CRD summary

This review concluded that parent management training appeared to be an effective treatment for children with disruptive behaviour problems although there was unexplained variation between studies in the estimates of effectiveness. The review included a large number of small trials, was reasonably well conducted and the conclusions are probably reliable.

Authors' objectives

To assess the effectiveness of parent management training for the treatment of child disruptive behaviour in different real-world contexts.

Searching

PsycINFO, MEDLINE and EMBASE were searched for studies reported in English and published in peer-reviewed journals between 1990 and October 2012. Search terms were reported. References of relevant reviews were searched.

Study selection

Randomised controlled trials (RCTs) that enrolled parents or carers whose child was aged between two and 12 years were eligible for inclusion. Children needed to be identified as having problem behaviour or were targeted because of conduct disorder or oppositional defiant disorder; universal or programmes based on other criteria were excluded. Trials had to compare a structured manualised parent management training programme targeting child disruptive behaviour with a waiting list condition. The programme had to be consistent with NICE 2006 clinical guidelines, be informed by principles of social learning theory and be facilitated by supervised therapists. Trials needed to assess child behaviour problems at the end of treatment using at least one standardised outcome measure.

Most of the included studies mostly enrolled parents of boys. Most of the included parents had children toward the younger end of the age spectrum (maximum ages in many studies were eight years or under). Available data indicated that only eight studies had a majority of families from socially disadvantaged backgrounds as defined by investigators. Most studies used a combination of group sessions in combination with homework and other elements. Outcomes assessed included the Eyberg Child Behavior Inventory (ECBI) and its subscales, Child Behavior Checklist (CBCL) Externalizing scale and the Strengths and Difficulties Questionnaire (SDQ) conduct problems scale.

Three reviewers assessed the abstracts for further consideration; full texts of potentially eligible studies were assessed by another reviewer and discrepancies were resolved by consensus with another reviewer.

Assessment of study quality

The studies were assessed using the Critical Appraisal Skills Program scale of randomisation, allocation concealment, blinding of outcome assessment, consistency of data-collection and follow-up and completeness of outcome data reporting. Assessments were performed by one reviewer and checked by a second. The external validity of studies was assessed by looking at four real-world practice criteria (use of a clinic-referred sample; conducted in a routine setting; conducted as apart of an established service; and use of non-specialist therapists) and calculating a total practice score.

Data extraction

Data were extracted on child disruptive behaviour outcomes after treatment. Where multiple interventions were used data were extracted only for the one closest to the standard format for programmes.

Data extraction was carried out by one author. Authors of primary studies were contacted where data were missing or unclear.

Methods of synthesis

Weighted mean differences were calculated using a DerSimonian and Laird random-effects model for post-treatment measures of child disruptive behaviour (ECBI Intensity and Problem scales, CBCL Externalizing scale and SDQ Conduct scale). Heterogeneity was quantified using the Ι² statistic. Heterogeneity was explored in the analyses of the ECBI subscales using subgroup analyses based on the external validity measured by the total practice score and the presence of individual criteria from the assessment. The relationship between total practice score and effect size was further investigated by meta-regression. Publication bias was assessed using contour-enhanced funnel plot analysis.

Results of the review

Twenty-eight RCTs were included in the review. There were 2,239 children whose behaviour was the reason for attendance (sample sizes ranged from 24 to 305). Only one study was considered to be free from bias; another five were at risk of bias on only one criterion. Most studies did not fully document randomisation and allocation concealment procedures or the level of attention given to participants in the control groups. Intention-to-treat analyses were not used in most studies. Only three RCTs satisfied all four of the external validity criteria and seven met three criteria; two met none of them and the rest scored one (eight RCTs) or two (eight RCTs).

There were significant reductions in child disruptive behaviour on all the outcomes assessed. The weighted mean difference for the ECBI Intensity scale was -20.90 (95% CI -26.26 to -15.53; Ι²=71.1%; 24 RCTs) and for the ECBI Problem scale it was -6.03 (95% CI -7.70 to -4.36; Ι² =71.1%; 17 RCTs). The CBCL Externalizing scale showed a weighted mean difference of -3.66 (95% CI -6.28 to -1.04; Ι²=26.9%; five RCTs) and the SDQ Conduct scale showed a weighted mean difference of -0.59 (95% CI -0.88 to -0.29; Ι²=0%; six RCTs).

There was no significant relationship between total practice score and the effect size on either of the ECBI subscales. Subgroup analyses found a significant relationship between a positive score on the routine service criterion and effect size but no other interactions between external validity measures and effectiveness.

Analysis of contour-enhanced funnel plots for the ECBI Intensity and Problem scales suggested the existence of publication bias.

Authors' conclusions

Parent management training appeared to be an effective treatment for children with disruptive behaviour problems. However, significant heterogeneity between studies' estimates of effectiveness could not be explained by real-world practice criteria.

CRD commentary

The review question was clear and supported by specific inclusion criteria. Three databases were searched but the restriction to published studies reported in English had potential to introduce selection bias as a consequence of smaller negative studies being disproportionately omitted. The authors reported using methods to reduce potential for reviewer bias and error at most stages of the review process but it was not clear whether this included data extraction. Relevant and appropriate criteria were used to assess both the internal and external validity of the included studies. The synthesis adopted was appropriate and attempts were made to explore heterogeneity.

The authors' conclusions reflect the results of the review and are probably reliable despite the potential for missing studies and the small size and uncertain quality of the included studies.

Implications of the review for practice and research

Practice: The authors stated that practitioners should be aware that parent management training can be effective when delivered in a variety of real world practice conditions. Reasons for selecting a less well-established treatment than a parent management training programme should be clearly elaborated, discussed in supervision and explained to families.

Research: The authors stated that funding for future large-scale randomised studies should be targeted towards methodologically rigorous trials designed under genuine real-world conditions; use of clinic-referred samples was particularly important. They also stated that an individual patient meta-analysis of current and future trials should be considered; this would be facilitated by better reporting of care provider and context factors as well as patient characteristics, in trials and by process evaluations conducted as integral parts of trials. The authors further recommended that practice evaluations be conducted using data which were already collected as part of routine practice.

Funding

Not stated.

Bibliographic details

Michelson D, Davenport C, Dretzke J, Barlow J, Day C. Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior Clinical Child and Family Psychology Review 2013; 16(1): 18-34. [PubMed: 23420407]

Original Paper URL

http://link.springer.com/article/10.1007%2Fs10567-013-0128-0

Indexing Status

Subject indexing assigned by CRD

MeSH

Attention Deficit and Disruptive Behavior Disorders; Child; Child Behavior; Humans; Parenting; Parents

AccessionNumber

12013014215

Database entry date

20/09/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.