etal. (2007) X 10.23 16.23 63.00 X –
Johnson etal. (2009) X 0.00 24.26 47.64 X X – 29.50
Jones (2003) X 34.60 35.52 61.00 – 29.20 X
Kersten-Alvarez etal. (2010) X 5.50 67.60 60.35 X 30.35 X
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Clinical Child and Family Psychology Review
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MA mental abilities, L language, EF executive functioning, PA pre-academics
a Based on the assessment included in the meta-analysis
b Sample A (Clarke etal., 2012; Sheridan etal., 2011); Sample B (Jeong etal., 2019; Obradovic etal., 2016; Yousafzai etal., 2014; Yousafzai etal., 2016); Sample D (Brennan etal., 2013; Chang etal., 2015;
Chang etal., 2017; Connell etal., 2019; Lunkenheimer etal., 2008); Sample E (Barrera etal., 1986; Barrera etal., 1991); Sample F (Green etal., 2015; Green etal., 2017); Sample G (Bagner etal., 2016; Gar-
cia etal., 2019; Heymann etal., 2020); Sample H (Kaaresen etal., 2008; Nordhov etal., 2010); Sample I (Koldewijn etal., 2010; van Hus etal., 2013; Verkerk etal., 2012); Sample J (Achenbach etal., 1990,
Achenbach etal., 1993; Nurcombe etal., 1984; Rauh etal., 1988; Rauh etal., 1990); Sample K (Slaughter etal., 1979; Slaughter etal., 1983)
c 1973 Cohort
d 1974 Cohort
e 1975 Cohort
f 1976 Cohort
Table 1 (continued)
Study Child outcomes Child age, months
(Baseline)a
Child age, months
(Outcome)a
Child, % male Child,
birth risk
Child, socio-
emotional risk
Context, low
education
Context, low
income
Context,
parent age
Context, parent
mental health
MA L EF PA
Klein and Alony (1993) X X 12.07 55.07 50.00 X X 28.00
Kyno etal. (2012) X X 0.00 36.00 59.64 X 32.25
Landry etal. (2006) X 6.20 12.00 48.48 X X 27.40
Landry etal. (2017) X X X 52.44 60.44 49.20 X X –
Landry etal. (2021) X X X 50.76 57.76 50.00 X X 37.17
Letourneau etal. (2011) X 5.29 7.99 50.00 X 28.00 X
Madden etal. (1984)cX X 26.00 50.00 56.00 X X 31.06
Madden etal. (1984)dX X 25.46 49.46 50.00 X X 28.65
Madden etal. (1984)eX X 26.17 50.17 44.52 X X 29.33
Madden etal. (1984)fX 25.47 49.47 41.69 X X 26.49
Magwaza and Edwards (1991) X 54.00 56.30 50.00 X X 35.00
McManus etal. (2020) X X 0.00 6.00 52.63 X X –
Metzl etal. (1980) X 1.38 6.00 50.00 –
Milgrom etal. (2013) X 0.00 6.00 42.21 X 33.75
Murray etal. (2016) X 0.00 18.00 52.47 X X 26.10 X
Newnham etal. (2009) X X 0.00 24.00 52.38 X 31.50
O'Bleness etal. (2015) X 30.68 33.16 51.61 X X 27.55
Pontoppidan etal. (2020) X 1.50 18.00 54.54 29.33
Roggman etal. (2009) X 5.00 36.00 51.00 X 22.84
Scarr and McCartney (1988) X X X X 27.00 45.00 50.00 X 27.70
Semenov etal. (2021) X X 49.43 53.43 54.88 X 32.11
Strayhorn and Weidman (1989) X 45.00 48.34 44.00 X X X 28.40 X
Tachibana etal. (2012) X 61.56 64.56 48.32 – 33.78
Walker etal. (2004) X 0.00 24.00 43.51 X X X 23.88
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overlapping samples, records were reported in journal arti-
cles (k = 74, 91.4%), book chapters (k = 2, 2.5%), disserta-
tions (k = 4, 4.9%), and a single working paper (1.2%). Sam-
ple sizes ranged from 29 to 1261 participants (median = 97,
IQR = 57.50–184.00). Participants were recruited from 21
countries, most frequently the United States (k = 26, 42.6%).
Interventions were delivered in the home (k = 26, 42.6%),
home and one other setting (e.g., hospital or community;
k = 14, 23%), hospital (k = 9, 14.8%), community (k = 4,
6.6%),research setting (k = 3, 4.9%), school (k = 3, 4.9%),
community (k = 4, 6.6%), and via technology (k = 1, 1.6%).
Risk ofBias
The risk of bias assessment for individual studies is pre-
sented in Fig.2. Summary descriptive information for each
criterion is provided in Table4. Based on ratings of prob-
ably yes or definitely yes, many studies reported adequate
allocation sequence generation (k = 33; 54.1), allocation
concealment (k = 33; 54.1%), and use of masked data col-
lectors (k = 36; 59%), thus mitigating potential selection and
detection biases. Most studies reported low attrition rates
(k = 39; 64%) and did not report other biases such as signifi-
cant baseline differences (k = 35; 57.4%). Regarding selec-
tive outcome reporting, most studies (k = 50; 82%)showed
consistency in the outcomes reported in their methods and
results sections. However,given that a minority of studies
reported trial registration information (k = 23, 37.7%), selec-
tive outcome reporting was mostly rated as probably low
risk, as we could not confirm planned analyses. Twenty stud-
ies (32.8%) reported a priori power analyses to determine
required sample sizes. Further, due to the nature of interven-
tion-based studies, those delivering the parenting interven-
tion could not be masked to participant group allocation (no
studies with masked interventionists), and participants were
not commonly masked (typically when two active treatments
were compared to a control group; k = 11; 18.0%). Finally,
three studies (4.9%) were rated as having masked data ana-
lysts, due to infrequent reporting on this item. Total risk of
bias scores ranged from 0 to 9 (mean score = 4.95).
Meta‑Analyses
Mental Abilities
Meta-analytic findings for all four meta-analyses, and sensi-
tivity analyses, can be found in Table5. Positive parenting
interventions led to significant improvements in children’s
mental abilities, based on 5746 participants (g = 0.46; 95%
CI 0.32, 0.61, p < 0.0001, k = 33; Fig. 3). Five samples
with missing data were excluded from analyses using list-
wise deletion (sensitivity analyses below).4 The Duval and
Tweedie’s trim-and-fill procedure did not provide evidence
of publication bias (i.e., no additional effect sizes were
imputed to balance reported positive intervention effects).
Significant heterogeneity (Q(32) = 197.62, p < 0.0001)
and true dispersion (I2 = 83.81) were evident. Moderation
results are presented in Table6. Only significant findings
are reported in-text, but several near-significant moderators
emerged and can be seen in Tables6, 7, 8. Studies that were
scored as having a higher risk of bias yielded larger effect
sizes than those that were rated as having a lower risk of
bias (β = − 0.07, CI −0.13, − 0.003, p < 0.05, z = −2.07;
Fig.4). Furthermore, larger improvements in mental abilities
were detected amongst studies that used standardized direct
assessments of child mental abilities (g = 0.53; 95% CI 0.36,
0.70, k = 27), as compared to those that used parent-reported
outcome measures (g = 0.16; 95% CI 0.06, 0.26, k = 6).
When statistically significant moderators (risk of bias
scores and method of assessment) were simultaneously
entered into a meta-regression, risk of bias was signifi-
cant (β = − 0.07, CI −0.13, −0.004, p < 0.05, z = −2.09),
and instrument measurement was reduced to p < 0.10
(β = − 0.32, CI −0.70, 0.06, z = − 1.64).
Language
Based on a meta-analysis of 30 studies (n = 6248), positive par-
enting interventions led to significant gains in children’s lan-
guage skills (g = 0.25, 95% CI 0.14, 0.35, p < 0.0001; Fig.5).
Four samples with missing data were excluded from analyses.
Duval and Tweedie’s trim-and-fill procedure indicated six stud-
ies imputed to balance reported positive intervention effects,
based on random effects models (adjusted point estimate = 0.16
(95% CI 0.05, 0.27; Fig.6). Rosenthal's (1991) Fail-safe N was
examined, as an additional indicator of potential publication
bias, which indicated that 516 studies with null results would
be required to reduce the p-value to below significance.
There was significant heterogeneity (Q(29) = 117.63,
p < 0.0001), with evidence of true dispersion I2 = 75.35.
Moderation analyses, presented in Table7, showed that
younger children made more gains than older children (β =
−0.01, CI−0.01, −0.002, p < 0.01, z = − 2.78; Fig.7).
Interventions were more effective with parents who had
more than a high school education (g = 0.36; 95% CI 0.23,
0.49, k = 15) as compared to those with less than or equal
to high school education (g = 0.14; 95% CI −0.01, 0.30,
4 We contacted the authors of 61 studies to request additional infor-
mation such as: means/SD, pre-post correlations or study characteris-
tics. We were successful in obtaining requested information from the
authors of 29 studies (the remaining studies had no response (k = 18)
or decline/unavailable data (k = 14).
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Table 2 Intervention characteristics
Study Intervention name 16 + Sessions 12 + Months Parent target Fathers Interventionist Comparison group
Sample A (2 papers)aGetting ready (and head start) X M Educators Head start only
Sample B (4 papers)aResponsive stimulation interven-
tion (a subset also had enhanced
nutrition)
X X ER Community volunteers Routine health and nutrition services
Sample D (5 papers)aFamily check-up X X BG X Trained interventionists Assessment procedures only
Sample E (2 papers)aParent-infant treatment + develop-
mental intervention (combined)
X X ER Mental health professionals Assessment schedule only
Sample F (2 papers)aIntervention in the British Autism
study of infant siblings-video
interaction for promoting positive
parenting (iBASIS-VIPP)
ER Mental health professionals Assessment schedule only
Sample G (3 papers)aInfant behaviour program BG Clinical health workers Standard pediatric primary care
Sample H (2 papers)aModified mother-infant transaction
program
ER X Clinical health workers Standard hospital protocol (e.g., infant
screening, baby massage, discharge
consultation) and follow-up care
Sample I (3 papers)aInfant behavioral assessment and
intervention program
ER X Clinical health workers Received standard care and optional
physical therapy
Sample J (5 papers)aMother-infant transaction program ER X Clinical health workers Routine nursery services
Sample K (2 papers)aToy demonstration program X X ER Mental health professionals Toys delivered every week
Abikoff etal. (2015) New forest parenting package M Mental health professionals Received treatment of choice fol-
lowing completion of assessment
schedule
Aboud and Akhter (2011) Responsive feeding and stimulation X X CR Community volunteers Received 12 informational sessions on
health, nutrition and child develop-
ment
Alvarenga etal. (2020) Maternal sensitivity program M Other Received magnets every month, show-
ing the main behavioral acquisitions
they should expect to observe in
their babies
Bernard etal. (2017) Attachment and biobehavioral
catch-up
ER Trained interventionists Developmental education for families
(DEF)
Boivin etal., (2013a) Mediational intervention for sensitiz-
ing caregivers
X X CR Other Nutrition and hygiene curriculum
Boivin etal., (2013b) Mediational intervention for sensitiz-
ing caregivers
X X CR Trained interventionists Nutrition and hygiene curriculum
Boivin etal. (2017) Mediational intervention for sensitiz-
ing caregivers
X X CR Other Nutrition and hygiene curriculum
Cameron etal. (2021) Growing: birth to three X X ER X Educators Regular follow-ups at the outpatient
clinic and one home-visit one month
after discharge from the hospital
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Table 2 (continued)
Study Intervention name 16 + Sessions 12 + Months Parent target Fathers Interventionist Comparison group
Cassidy etal. (2017) Circle of security parenting interven-
tion
ER Clinical health workers Offered to attend the circle of security-
P program following assessment
schedule
Cicchetti etal. (2000) Toddler-parent psychotherapy X X ER Mental health professionals Assessment schedule only
Colditz etal. (2019) Baby triple P for preterm infants ER Clinical health workers Routine care for preterm infants
Cooper etal. (2015) Index Intervention ER Clinical health workers Routine primary care
Dubois-Comtois etal. (2017) Attachment video-feedback interven-
tion
ER Clinical health workers Received standard agency services,
(i.e., monthly visit by a child welfare
caseworker)
Elizur etal. (2017) Hitkashrut M X Mental health professionals Minimal Intervention. Two consulta-
tion sessions using Hitkashrut's key
components and handouts
Feeley etal. (2012) Cues intervention ER Research staff Attention control. Discussed topics
related to newborn care and received
information booklets
Feil etal. (2020) Play and learning strategies (internet
adaptation)
M Trained interventionists Attention control program
Fewell and Wheeden (1998) Play and learn strategies X M Research staff Continued participation in public
school program which included
childcare curriculum
Flierman etal. (2016) Transmural developmental support
for preterm children and their par-
ents (ToP) AND additive respon-
sive parenting program (ToP +)
M Mental health professionals Usual care (which included participa-
tion in the ToP program during the
first year)
Fong etal. (2019) Phadthana khong dek M Clinical health workers Assessment schedule only
Francis and Baker-Henningham
(2021)
The irie homes toolbox BG Research staff Waitlist control. Preschools were
offered training in the Irie homes
toolbox
Guttentag etal. (2014) My baby & me X X M Trained interventionists Low-intensity condition. Monthly
phone calls from a coach, printed
informational materials, and com-
munity resource referrals
Hutchings etal. (2017) Incredible years toddler parenting
programme
BG Clinical health workers Wait-list. Offered the intervention
after the 6-month follow-up assess-
ment
Jensen etal. (2021) Sugira muryango ER X Trained interventionists Offered the social protection public
works programme and other services
as usual
Jin etal. (2007) The mother's card M Mental health professionals Assessment schedule only
Johnson etal. (2009) Parent baby interaction programme ER Clinical health workers Standard care in neonatal unit
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Table 2 (continued)
Study Intervention name 16 + Sessions 12 + Months Parent target Fathers Interventionist Comparison group
Jones (2003) Early childhood family check-up BG Mental health professionals Wait-list control
Kersten-Alvarez etal. (2010) Mother-baby intervention ER Trained interventionists Three 15-min telephone calls provid-
ing information about child-rearing
skills
Klein and Alony (1993) Maternal mediation intervention X CR Trained interventionists Information on milestones in early
development
Kyno etal. (2012) Mother-infant transaction program ER X Clinical health workers Assessment schedule only
Landry etal. (2006) Playing and learning strategies M Trained interventionists Developmental feedback
Landry etal. (2017) Play and learning strategies (in addi-
tion to head start)
X M Trained interventionists Head start only
Landry etal. (2021) Online play and learning strategies,
ePALS (and head start)
X M X Other Head start only
Letourneau etal. (2011) Peer support and maternal-infant
interaction intervention
ER Community volunteers Two weeks of peer support after a
12-week waiting period
Madden etal. (1984)bMother–child home program X X CR Trained interventionists Provision of toys and books
Madden etal. (1984)cMother–child home program X X CR Trained interventionists Toys and books but no home sessions
were provided
Madden etal. (1984)dMother–child home program X X CR Trained interventionists Toys and books, but no home sessions
were provided
Madden etal. (1984)eMother–child home program X X CR Trained interventionists Toys and books, but no home sessions
were provided
Magwaza and Edwards (1991) An integrated parent-effectiveness
and children's enrichment pro-
gramme
CR Research staff Weekly two-hour home visits to
discuss issues related to general
community affairs
McManus etal. (2020) Newborn behavioral observations
(NBO) system
ER Trained interventionists Usual care. EI home-based service
delivery, including therapeutic and
developmental activities
Metzl etal. (1980) Infant language program M X Research staff Assessment schedule only
Milgrom etal. (2013) PremieStart-enhanced mother-infant
transaction program
ER Mental health professionals Standard best-practice procedures for
the care of preterm infants
Murray etal. (2016) Home visiting intervention X X ER Community volunteers Fortnightly visits by a community
health worker who monitored mater-
nal and infant health
Newnham etal. (2009) Modified mother-infant transaction
program
ER Research staff Standard hospital care
O'Bleness etal. (2015) Child's game M Research staff Play-as-usual. Eight play sessions
once per week for 20min each time
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Table 2 (continued)
Study Intervention name 16 + Sessions 12 + Months Parent target Fathers Interventionist Comparison group
Pontoppidan (2020) Incredible years parents and babies
program
M X Trained interventionists Usual care. Home visits, open consul-
tation hours at a local clinic, volun-
tary participation in a social group,
and extra support if needed
Roggman etal. (2009) Bear river early head start program X X ER Educators Assessment schedule only
Scarr and McCartney (1988) Mother–child home program X X CR Trained interventionists Assessment procedures only
Semenov etal. (2021) R4R intervention and PEER(E) M Trained interventionists Wait-list. Business as usual head start
and early head start
Strayhorn and Weidman (1989)Preventive mental health intervention BG Research staff Minimal intervention. Shown the first
two videotapes of the experimental
group and received a copy of the
parent handout
Tachibana etal. (2012) Mother–child play activity program X CR Other Received play activity program after
completion of assessment schedule
Walker etal. (2004) Psychosocial intervention based on
the programme for the enrichment
of interactions between mothers
and children
X X M Clinical health workers Infants were visited weekly to obtain
information on infant feeding and
morbidity
ER emotional responsiveness, BG behavioural guidance, CR cognitive responsiveness, M mixed; combination of 2 + targets
a Sample A (Clarke etal., 2012; Sheridan etal., 2011); Sample B (Jeong et al., 2019; Obradovic etal., 2016; Yousafzai etal., 2014; Yousafzai etal., 2016); Sample D (Brennan etal., 2013;
Chang etal., 2015; Chang etal., 2017; Connell etal., 2019; Lunkenheimer etal., 2008); Sample E (Barrera etal., 1986; Barrera etal., 1991); Sample F (Green etal., 2015; Green etal., 2017);
Sample G (Bagner etal., 2016; Garcia et al., 2019; Heymann etal., 2020); Sample H (Kaaresen etal., 2008; Nordhov etal., 2010); Sample I (Koldewijn etal., 2010; van Hus etal., 2013;
Verkerk etal., 2012); Sample J (Achenbach etal., 1990, Achenbach etal., 1993; Nurcombe etal., 1984; Rauh etal., 1988; Rauh etal., 1990); Sample K (Slaughter etal., 1979;Slaughter etal.,
1983)
b 1973 Cohort
c 1974 Cohort
d 1975 Cohort
e 1976 Cohort
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Table 3 Methodological characteristics
Study Record Sample size Setting Country
Sample A (2 papers)a1 Working paper
1 Journal article
217 Home United States
Sample B (4 papers)a4 Journal articles 1261 Home + other setting Pakistan
Sample D (5 papers)a5 Journal articles 645 Home United States
Sample E (2 papers)a2 Journal articles 45 Home Canada
Sample F (2 papers)a2 Journal articles 50 Home UK
Sample G (3 papers)a3 Journal articles 60 Home United States
Sample H (2 papers)a2 Journal articles 131 Hospital Norway
Sample I (3 papers)a2 Book chapters
1 Journal article
151 Hospital Netherlands
Sample J (5 papers)a5 Journal articles 74 Hospital United States
Sample K (2 papers)a2 Journal articles 40 Home + other setting United States
Abikoff etal. (2015) Journal article 101 Home United States
Aboud and Akhter (2011) Journal article 186 Community Bangladesh
Alvarenga etal. (2020) Journal article 44 Home Brazil
Bernard etal. (2017) Journal article 52 Home United States
Boivin etal., (2013a) Journal article 114 Research setting Uganda
Boivin etal., (2013b) Journal article 100 Home + other setting Uganda
Boivin etal. (2017) Journal article 221 Home + other setting Uganda
Cameron etal. (2021) Journal article 36 Home Norway
Cassidy etal. (2017) Journal article 141 School United States
Cicchetti etal. (2000) Journal article 97 Home + other setting United States
Colditz etal. (2019) Journal article 304 Hospital Australia
Cooper etal. (2015) Journal article 148 Home UK
Dubois-Comtois etal. (2017) Journal article 41 Home Canada
Elizur etal. (2017) Journal article 182 –bIsrael
Feeley etal. (2012) Journal article 96 Hospital Canada
Feil etal. (2020) Journal article 150 Technological United States
Fewell and Wheeden (1998) Journal article 62 School United States
Flierman etal. (2016) Journal article 60 Home Netherlands
Fong etal. (2019) Dissertation 121 Home Laos
Francis and Baker-Henningham (2021) Journal article 212 – Jamaica
Guttentag etal. (2014) Journal article 225 Home + other setting United States
Hutchings etal. (2017) Journal article 89 Community UK
Jensen etal. (2021) Journal article 1084 Home Rwanda
Jin etal. (2007) Journal article 87 Home China
Johnson etal. (2009) Journal article 194 Hospital UK
Jones (2003) Dissertation 59 Research setting United States
Kersten-Alvarez etal. (2010) Journal article 58 Home Netherlands
Klein and Alony (1993) Journal article 59 Home Israel
Kyno etal. (2012) Journal article 57 Hospital Norway
Landry etal. (2006) Journal article 264 Home United States
Landry etal. (2017) Journal article 220 Home United States
Landry etal. (2021) Journal article 293 Home + other setting United States
Letourneau etal. (2011) Journal article 48 Home + other setting Canada
Madden etal. (1984)cJournal article 34 Home + other setting United States
Madden etal. (1984)dJournal article 48 Home + other setting United States
Madden etal. (1984)eJournal article 29 Home + other setting United States
Madden etal. (1984)fJournal article 55 Home + other setting United States
Magwaza and Edwards (1991) Journal article 60 Home South Africa
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k = 15). Furthermore, interventions that only included moth-
ers (g = 0.29; 95% CI 0.16, 0.41, k = 23) were more effec-
tive than those that also included fathers (g = 0.09; 95% CI
−0.04, 0.23, k = 7).
When child age (at baseline), parental education, and
father involvement were entered into a meta-regression
simultaneously, child age at baseline (β = −0.01, CI −0.01,
−0.0003, z = −1.85) was reduced to near-significance
(p = 0.06), whereas parental education and father involve-
ment were no longer significant moderators.
Executive Functioning
There were 14 studies (n = 3628) included in the meta-anal-
ysis of executive functioning outcomes, with results indi-
cating a nonsignificant pooled effect size (g = 0.07; 95% CI
−0.09, 0.23, ns; Fig.8). The Duval and Tweedie’s trim and
fill procedure did not provide evidence of publication bias.
There was evidence of significant heterogeneity
(Q(13) = 74.88, p < 0.0001), including true dispersion
(I2 = 82.64). Categorical moderators were not examined due
to small cell sizes (i.e., < 5 studies per cell), except for inter-
vention intensity, with cell sizes allowing for moderation
analysis. Intervention intensity did not emerge as a signifi-
cant moderator. As shown in Table8, only one continuous
moderator emerged to explain between-study variability;
parental age was negatively associated with effect size,
wherein interventions that included samples of younger
mothers had larger effect sizes than those with older moth-
ers (β = −0.04, CI −0.08, −0.003, p < 0.05, z = 2.11). To
examine the potential confounding effect of child age, we
included child and parental age in a meta-regression simul-
taneously. When controlling for baseline child age, parental
age was reduced to p < 0.10.
Pre‑Academics
A meta-analysis of studies that included an outcome assess-
ment of pre-academics (k = 7; n = 2365) yielded a positive
but nonsignificant pooled effect (g = 0.16; 95% CI −0.03
0.34, p < 0.10; Fig.9). One sample with missing data was
excluded from analyses. The Duval and Tweedie’s trim-
and-fill procedure did not provide evidence of publication
bias (i.e., no additional effect sizes were imputed). There
was significant heterogeneity (Q(5) = 29.89, p < 0.01) and
dispersion (I2 = 79.93). However, limited studies precluded
moderation analyses.
a Sample A (Clarke etal., 2012; Sheridan etal., 2011); Sample B (Jeong etal., 2019; Obradovic etal., 2016; Yousafzai etal., 2014; Yousafzai
etal., 2016); Sample D (Brennan etal., 2013; Chang etal., 2015; Chang etal., 2017; Connell etal., 2019; Lunkenheimer etal., 2008); Sample E
(Barrera etal., 1986; Barrera etal., 1991); Sample F (Green etal., 2015; Green etal., 2017; Sample G: Bagner etal., 2016; Garcia etal., 2019;
Heymann etal., 2020); Sample H (Kaaresen etal., 2008; Nordhov etal., 2010); Sample I (Koldewijn etal., 2010; van Hus etal., 2013; Verkerk
etal., 2012); Sample J (Achenbach etal., 1990, Achenbach etal., 1993; Nurcombe etal., 1984; Rauh etal., 1988; Rauh etal., 1990); Sample K
(Slaughter etal., 1979;Slaughter etal., 1983)
b Missing data
c 1973 Cohort
d 1974 Cohort
e 1975 Cohort
f 1976 Cohort
Table 3 (continued)
Study Record Sample size Setting Country
McManus etal. (2020) Journal article 38 – United States
Metzl etal. (1980) Journal article 40 Home United States
Milgrom etal. (2013) Journal article 91 Hospital Australia
Murray etal. (2016) Journal article 263 Home South Africa
Newnham etal. (2009) Journal article 63 Hospital Australia
O'Bleness etal. (2015) Dissertation 155 Research setting United States
Pontoppidan etal. (2020) Journal article 81 Home + other setting Denmark
Roggman etal. (2009) Journal article 161 Home United States
Scarr and McCartney (1988) Journal article 117 Home Bermuda
Semenov etal. (2021) Dissertation 128 – United States
Strayhorn and Weidman (1989) Journal article 95 – United States
Tachibana etal. (2012) Journal article 219 Home + other setting Japan
Walker etal. (2004) Journal article 131 Home Jamaica
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Fig. 2 Clarity tool: risk of bias assessment. One optional question is not included due to a large amount of missing data: ‘Masking Questions E:
Other groups masked to group allocation’. 11973 cohort, 21974 cohort, 31975 cohort, 41976 cohort
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Fig. 2 (continued)
Table 4 Risk of bias summary
Definitely yes f(%) Probably yes f(%) Probably no f(%) Definitely no f (%)
1. Allocation sequence adequately generated? 31 (50.8) 2 (3.3) 28 (45.9) –
2. Allocation adequately concealed? 14 (23) 19 (31.1) 28 (45.9) –
3. Parents masked to allocation? 3 (4.9) 8 (13.1) 21 (34.4) 29 (47.5)
4. Interventionists masked? – – 1 (1.6) 60 (98.4)
5. Data collectors masked? 33 (54.1) 3 (4.9) 19 (31.1) 6 (9.8)
6. Data analysts masked? 2 (3.3) 1 (1.6) 58 (95.1) –
7. Loss to follow-up infrequent? 37 (60.7) 2 (3.3) 7 (11.5) 15 (24.6)
8. Free of selective outcome reporting? 7 (11.5) 43 (70.5) 8 (13.1) 3 (4.9)
9. Trial registered? 23 (37.7) – 37 (60.7) 1 (1.6)
10. Power analysis completed? 20 (32.8) – 38 (62.3) 3 (4.9)
11. Study sufficiently powered? 19 (31.1) – 36 (59.0) 6 (9.8)
12. Free of other problems? 32 (52.5) 3 (4.9) 7 (11.5) 19 (31.1)
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Table 5 Meta-analytic results and sensitivity analyses for all outcomes
**p < 0.01; *p < 0.05; †p < 0.1
Main analysis Sensitivity analyses
Pre-post cor-
relation
Combining out-
comes
Outcome assess-
ment
Missing data
k n g Q g Q g Q g Q k g Q
Mental Abilities 33 5746 0.46** 197.62** 0.43** 171.83** 0.47** 197.24** 0.43** 182.51** 38 0.41** 210.02**
Language 30 6248 0.25** 117.63** 0.24** 98.42** 0.25** 110.88** 0.25** 75.40** 34 0.23** 119.45**
Exec. Functions 14 3628 0.07 74.88** 0.07 57.51** 0.07 53.18** 0.06 70.24** 14 0.07 74.88**
Pre-Academics 7 2365 0.16†29.89** 0.14†21.04*0.16†21.2*0.16†29.89** 8 0.14†33.55**
Fig. 3 Forest plot for meta-analysis of mental abilities outcomes
(k = 33). Sample B (Jeong et al., 2019; Obradovic et al., 2016;
Yousafzai etal., 2014; Yousafzai etal., 2016); Sample H (Kaaresen
etal., 2008; Nordhov etal., 2010); Sample I (Koldewijn etal., 2010;
van Hus et al., 2013; Verkerk etal., 2012); Sample J (Achenbach
et al., 1990, Achenbach et al., 1993; Nurcombe etal., 1984; Rauh
et al., 1988; Rauh etal., 1990); Sample K (Slaughter et al., 1979;
Slaughter etal., 1983)
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Table 6 Results of moderator analyses for meta-analysis of mental abilities (k = 33)
Categorical moderators
k g 95% CI lower 95% CI upper Q
Child characteristics
Child birth risk – – – – 3.18†
None reported 20 0.57 0.35 0.80
Some reported 13 0.32 0.28 0.55
Child emotional-behavioural risk – – – – –
None reported 31 – – –
Some reported 2 – – –
Contextual characteristics
Parental education – – – – 0.85
Mid/High 17 0.58 0.30 0.85
Low 14 0.42 0.24 0.60
Household income – – – – 0.09
Mid/High 16 0.52 0.27 0.76
Low 16 0.47 0.28 0.65
Parental mental health – – – – 3.69†
None reported 28 0.52 0.36 0.68
Some reported 5 0.22 -0.05 0.48
Intervention characteristics
Intervention type – – – – 2.27
Behavioural guidance 1 – – –
Cognitive responsiveness 6 0.49 0.11 0.87
Emotional responsiveness 19 0.32 0.18 0.45
Mixed (1 + of above) 7 0.61 0.20 1.02
Intensity – – – – 1.85
 < 16 sessions 20 0.56 0.32 0.80
16 + sessions 13 0.37 0.24 0.50
Duration – – – – 2.17
 < 12months 22 0.55 0.33 0.77
12 + months 11 0.36 0.22 0.49
Father involvement – – – – 0.05
None 25 0.48 0.31 0.65
Some 8 0.44 0.15 0.73
Methodological characteristics
Publication status – – – – –
Published 32 – – –
Unpublished 2 – – –
Instrument measure – – – – 13.25**
Observation 0 – – –
Report 6 0.16 0.06 0.26
Standardized/direct assessment 27 0.53 0.36 0.70
Continuous moderators
k β 95% CI lower 95% CI upper z score
Substantive moderators
Child age, baseline 33 0.005 −0.004 0.01 1.04
Child age, outcome assessment 33 −0.001 −0.01 0.01 −0.19
Child sex, male 33 0.01 −0.02 0.05 0.77
Parental age 29 −0.01 −0.05 0.02 −0.65
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Sensitivity Analyses
Sensitivity analyses were conducted independently for
each of the four meta-analyses. First, a sensitivity analysis
for the imputation of pre-post score correlations was con-
ducted, when not available (default = 0.7; sensitivity analy-
sis = 0.5). Second, we examined the sensitivity of findings
to our method of adjusting for the imputed correlations
amongst outcome variables when combining effect sizes
(default = 0.2; sensitivity analysis = 0.7). Third, analyses
were conducted wherein the latest available outcome assess-
ment was included (rather than earliest). Finally, analyses
were conducted wherein 0.0 was substituted for missing
values where data were not available for the calculation of
standardized difference scores. Across sensitivity analyses,
results of the pooled point estimates did not substantively
change (Table5). Thus, meta-analytic results appear robust.
Discussion
The aim of the current systematic review and meta-anal-
ysis was to synthesize the extant literature on RCTs of
positive parenting interventions that include an outcome
**p < 0.01; *p < 0.05; †p < 0.1
Table 6 (continued)
Continuous moderators
k β 95% CI lower 95% CI upper z score
Methodological moderators
Year 33 −0.013 −0.03 0.0001 −1.95†
Sample size 33 −0.0003 −0.001 0.0002 −1.02
Risk of bias, total score 33 −0.07 −0.13 −0.01 −2.07*
Fig. 4 Meta-regression of Hedge’s g on risk of bias for mental abilities meta-analysis. Higher scores on risk of bias represents lower risk of bias
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assessment of child cognition in children under age six.
Sixty-one studies from independent samples, spanning
1979 to 2021, were included in the review, yielding
diverse methodologies related to sample, intervention, and
publication characteristics. Findings highlight variability
in effect sizes as a function of outcome domain, with men-
tal abilities and language analyses yielding positive and
significant pooled effect sizes, and executive functioning
and pre-academics yielding smaller and nonsignificant
pooled effect sizes. Outcome-specific moderation analyses
in the mental abilities and language meta-analyses illus-
trate important conditions under which positive parent-
ing interventions yield the strongest effects. Findings are
considered robust based on a series of four sets of sensitiv-
ity analyses, which derived similar results in every case.
Outcome Domains
Positive parenting interventions were effective in enhanc-
ing mental abilities and language. Children whose parents
were assigned to a positive parenting intervention made
mental gains that were close to half (g = 0.46) of a stand-
ard deviation higher, and language gains that were a quarter
(g = 0.25) of a standard deviation higher, than those whose
parents were assigned to a control group. This contrasts with
executive functioning and pre-academic outcomes, where
Fig. 5 Forest plot for meta-analysis of language outcomes (k = 30).
Sample A (Clarke et al., 2012; Sheridan et al., 2011); Sample B
(Jeong et al., 2019; Obradovic et al., 2016; Yousafzai et al., 2014;
Yousafzai etal., 2016); Sample D (Brennan etal., 2013; Chang etal.,
2015; Chang etal., 2017; Connell et al., 2019; Lunkenheimer etal.,
2008); Sample F (Green etal., 2015; Green et al., 2017); Sample G
(Bagner etal., 2016; Garcia etal., 2019; Heymann etal., 2020); Sam-
ple H (Kaaresen etal., 2008; Nordhov etal., 2010); Sample I (Kold-
ewijn etal., 2010; van Hus etal., 2013; Verkerk etal., 2012); Sample
K (Slaughter etal., 1979; Slaughter etal., 1983)
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Clinical Child and Family Psychology Review
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the pooled effect sizes were smaller and nonsignificant.
This pattern of findings is consistent with the recent review
by Jeong etal. (2021), wherein moderate effect sizes were
found for mental abilities and language, with smaller effects
for behaviour problems, which show significant overlap with
executive functioning (Schoemaker etal., 2013). The differ-
ences in effect sizes amongst outcomes are substantial and
likely meaningful, further elaborated below.
The effect of positive parenting interventions on pre-
academic skills was positive but nonsignificant. Positive
parenting programs may not directly influence children’s
pre-academic skills. Parenting interventions that focus on
home-literacy activities and skill development may confer
greater benefits to children’s developing literacy and numer-
acy skills, though this remains speculative. As a possible
alternative, the fewer studies in the pre-academic analyses
(k = 7) may have affected power and precision of effect
estimates. As the number of primary studies grows, future
meta-analyses will be informative, as will an examination of
potential moderators of intervention effectiveness.
There was no evidence of positive parenting programs
enhancing executive functioning skills. Positive parenting
programs may not directly influence children’s developing
executive processes. Given that executive functioning is
highly heritable (Miyake & Friedman, 2012), it is important
to consider whether it is influenced by normative variations
in positive parenting. Rather, it may be that early execu-
tive functioning is more dependent on experiences of severe
environmental adversity, such as threat (e.g., abuse, expo-
sure to IPV) and/or deprivation (i.e., neglect, institutional
rearing, and food insecurity Johnson etal., 2021; Zelazo,
2020). Alternatively, there may be undetected timing effects
operating. For instance, only four of the 14 studies examin-
ing executive functioning as an outcome included interven-
tions prior to child age 24months. However, of the three
studies that showed positive and significant effects, two were
initiated prior to child age 24months (Green etal., 2015;
Obradović etal., 2016), and one was initiated at 48months
(Elizur etal., 2017). This provides some preliminary evi-
dence that interventions initiated earlier may be more
effective, which is in line with findings from the language
meta-analysis (elaborated below) and other psychosocial
interventions assessing cognitive recovery (Baudry etal.,
2017; Castle etal., 1999; Nelson etal., 2007). In the future,
with a larger number of primary studies, timing effects and
social disadvantage, as well as interactions between these
variables, should be examined as moderators of intervention
effectiveness.
There are two additional considerations regarding differ-
ential patterns of effectiveness. First, language and mental
abilities are easily (and typically) assessed by well-validated,
extensively used standardized direct assessments. In con-
trast, definitions, operationalization, and measurement vary
widely across methods of assessment of executive function-
ing and pre-academics. Furthermore, whereas mental abili-
ties and language emerge in the first two years of life, more
complex executive functions and pre-academic skills emerge
in toddlerhood and beyond. Thus, the latter constructs are
particularly difficult to assess in the earlier years, as nascent
skills are only beginning to emerge. As a result, observed
differences in effect sizes may, in part, be due to differences
in measurement, particularly early in development. Finally,
Fig. 6 Funnel plot of observed and imputed studies for language meta-analysis
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Clinical Child and Family Psychology Review
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Table 7 Results of moderator analyses for meta-analysis of language (k = 30)
Categorical moderators
k g 95% CI lower 95% CI upper Q
Child characteristics
Child birth risk – – – – 3.19†
None reported 19 0.21 0.07 0.34
Some reported 11 0.36 0.26 0.45
Child emotional-behavioural risk – – – – –
None reported 26 – – –
Some reported 4 – – –
Contextual characteristics
Parental education – – – – 4.32*
Mid/High 15 0.36 0.23 0.49
Low 15 0.14 −0.01 0.30
Household income – – – – 2.02
Mid/High 12 0.32 0.22 0.43
Low 18 0.19 0.04 0.34
Parental mental health – – – – 0.64
None reported 25 0.27 0.16 0.38
Some reported 5 0.09 −0.33 0.51
Intervention characteristics
Intervention type – – – – .07
Behavioural guidance 3 – – – –
Cognitive responsiveness 3 – – – –
Emotional responsiveness 15 0.26 0.12 0.41
Mixed (1 + of above) 9 0.23 0.04 0.42
Intensity – – – – 0.28
 < 16 sessions 19 0.22 0.09 0.35
16 + sessions 11 0.29 0.10 0.47
Duration – – – – 0.11
 < 12months 21 0.23 0.11 0.35
12 + months 9 0.27 0.06 0.49
Father involvement – – – – 4.19*
None 23 0.29 0.16 0.41
Some 7 0.09 −0.04 0.23
Methodological characteristics
Publication status – – – – –
Published 27 – – –
Unpublished 3 – – –
Instrument measure – – – – 0.21
Report/observation 9 0.28 0.12 0.44
Standardized/direct assessment 21 0.23 0.09 0.37
Continuous moderators
k β 95% CI lower 95% CI upper z score
Substantive moderators
Child age, baseline 30 −0.01 −0.01 0.00 −2.78**
Child age, outcome assessment 30 0.00 −0.01 0.00 −1.03
Child sex, male 29 0.00 −0.02 0.03 0.38
Parental age 26 0.00 −0.03 0.02 −0.10
Methodological moderators
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Clinical Child and Family Psychology Review
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it is helpful to consider the nature of content in positive par-
enting interventions. Specifically, most studies targeted emo-
tional responsiveness (k = 25), with only six studies targeting
behavioural guidance and an additional 12 targeting cogni-
tive responsiveness. It may be that executive functioning and
pre-academics are better targeted by programs that encour-
age behavioural guidance and/or cognitive responsiveness.
Indeed, as mentioned, positive parenting is a non-specific
term that includes varied, though overlapping, behaviours.
Given this, future research needs to identify those aspects
of positive parenting that are most powerfully linked to dif-
ferent cognitive outcomes.
Importantly, gains made in mental abilities and lan-
guage following positive parenting interventions may
have positive cascading effects on executive functioning
and/or pre-academic skills. For instance, language abili-
ties and executive functioning are reciprocally related in
early childhood (Romeo etal., 2022; Xing etal., 2021),
and children’s language and nonverbal problem-solving
skills mediate children’s later executive processes (Lan-
dry etal., 2002). Indeed, in a study included in the cur-
rent review, though no direct effects were observed for
executive functioning following a positive parenting inter-
vention, positive changes to language functioning led to
subsequent gains in executive functioning (Chang etal.,
**p < 0.01; *p < 0.05; †p < 0.1
Table 7 (continued)
Continuous moderators
k β 95% CI lower 95% CI upper z score
Year 30 −0.01 −0.02 0.006 −0.95
Sample size 30 −0.0001 −0.0004 0.0003 −0.51
Risk of bias, total score 30 −0.01 −0.05 0.04 −0.34
Fig. 7 Meta-regression of Hedge’s g on child age (at baseline) for language meta-analysis
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Clinical Child and Family Psychology Review
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2015). Relatedly, children's aptitudes for reasoning, prob-
lem-solving, and language subserve pre-academic skill
development. For instance, verbal reasoning is predictive
of emerging math and reading competence (Durand etal.,
2005), and children’s vocabulary links positive parenting
behaviours to later pre-mathematic skills (Wade etal.,
2018). Taken together, positive parenting interventions
may indirectly affect executive functions and pre-academ-
ics through language and mental abilities.
Overall, the current findings illustrate the importance of
assessing similarities and differences across outcomes of
early development to better understand differential processes
of development and intervention effectiveness.
Causal Pathways
This meta-analysis demonstrates that positive parenting
interventions improve the development of children’s mental
abilities and language. The use of RCTs allows us to con-
clude that this relationship is causal. Despite this, there is
continued need for further study of mechanism for ampli-
fication of theory and clinical application. Though we had
intended to examine mechanistic explanations vis a vis
Fig. 8 Forest plot for meta-analysis of executive functioning out-
comes (k = 14). Sample B (Jeong etal., 2019; Obradovic etal., 2016;
Yousafzai etal., 2014; Yousafzai etal., 2016); Sample D (Brennan
etal., 2013; Chang et al., 2015; Chang et al., 2017; Connell et al.,
2019; Lunkenheimer et al., 2008); Sample F (Green et al., 2015;
Green et al., 2017); Sample G (Bagner et al., 2016; Garcia et al.,
2019; Heymann etal., 2020); Sample I (Koldewijn etal., 2010; van
Hus etal., 2013; Verkerk etal., 2012)
Table 8 Results of moderator
analyses for meta-analysis of
executive functioning (k = 14)
**p < 0.01; *p < 0.05; †p < 0.1
Continuous moderators k β 95% CI Lower 95% CI Upper z score
Substantive moderators
Child age, baseline 14 −0.005 −0.01 0.003 −1.18
Child age, outcome assessment 14 −0.01 −0.02 0.01 −1.17
Child sex, male 14 0.01 −0.01 0.03 1.1
Parental age 11 −0.04 −0.08 −0.003 −2.11*
Methodological moderators
Year 14 −0.01 −0.03 0.01 −1.27
Sample size 14 0.0001 −0.0003 0.001 0.44
Risk of bias, total score 14 0.02 −0.03 0.08 0.78
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Clinical Child and Family Psychology Review
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positive parenting through pooled mediation analyses (see
Prime etal., 2021), this was not feasible. Future research
would benefit from assessing indirect effects. For instance, it
is unclear which specific elements of positive parenting pro-
grams are most influential in improving childhood cognition.
Moreover, unmeasured familial processes may be operating
(e.g., improvements to parental linguistic input, family rou-
tines, parental well-being and/or self-efficacy; Baudry etal.,
2015). This is especially a risk for some positive parenting
interventions that have minor add-on components.
Relatedly, there are indirect effects that may operate
through child self-regulation and/or behavioural prob-
lems. Specifically, positive parenting interventions are
commonly designed to alter parenting behaviour as a
mechanism for addressing children’s behaviour problems
(DeGarmo etal., 2004; Dishion etal., 2008; Gardner etal.,
2006). Positive parenting programs may directly improve
both self-regulation and cognition (via positive parenting),
and/or benefits to one child domain may confer benefits to
the other. Early parenting programs have a stronger effect
on cognition and language as compared to socioemotional,
behavioural, and attachment outcomes (Jeong etal., 2021).
Furthermore, cognitive abilities are more strongly predic-
tive of children’s self-regulation and behaviour than the
reverse (Patwardhan etal., 2021; Peterson etal., 2013;
Wang etal., 2018). For these reasons, it is likely that posi-
tive parenting interventions directly impact cognition,
leading to subsequent improvements in self-regulation and
behaviour. However, there is also evidence for a reciprocal
relationship between cognition and behavioural develop-
ment, including in the case of reading and externalizing
behaviour (Trzesniewski etal., 2006), and preschool inat-
tention and academic achievement (Metcalfe etal., 2013).
Thus, any benefits to behaviour—resulting from improved
parenting or cognitive skills—are likely to have benefits
for children’s subsequent learning.
All told, there is a need to assess the processes through
which positive parenting interventions impact cognitive
development, which will inform theoretical and applied
perspectives. These lines of inquiry are best addressed
through meta-analytic techniques using path analyses
involving parenting, behaviour problems, and cognition.
Moderation Analyses
Next, we consider moderating effects in the meta-analyses
examining mental abilities and language—first substan-
tive and then methodological. Of note, there were several
moderators that emerged as near-significant, marked in
tables that are not discussed here. However, they may sig-
nal important differentiators of intervention effectiveness
and warrant further evaluation.
Substantive Moderators
In the language meta-analysis, positive parenting interven-
tions yielded stronger effect sizes with younger, as compared
to older, children. Despite the highly cited idea that ‘earlier
is better’ (Heckman, 2008), timing effects in parenting-
developmental research have been mixed (Gardner etal.,
2019a; Jeong etal., 2021; Sanders etal., 2014). By including
infants, toddlers, and preschoolers in the current review, we
were able to examine this question using a wide age range
in early childhood, which diverges from previous syntheses
including only 0–3years old (Jeong etal., 2021), or chil-
dren ages 2years or older (Gardner etal., 2019a, 2019b).
Fig. 9 Forest plot for meta-analysis of pre-academic outcomes (k = 7). Sample A (Clarke etal., 2012; Sheridan etal., 2011); Sample B (Jeong
etal., 2019; Obradovic etal., 2016; Yousafzai etal., 2014; Yousafzai etal., 2016); Sample E (Barrera etal., 1986; Barrera etal., 1991)
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Clinical Child and Family Psychology Review
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The current review provides evidence that, in the case of
language development following positive parenting interven-
tions, earlier may be better. That is, intervention effective-
ness was reduced for samples of older children, a finding
that was robust to simultaneous modeling of other significant
predictors. Findings are consistent with another meta-analy-
sis involving parenting interventions for adolescent parents,
wherein there was a trend for those involving younger chil-
dren to show greater intervention effects on children’s cog-
nitive outcomes (Baudry etal., 2017). In contrast, findings
diverge from Jeong etal. (2021) recent review. It is enticing
to use the two reviews as complementary to one another;
there may not be age effects in the first few years of life (ages
0–3years as in Jeong’s review), with clear distinctions only
emerging when comparing infancy to preschool years (as in
the current review). Such interpretations must be made with
caution, given the differences in inclusion criteria related to
the nature of parenting interventions. In the current review,
greater change observed in relatively younger children may
be due to the rapid development of language skills in the
first few years of life, and associated neuroplasticity. That
timing effects emerged for language, only, further highlights
that such effects may depend on the developmental domain
under investigation (Maughan & Barker, 2019).
Interventions were less effective in enhancing child lan-
guage when implemented with parents with less than or
equal to high school education, as compared to those with
more than high school education. Positive parenting medi-
ates socioeconomic disparities in early language develop-
ment (Borairi etal., 2021; Noble etal., 2015). Despite this,
the current review does not provide evidence that positive
parenting interventions, in isolation, are effective for par-
ents with less than or equal to a high school education. It
may be that early language disparities are best supported
by programs that target both parental responsiveness and
home-literacy/learning activities (Cates etal., 2018; Roby
etal., 2021). Alternatively, existing programs may need to
be tailored to the sociocultural values, goals, and needs of
individual families through a collaborative delivery model
to enhance uptake and effectiveness (Gardner etal., 2019a,
2019b; Lunkenheimer etal., 2008). Notably, when modelled
simultaneously with other significant moderators, parent
education was not a robust moderator. Studies targeting par-
ents with lower levels of formal education may also be initi-
ated later in development (i.e., confounded by the stronger
predictor of child age at baseline). Alternatively, parental
education may be a true moderator with a small effect that
is not robust to a loss in degrees of freedom. In any case,
moderation should be interpreted with caution as it reflects
associations between studies rather than causal processes.
Notably, only 11 studies (18%) reported father involve-
ment in interventions, a minority proportion consistent
with Jeong etal. (2021) recent review. Despite this, father
involvement emerged as a significant moderator in the
language meta-analysis, wherein studies with some level
of father involvement had smaller effect sizes than those
without reported father involvement. This finding should be
interpreted with caution, given there were few studies in
the language meta-analysis that included fathers (k = 7) and
because the level of father involvement could not be ascer-
tained well, based on the reporting in studies. Furthermore,
this pattern was not robust to the inclusion of other predic-
tors (child age at baseline). Regardless, further investigation
is warranted to assess how father involvement influences
intervention effectiveness, given naturalistic evidence link-
ing paternal sensitivity and children’s cognition, learning,
and socioemotional adjustment (Rodrigues etal., 2021).
Tailoring of interventions may be needed to account for
differences amongst mothers and fathers, and to work with
interparental couples and children (i.e., triads) rather than
focusing on only one parent–child dyad (Nunes etal., 2020).
Overall, there was a dearth of certain high-risk popula-
tions, including samples of adolescent parents (k = 3) and
parents with mental health difficulties (k = 10). Given each
of these contextual risk factors has been linked to devel-
opmental difficulties in children, in part through parenting
behaviours (Ahun & Côté, 2019; Firk etal., 2018; Liu etal.,
2017), a future endeavour will be to examine the extent to
which positive parenting programs can buffer against these
contextual risk factors.
Methodological Characteristics
For the mental abilities meta-analysis, stronger interven-
tion effects were observed when using standardized direct
assessments of child mental abilities, as compared to par-
ent-reported outcome measures. Significant moderation by
measurement approach is not uncommon in developmental
research, though the pattern of findings has not been consist-
ent. That is, some studies find stronger associations between
a predictor/treatment and outcome when observations/direct
assessments (rather than parent-report) are used (Madigan
etal., 2013), and in other studies the opposite pattern has
emerged (Andrews etal., 2021; Nowak & Heinrichs, 2008).
Informant discrepancies are likely to inform researchers
about meaningful differences across tasks, situations, or
contexts, rather than simply reflecting measurement error
(De Los Reyes, 2011; De Los Reyes etal., 2009; Kerr etal.,
2007). Thus, multi-informant approaches are likely the best
approach to comprehensively evaluating intervention effects
across settings.
Importantly, outcome measurement approach was
reduced to non-significance when modelled simultaneously
with risk of bias. Specifically, in the current review, stud-
ies with a higher risk of bias yielded stronger intervention
effects. This is in line with seminal work demonstrating that
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Clinical Child and Family Psychology Review
1 3
low-quality RCTs are associated with increased estimates
of benefits of intervention (Moher etal., 1998). This can be
said of previous reviews of parenting interventions, as well
(Nowak & Heinrichs, 2008; Sanders etal., 2014). This is a
critical finding, and divergent from the Jeong (2021) review,
which did not identify risk of bias as a significant modera-
tor of effect sizes. This raises significant concerns about the
robustness of effect sizes reported for positive parenting
interventions in relation to early childhood cognition, given
several challenges reported in primary studies based on our
risk of bias assessment. Similar to Jeong etal., (2021), the
current review identified a crucial need for greater study
transparency via pre-registration of hypotheses, outcome
assessments, and data analytic plans. Additional issues
included poor reporting of a priori power analyses and
masking status of data analysts, an important element of
psychosocial RCTs. However, strengths identified in the risk
of bias assessments (e.g., low risks of selection and detec-
tion biases), as well as minimal evidence of publication bias,
provide partial support to the reliability ofthe meta-analysis
findings. Furthermore, a correlation analysis showed that
more recent studies are associated with a lower risk of bias
(r = 0.41, p < 0.001). Thus, studies are increasingly address-
ing risk of bias in their study designs and execution. There is
no available tool specifically tailored to psychosocial RCTs
such as those included in the current meta-analysis. Future
development of a refined tool is necessary for more robust
risk of bias assessments.
Limitations
In addition to limitations of primary studies available to the
current review, highlighted above, there are limitations due
to specific review protocol decisions. First, we only included
RCTs, and not non-randomised or single-arm designs. The
advantage of this decision was enhanced internal validity, as
our primary question related to causal processes involved in
positive parenting and early cognition. However, this deci-
sion comes with disadvantages, too, including loss of eco-
logical validity (e.g., commonplace settings, representative
clinicians), and inclusion of participants who are willing
and/or able to participate in random assignment. Future
reviews can shed light on systematic differences in the cur-
rent line of inquiry in randomised versus non-randomised
designs.
Second, our review did not include studies when positive
parenting interventions were bolstered by other significant
program components. Again, this may not reflect the reality
of community programming, which integrates several inter-
vention targets with the aim of addressing early disparities
in cognitive development. The benefit of this decision is that
it uses a single-focused approach; that is, we have identified
several circumstances wherein targeting positive parenting,
only, is sufficient for improving children’s early mental abili-
ties and language.
Finally, primary studies included in the review were
limited to English. Guidelines from organizations such as
Cochrane and the Campbell Collaboration do not recom-
mend excluding RCTs reported in languages other than
English. However, there is little evidence for increased bias
among reviews excluding non-English records in terms
of effect estimates and conclusions of systematic reviews
(Dobrescu etal., 2021; Moher etal., 2003; Morrison etal.,
2012). In any case, this is considered a limitation of the
current review.
Conclusion
Early cognition is an important marker for readiness at
school entry, relatively stable across development, and
predictive of several adult outcomes in critical domains of
education, occupation, health, and well-being. In the cur-
rent review, positive parenting interventions were effective
in promoting positive change in the areas of mental abilities
and language. Though effect sizes were smaller and nonsig-
nificant for executive functioning or pre-academics, addi-
tional primary studies are required to obtain more precise
estimates and examine potential moderators of effectiveness.
The current review is the first to isolate positive parenting
interventions as an effective approach for enhancing early
mental abilities and language based on a synthesis of the
extant literature, further underpinning the critical role of
parenting interventions for promoting early childhood
development.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s10567- 022- 00423-2.
Acknowledgements This systematic review was funded by the Social
Sciences and Humanities Research Council Insight Grant (Principal
Investigator: HP). Additional funding supports for individual authors
include the Hamilton Health Sciences Strategic Directions Initiative
Award and Jack Laidlaw Endowed Chair in Patient-Centered Health-
care (TB), and the Tier 2 Canada Research Chair in Knowledge Synthe-
sis (AT) and Family Health and Preventive Interventions (AG). Funders
and institutions did not have any role in the review. Thank you to all
volunteers, research assistants, and students in the Prime Family Lab
who contributed to the systematic review and meta-analysis.
Data Availability The systematic review and meta-analysis was pre-reg-
istered at CRD42020222143. PRISMA-P checklist was used to prepare
the protocol (Prime etal., 2021) and for reporting in the final report. All
data and research materials (screening, full-text assessment, and data
extraction manuals) will be available at APA’s repository on the open
science framework (OSF) [see Supplemental Materials]. Data were
modeled using Comprehensive Meta-Analysis Version 3 and, thus,
code/syntax is not applicable.
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Clinical Child and Family Psychology Review
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Compliance with Ethical Standards
Conflict of interest None to Report.
Ethical Approval No ethics approval was needed because data come
from previously published studies.
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bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
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