This randomized clinical trial tested the efficacy of providing an evidence-based parenting program (The Incredible Years) to parents of young children with disruptive behaviors in pediatric settings. Parents assigned to the intervention group completed 10 weekly parenting sessions led by study psychologists and pediatric staff. Compared to those on a waiting list, parents who received the intervention reported fewer disruptive child behaviors, improved parenting skills, and less negative parent-child interactions both immediately after and up to 12 months following the program. The results support delivering evidence-based parenting programs in pediatric practices to help address early disruptive behaviors.

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JAMA Pediatrics Journal Club Slides:
Improving Parenting Skills
Perrin EC, Sheldrick RC, McMenamy JM, Henson BS,
Carter AS. Improving parenting skills for families of young
children in pediatric settings: a randomized clinical trial.
JAMA Pediatr. Published online November 4, 2013.
doi:10.1001/jamapediatrics.2013.2919.

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• Disruptive Behavior Disorders
– Symptoms evident as early as 1 to 3 years of age.
– Symptoms typically continue into adolescence.
– Often result in academic underachievement, reduced social
competence, and various mental health disorders.
– Common but modifiable.
• BUT
– Infrequently identified early.
– Intervention based on mental health referral.
– Fewer than 25% treated.
Introduction

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Intervention
• Parent-training programs have been shown to be effective.
• The Incredible Years (IY) program in particular has received support in
multiple randomized clinical trials.
However,
• Evidence-based parent-training programs are not widely available.
• Evidence for their feasibility and efficacy in primary care settings is limited.
Objective
• To test the efficacy of offering an evidence-based parenting program within
pediatric practices to parents of 2- to 4-year-old children with early
evidence of disruptive behaviors.
Introduction

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• Study Design
– Routine screening for disruptive behavior at 2- and 3-year well-child
care visits.
– Eligible parents were enrolled and assigned by random number to
immediate intervention (parent-training group [PTG]) or waiting list (WL)
control group.
– PTG: 10-week version of the IY parent-training program
(see http://www.incredibleyears.com).
– Leaders were study psychologists plus members of the pediatric staff
(nurse, social worker, pediatrician).
• Setting and Sample
– Four federally qualified health centers, 7 suburban pediatric practices.
– Parents of 345 children enrolled.
• 29% Nonwhite/non-Hispanic
• 26% With annual income less than $20 000.
Methods

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Methods
• Outcomes
– Early Childhood Behavior Inventory (ECBI).
– Parenting Scale.
– Standardized observation of parent-child interaction (coded according to
Dyadic Parent-Child Interactive Coding System−Revised).
– Assessments before intervention, immediately following intervention, 6
months later, and 12 months later.
• Limitations
– Slow recruitment resulted in the following:
• Fewer participants in WL groups than intervention groups.
• Intervention groups without control in 6 practices. These participants
were analyzed as a separate condition: nonrandomized PTG.
– Videotaped observations technically challenging.
– Only about half of parents who acknowledge disruptive behavior in their
toddlers are able to participate fully in parent-training intervention.
– Research burden high; loss to follow-up.

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830
Consented To Contact
290
Provided time 1 data &
assigned to conditions
485 did not
enroll
345
Enrolled
55
Dropped out
150
Randomized
123
Assigned directly to PTG
89
PTG
61
WL
18
< 3 PTG
sessions
50
F/U
11
D/O
71
≥ 3 PTG
sessions
67
F/U
5
F/U
4
D/O
13
D/O
73
≥ 3 PTG
sessions
50
< 3 PTG
sessions
7
F/U
65
F/U
8
D/O
43
D/O
17 Dropped out
Note. PTG = parent training group; WL = waitlist; F/U = follow-up; D/O = dropped out
Results
• Overall: 144 of 212 families
(68%) assigned to
intervention completed at
least 3 IY sessions.
• High fidelity to the IY protocol
was maintained throughout
the study.

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Waitlist Condition
Randomized PTG
Non-randomized PTG
5
7
9
11
13
15
17
Pre-
Treatment
Post-
Treatment
6-month
follow-up
12-month
follow-up
Results: ECBI Problem Scale
• In both parent-training conditions, parents’ reports of child disruptive behaviors were lower
than baseline at all follow-up assessments.
• Both parent-training conditions were superior to WL at all follow-up assessments.
• ECBI Intensity Scale followed same pattern with 1 exception (nonsignificant at 6-month
follow-up).

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Waitlist Condition
Randomized PTG
Non-randomized PTG
2.2
2.4
2.6
2.8
3
3.2
Pre-
Treatment
Post-
Treatment
6-month
follow-up
12-month
follow-up
Results: Parenting Scale
• In both parent-training conditions, self-reports of negative parenting behaviors were lower
than baseline at all follow-up assessments.
• Both parent-training conditions were superior to WL at all follow-up assessments.

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Waitlist Condition
Randomized PTG
Non-randomized PTG
-0.1
0
0.1
0.2
0.3
0.4
0.5
Pre-
Treatment
Post-
Treatment
6-month
follow-up
12-month
follow-up
Results: Standardized Observation
of Parent-Child Interaction
• In both parent-training conditions, observed negative parent-child interaction was lower
than baseline at both follow-up assessments.
• Both parent-training conditions were superior to WL at both follow-up assessments.

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Comment
• Results support feasibility and effectiveness of parent training for young
children in pediatric settings.
• For parents who are able to participate, the intervention is successful
across a wide range of risk.
• Pediatric office staff can be trained to deliver the evidence-based
parent-training intervention.
• Sustainability of parent training provided within pediatric practices is
dependent on changes in health insurance policies.

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• If you have questions, please contact the corresponding author:
– Ellen C. Perrin, MD, Division of Developmental-Behavioral Pediatrics,
Floating Hospital for Children, Tufts Medical Center, 800 Washington
St, Ste 854, Boston, MA 02111 (eperrin@tuftsmedicalcenter.org).
Funding/Support
• This study was funded by the National Institute of Mental Health R01 grant
MH076244-01.
Conflict of Interest Disclosures
• None reported.
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