Universal, selective and indicated parenting interventions to prevent the development of adverse mental health outcomes in youth: a meta-review of systematic reviews
Social, Genetic and Developmental Psychiatry Centre, King’s College London Institute of Psychiatry, Psychology and Neuroscience, London, UK
Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Department of Addictions, King’s College London Institute of Psychiatry, Psychology and Neuroscience, London, UK
South London and Maudsley NHS Foundation Trust, London, UK
Institute for Human Development and Potential, Agency for Science Technology and Research, Singapore
Department of Psychology, King’s College London, London, UK
Sackler Program for Epigenetics and Psychobiology, Douglas Hospital Research Centre, McGill University, Montreal, Quebec, Canada
Khoo Teck Puat – National University Children’s Medical Institute, National University Hospital, Singapore
Abstract
Background
Preventive interventions in the form of parenting support can reduce the risk of mental disorders in children. Summarising the effectiveness of parenting interventions across different levels of prevention can inform the prioritisation of the intervention.
Objectives
We conducted a meta-review of systematic reviews and meta-analyses on universal, selective and indicated parenting interventions to prevent adverse mental health outcomes in youth.
Study selection and analysis
PubMed, Ovid, Embase and PsycNet were searched. Systematic reviews consisting of randomised controlled trials of preventative parenting interventions were included. We provided a narrative synthesis of the results and assessed the quantity and quality of evidence for each level of prevention (ie, universal, selective, indicated) and mental health outcome.
Findings
We identified 32 systematic reviews and meta-analyses, which included 354 randomised controlled trials, consisting of over 74 558 children and adolescents. Universal parenting interventions were effective in delaying the initiation of alcohol and cannabis use, but did not have consistent findings in preventing disruptive behaviour and mood disorders. Selective interventions were predominantly beneficial for disruptive behavioural problems across a variety of risk factors. Indicated interventions found substantial and consistent evidence for reducing problems in children with behavioural problems. Caution is warranted when interpreting findings, as the overall confidence rating of most reviews was very low, especially in the reporting of study selection and justifying exclusions in the AMSTAR-2.
Conclusions
Our findings highlight the need for robust evidence synthesis. Despite the limitations of the current evidence base, parenting interventions hold promise for preventing mental health disorders.
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Keywords: Child & adolescent psychiatry, Impulse control disorders, Depression & mood disorders, Anxiety disorders
Article notes
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Received 2025 Feb 13; Accepted 2025 Jun 15; Collection date 2025.
Boxed Text
WHAT IS ALREADY KNOWN ON THIS TOPIC
- Early parenting interventions show promise as a primary prevention for mental health outcomes in children and adolescents, but evidence on which level of prevention is most effective for specific mental health outcomes is limited.
WHAT THIS STUDY ADDS
- To the best of our knowledge, this is the first study to conduct a meta-review assessing the quantity and quality of evidence for parenting interventions across different levels of primary prevention and mental health outcomes. Based on 354 randomised controlled trials, the review suggests that the effectiveness of these interventions in preventing youth mental health issues may vary depending on the level of primary prevention. However, the majority of the reviews were of low quality, which limits our ability to make evidence-based policy recommendations.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
- The quality of the reviews highlights the need for more robust research methodologies. High-quality systematic reviews can potentially help inform policies that prioritise parenting interventions at the appropriate level of primary prevention to address specific mental health outcomes.
Background
Mental disorders are one of the largest causes of disability worldwide.1 Half of these disorders begin in childhood and adolescence.2 As access to mental health services is inadequate to manage early symptoms, prevention remains a clear goal.3 Positive experiences with parents are recognised as resilience factors that buffer children against mental health risks.4 As a result, parenting interventions are promising targets for primary prevention as they protect children from toxic stress and reduce mental health symptoms.
Primary preventive interventions, which aim to prevent the onset of disorders, are classified into three subtypes, depending on the target population.5 Universal preventive interventions are provided to all children, irrespective of their risk of developing a disorder or their current mental health. Selective preventive interventions are provided to those at higher risk of developing a disorder, for example, individuals with a family history of psychiatric disorder. Indicated preventive interventions are provided to individuals who do not meet the criteria for a disorder, but are displaying emerging symptoms.
Each level of prevention has clear advantages. Universal prevention is not associated with the stigma of seeking help, as all children receive the benefits.6 However, universal interventions are unable to target resources at those who are most at risk and may increase disparity due to accessibility issues. Selective and indicated preventions are targeted to those in need and may be more cost-effective because they target a subset of families who will benefit from the intervention.7 Screening and prioritising the most appropriate children for these two levels of prevention remains a challenge, as they rely on the ability of parents to identify children who are at risk or have emerging symptoms.3
Parenting interventions are based on theories, including attachment theory,8 operant conditioning theory9 and social cognitive theory.10 These approaches are accompanied by reflective practice by parents and are applied at an early stage, even in infancy.11 12 The aim of parenting interventions is to teach positive parenting skills, reduce harsh parenting practices,13 increase parenting competence14 and improve parent–child relationships.15 Different parenting programmes are recommended based on the age and needs of the child. Parenting programmes during infancy are based on attachment theories and aim to improve the responsiveness of caregivers to infants’ physical and emotional needs.8 During childhood to adolescence, parent training programmes are recommended to teach positive reinforcement (eg, giving specific and proximal praise) and behavioural management techniques (eg, time-out) and improve communication.9 Recently, parenting supports which address emotion socialisation practices have been developed.15 These aim to help parents understand the emotions behind behavioural problems and teach children emotion regulation skills.
A large number of systematic reviews have been conducted on the effectiveness of parenting interventions in preventing mental disorders in children and adolescents. However, most of these analyses focused on a single outcome, limiting the ability to assess whether interventions may also have beneficial effects on related psychiatric outcomes.14 16 17 It is also unclear whether certain mental health conditions may benefit from earlier intervention compared with those offered when early symptoms appear. Given the substantial costs and resources associated with mental health conditions, it is important to gain a greater understanding of the effectiveness of parenting supports across prevention levels. This meta-review aimed to summarise the effectiveness of universal, selective and indicated parenting interventions in reducing adverse mental health outcomes in youth. We included systematic reviews of randomised controlled trials (RCTs) that involved either parents alone, children alone or both parents and children together, conducted in any setting with no limitations on the age of the child.
Study selection and analysis
We conducted a meta-review of systematic reviews and meta-analyses on parenting interventions and child mental health outcomes. The study followed the Preferred Reporting Items for Overviews of Reviews guidelines,18 and was pre-registered (PROSPERO; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023429751).
Search strategy
We searched MEDLINE, Embase, PsycINFO and PubMed databases to identify systematic reviews and meta-analyses which included RCTs of parenting interventions for the prevention of youth mental health outcomes. Each database was searched from database inception until 25 September 2024. The search included full-text, published and unpublished articles but excluded dissertation chapters and excluded studies published in languages other than English or non-human populations. The full search strategy is described in the online supplemental methods.
Study selection was completed in pairs by five reviewers (MXH, EC, JB, YKS and VN). Titles and abstracts were screened, and duplicate references were removed using EndNote.19 Full texts were reviewed for inclusion and exclusion criteria. Disagreements at the title or abstract screening stage were retained for full-text review. Discrepancies were discussed with the senior researcher (ECL).
Eligibility criteria
Inclusion and exclusion criteria used to select reviews and meta-analyses are organised in the format of population, intervention, comparators, outcomes (PICO; online supplemental eTable 1). Reviews had to contain at least one RCT evaluating the effectiveness of a parenting intervention on offspring mental health. Only RCTs were included to support causal inference and provide stronger evidence for policy development. Inclusion criteria were: (1) at least one RCT of a parenting intervention; (2) universal, selective or indicated preventive parenting interventions; (3) clear description of sample characteristics, including demographics and child age; (4) no medical conditions (eg, cancer) in parents or children; and (5) no offspring with a clinical mental health diagnosis. Trials with any comparison group (eg, alternative intervention, usual care or wait-list control) were eligible.
A preventive parenting intervention is defined as parent (either biological, foster and/or adoptive) supports that aim to improve child outcomes before the onset of a clinical diagnosis in the child. The main elements within interventions include modifying discipline styles, improving parent–child relationships and improving parental functioning (online supplemental eTable 1).
Mental health outcomes were clinical diagnoses or symptoms described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, measured using parent-reported or teacher-reported questionnaires (eg, Strengths and Difficulties Questionnaire). This included mood disorders (eg, anxiety, depression), disruptive behavioural disorders (eg, attention-deficit/hyperactivity disorder (ADHD), conduct problems, substance use disorders). ADHD was included as symptoms involve mental functioning that can be associated with significant impairment in daily life.20 Given differences in symptom presentation in early development, infant mental health was considered a distinct outcome.21 We excluded neurodevelopmental disorders (eg, autism spectrum disorders) and non-mental health-related outcomes (eg, motor skills).
Data extraction
Variables extracted included level of prevention, period of systematic search, number of relevant clinical trials, sample size of the populations included across relevant trials, age range of youths targeted, type or name of parenting intervention, delivery method, country in which the intervention was implemented, comparators, mental health outcome measures and summary of findings of individual trials, including effect sizes, ORs and standardised mean differences, where available. Economic status of countries was defined by their gross national income.22 In meta-analyses, the pooled effect size was extracted. We documented study heterogeneity, risk of publication bias and quality of included studies. When reviews were discrepant or provided limited description, results were extracted from the primary research studies. All data were extracted by MXH and were reviewed by a second reviewer (either EC, EB, YKS or ECL).
Synthesis of results
We conducted a narrative synthesis of the results, supported by tables arranged by the level of prevention (ie, universal, selective, indicated) and mental health outcome. Quantity of evidence was determined using participant numbers: large (>2500 participants), moderate (>1000 to 2500 participants), limited (500 to 1000 participants) and very limited (<500 participants). The strength and direction of evidence were assessed using the criteria: in favour of intervention or at least 75% of trials reporting significant effects in reducing mental health outcomes; mixed results or 50 to <75% of the trials reporting significant effects in reducing mental health outcomes; and not in favour of the intervention (meta-analysis effect size was not statistically significant or less than 50% of trials reporting significant effects in reducing mental health outcomes).
Quality assessment
The AMSTAR-2 scale was used to assess the methodological quality of the included reviews.23 This tool categorises systematic reviews and meta-analyses based on 16 domains with seven critical domains (online supplemental methods). Two authors (MXH and VN) assessed each publication independently. Discrepancies were resolved through consensus or after discussion with a third senior researcher (ECL). An inter-rater reliability of Cohen’s k=0.63 (95% CI: 0.30 to 0.97) was achieved on the AMSTAR-2 quality ratings.
Findings
The systematic literature search yielded 7222 records. 2004 reviews were kept after title screening and 558 reviews after abstract screening. 54 systematic reviews and meta-analyses met our inclusion criteria after full-text review (figure 1). 33 reviews overlapped in terms of outcomes, populations, types of intervention and included trials. Of these 33 reviews, 2 reviews overlapped in universal prevention, 21 reviews overlapped in selective prevention and 10 reviews overlapped in indicated prevention. As per our methods, we chose reviews that were both more up-to-date and comprehensive among the overlapping reviews; thus, 22 of the 33 reviews were excluded (online supplemental eTable 2). Of the 32 included reviews, 12 examined universal, 22 selective and 12 indicated prevention; 10 reviews covered two levels of primary prevention, and 2 addressed all three.17 24 There were more than 103 different types of parenting interventions provided to samples of youth aged 0–21 years (online supplemental eTable 3).
Universal interventions
We included 12 systematic reviews and meta-analyses consisting of 57 RCTs and 24 457 participants (table 1) online supplemental eTable 4 provides an in-depth description of reviews.1114 15 17 24,31 These reviews identified trials investigating the effect of universal parenting interventions provided during pregnancy and to children aged 0 to 18 years. The confidence in these reviews was low (three reviews) and critically low (nine reviews) (online supplemental eTable 5). Participants identified were from high-income countries, including USA, Australia, Germany and Japan. Only one review included participants from middle-income countries (Pakistan and Kenya) and low-income countries (Rwanda and Uganda).25 Parenting interventions included Triple P, Incredible Years and Tuning into Kids, and they were primarily delivered in group settings in the community by trained providers. Six of the 12 reviews described evidence in support of universal parenting interventions for one or more mental health outcomes (table 1).
| Child mental health outcome | Review | Topic of the review | Number of relevant RCTs (k) | Total sample size | Age groups | Amount of evidence* | Effectiveness of the intervention on the outcome† | AMSTAR-2 rating |
|---|---|---|---|---|---|---|---|---|
| General mental health | 11 | General mental health in infants | 4 | 2638 | Pregnancy to 8 months | Large | Mixed | Critically low |
| Infant mental health | 15 | Attachment and externalising in infants | 4 | 2710 | Pregnancy to 2 years | Large | No | Low |
| Infant attachment | 15 | Attachment and externalising in infants | 3 | 408 | Pregnancy to 2 years | Very limited | Yes | Low |
| Mood disorders: depressive symptoms | 24 | Internalising, anxiety and depressive symptoms | 2 | 658 | 10–13 years | Limited | Yes | Low |
| Mood disorders: anxiety symptoms | 24 | Internalising, anxiety and depressive symptoms | 1 | 229 | 10–13 years | Very limited | Yes | Low |
| Mood disorders: anxiety incidence | 24 | Internalising, anxiety and depressive symptoms | 1 | 734 | 3–7 years | Limited | No | Low |
| Mood disorders: internalising symptoms | 25 | Socioemotional outcomes in low- and middle-income countries | 4 | 3883 | 0–2 years | Large | Yes | Low |
| 24 | Internalising, anxiety and depressive symptoms | 7 | 970 | 2–7 years | Limited | No | Low | |
| 26 | Socioemotional outcomes in low- and middle-income countries | 3 | 1002 | Pregnancy to 15 months | Moderate | No | Critically low | |
| 27 | Triple P | 2 | 369 | 2–12 years | Very limited | No | Critically low | |
| Disruptive behaviour disorders and ADHD | 27 | Triple P | 2 | 369 | 2–12 years | Very limited | Yes | Critically low |
| 14 | Group Triple P for externalising | 6 | 708 | 2–12 years | Limited | No | Critically low | |
| 17 | Externalising/disruptive (including ADHD) | 8 | 1715 | 2–8 years | Moderate | No | Critically low | |
| 28 | Externalising (interventions for fathers) | 2 | 442 | 2.5–6 years | Very limited | Yes | Critically low | |
| Substance-use disorders (initiation) | 29 | Alcohol and tobacco use | 4 | 2336 | 10–14 years | Moderate | Mixed | Critically low |
| 31 | Substance use | 5 | 1636 | 6–16 years | Moderate | Yes(cannabis use) | Critically low | |
| 30 | Alcohol use | 8 | 3435 | 11–14 years | Large | Yes | Critically low | |
| Substance-use disorders (frequency) | 30 | Alcohol use | 5 | 1959 | 9–14 years | Moderate | Yes | Critically low |
| 29 | Alcohol and tobacco use | 7 | 5438 | 10–15 years | Large | No | Critically low | |
| 31 | Substance use | 4 | 1434 | 11–18 years | Moderate | Yes | Critically low |
According to our criteria, the most consistent findings with moderate to large amount of evidence were for delaying alcohol (OR=0.71 (95% CI: 0.54 to 0.94); k=8) and cannabis initiation (OR=0.72 (95% CI: 0.56 to 0.94); k=5).30 31 The reviews, however, provided mixed support for the role of universal prevention on frequency of alcohol or tobacco use, and no support for preventing the initiation of other illicit drugs.29
Reviews on disruptive behavioural outcomes showed mixed results, with two out of four reviews providing support for universal parenting interventions. Studies included in these reviews demonstrated a very limited amount of evidence due to small sample sizes.27 28 For mood disorders, there was one review which reported reduction in depressive (d=0.14 (95% CI: 0.11 to 0.18); k=2) and anxiety symptoms (d=0.26 (95% CI: 0.23 to 0.30); k=1), but no effect on the incidence of anxiety diagnosis.24 Only one review with participants from low- to middle-income countries found an effect of parenting interventions on reducing internalising problems with a large amount of evidence (Hedges’ g=−0.06 to 0.46).25 No review provided definite support for universal parenting interventions in reducing infant mental health or general mental health problems in high-income countries.
It is important to note that while one level of prevention is not effective for a certain outcome, another level (ie, selective or indicated) of prevention may show good evidence. Additionally, only one review focused on assessing interventions directed at fathers for child behavioural problems.28
Selective interventions
We identified 22 systematic reviews (table 2 and online supplemental eTable 4) with 204 clinical trials and 39 829 participants that investigated selective parenting interventions on child mental health outcomes.1215,17 24 Reviews covered interventions provided during pregnancy and to youth aged between 0 to 21 years across various risk factors. One review was interpreted with high confidence, 5 reviews with low confidence and 16 reviews with critically low confidence (online supplemental eTable 5). Participants identified in these reviews were from high- and middle-income countries, including USA, Australia, Germany, UK, Netherlands, Canada, China, Brazil, Poland and Lithuania. One review included participants from low-income countries, specifically on forcibly displaced families, such as Somali, Syrian and Palestinian refugees.35 Parenting interventions included SFP (Strengthening Families Programme), Attachment and Biobehavioural Catch-Up (ABC), Triple-P, Incredible Years and Video-feedback Intervention to Promote Parenting.
| Child mental health outcome | Review | Topic of the review/risk factor | Number of relevant RCTs (k) | Total sample size | Age groups | Amount of evidence* | Effectiveness of the intervention on the outcome† | AMSTAR-2 rating |
|---|---|---|---|---|---|---|---|---|
| General mental health | 39 | Adoption and foster care | 11 | 1960 | 0–21 years | Moderate | Mixed | Critically low |
| 40 | Parents with mental health conditions | 12 | 1602 | 0–12 years | Moderate | Mixed | Low | |
| 28 | Divorce, ethnic minorities | 2 | 423 | 3–18 years | Very limited | Yes | Critically low | |
| 35 | Refugees and forcibly displaced families | 2 | 167 | 1–12 years | Very limited | Mixed | Low | |
| 12 | Mothers with depressive symptoms | 4 | 465 | 0–1 year | Very limited | No | Critically low | |
| Infant mental health: attachment | 15 | Various risks (SES, adoption, adolescent mothers, family history) | 13 | 1958 | Pregnancy to 2 years | Moderate | No | Low |
| 39 | Adoption and foster care | 5 | 369 | 0–5 years | Very limited | No | Critically low | |
| 38 | Maltreatment | 5 | 592 | 0–13 years | Limited | Yes | High | |
| 43 | VIPP for parents with mental health conditions | 10 | 709 | NR | Limited | Mixed | Critically low | |
| Infant mental health: socioemotional problems | 15 | Various risks (SES, adoption, adolescent mothers, family history) | 5 | 466 | 0–1 year | Very limited | Mixed | Low |
| Mood disorders: internalising symptoms | 24 | SES and contextual factors | 26 | 2753 | 0–18 years | Large | Yes | Low |
| 25 | Low- to middle-income countries: SES, low birth weight, undernourished children | 3 | 714 | 0–16 months | Limited | No | Critically low | |
| 26 | SES and contextual factors | 4 | 1251 | From pregnancy to school entry | Moderate | Mixed | Low | |
| 16 | Parents with depression | 5 | 564 | 6–18 years | Limited | No | Critically low | |
| 38 | Maltreatment | 5 | 513 | 0–13 years | Limited | Mixed | High | |
| 37 | SES and contextual factors | 9 | 8042 | 0–18 years | Large | Yes | Critically low | |
| Mood disorders: depressive symptoms | 24 | SES and contextual factors | 8 | 1262 | 3–12 years | Moderate | No | Low |
| Mood disorders: depression incidence | 24 | SES and contextual factors | 2 | 284 | 0–18 years | Very limited | No | Low |
| Mood disorders: anxiety symptoms | 24 | SES and contextual factors | 10 | 1155 | 3–12 years | Moderate | No | Low |
| Mood disorders: anxiety incidence | 24 | Maltreatment | 3 | 343 | 4–12 years | Very limited | No | Low |
| Post-traumatic stress disorder | 38 | SES and contextual factors | 1 | 30 | 1.5–16 | Very limited | No | High |
| Disruptive behaviourdisorders and ADHD | 17 | Technology-assisted interventions for low SES families | 50 | 5071 | 0–4.6 years | Large | Yes | Critically low |
| 32 | Short-term interventions for low SES families | 3 | 404 | 1–11 years | Very limited | Mixed | Critically low | |
| 33 | Incredible Years intervention for low SES and foster care families | 8 | 1538 | 3–9 years | Moderate | Yes | Critically low | |
| 34 | Refugees and forcibly displaced families | 10 | 1179 | 2–17 years | Moderate | Yes | Critically low | |
| 35 | Ethnic minorities | 4 | 402 | 0–1 years | Very limited | Mixed | Low | |
| 36 | Maltreatment | 11 | 2329 | 0–13 years | Moderate | Mixed | Critically low | |
| 38 | Parents with mental health conditions (bipolar disorder) | 6 | 1198 | 4–10 years | Moderate | No | High | |
| 41 | Online interventions (SES, family history) | 1 | 39 | 2–10 years | Very limited | Yes | Critically low | |
| 42 | VIPP for parents with mental health conditions | 2 | 176 | NR | Very limited | No | Critically low | |
| 43 | Various risks (SES, adoption, adolescent mothers, family history) | 8 | 806 | 0–3 years | Limited | No | Critically low | |
| 15 | Rural China: SES | 2 | 402 | 0–4 years | Very limited | Mixed | Low | |
| Substance-use disorders(initiation) | 31 | Various risks (divorce, SES parental bereavement, parental drug use) | 6 | 1464 | 6–21 years | Moderate | No | Critically low |
| 29 | Various risks (SES, foster home, ethnic minorities, family history) | 3 | 1194 | 10–12 years | Moderate | Mixed | Critically low | |
| Cannabis-use disorder | 31 | Various risks (divorce, SES, parental bereavement, parental drug use) | 4 | 1739 | 6–17 years | Moderate | No | Critically low |
| Substance-use disorders (frequency) | 29 | Various risks (SES, foster home, ethnic minorities, family history) | 8 | 2327 | 11–16 years | Moderate | No | Critically low |
| 31 | Various (divorce, SES, parental bereavement, parental drug use) | 7 | 2561 | 9–21 years | Large | Yes | Critically low |
In a high-quality review, which included children exposed to maltreatment, the review examined different forms of attachment-focused preventive interventions, including ABC, delivered as 10 weekly home visits by trained providers.38 This review found that the interventions increased secure attachment with medium to large effect sizes. However, no other review examining attachment as the outcome reported positive effects of the intervention.15 39 43
For the outcome of internalising symptoms, reviews included large amounts of evidence with sample sizes >2500 and indicated a positive effect of selective intervention in reducing internalising symptoms in children with contextual risk factors (d=0.13 (95% CI: 0.05 to 0.22); k=26),24 and for children in rural China.37 No effect was found for depressive or anxiety symptoms, when analysed separately, or post-traumatic stress disorder (PTSD) symptoms.24 38 There was more support for reducing disruptive behaviour disorder and ADHD symptoms, with four reviews reporting a positive effect.17 33 34 41 One review reported parenting interventions reduced disruptive behavioural problems with a small effect size (d=0.27 (95% CI: 0.17 to 0.36); k=50).17 Similarly, positive effects were found for a short-term parenting intervention for low-income families (Hedges’ g=0.38 (95% CI: 0.27 to 0.49)),33 Incredible Years intervention for foster care and low-income families34 and interventions targeting parents with bipolar disorder.41
Mixed results were found in reviews that appraised the prevention of general mental health problems in foster care children,39 in refugee children35 and in children with familial risk.12 40 Very limited but positive evidence is found for interventions targeting fathers.28 Inconsistent results were also found for socioemotional problems in infants,15 and substance use.29 31
Indicated interventions
We included 12 systematic reviews and meta-analyses with 93 clinical trials and 10 272 participants that investigated the effect of indicated parenting interventions (table 3 and online supplemental eTable 4).1724 31 34 36 42 44,49 Reviews included participants aged 0–21 years. The overall confidence was high for 1 review,44 low for 1 review24 and critically low for 10 reviews (online supplemental eTable 5). Participants identified in these reviews were from high- and middle-income countries, including USA, Australia, UK, Mexico and Lebanon. One review included Syrian refugees in Jordan and Lebanon.36 Parenting interventions included Triple-P, Incredible Years and Tuning into Kids delivered in group settings and home visits by trained providers and healthcare professionals.
| Child mental health outcome | Review | Topic of the review/risk factor | Number of relevant RCTs (k) | Total sample size | Age groups | Amount of Evidence* | Effectiveness of the intervention on the outcome† | AMSTAR-2 rating |
|---|---|---|---|---|---|---|---|---|
| Infant mental health: Attachment | 44 | Attachment | 2 | 320 | 6–9 months | Very limited | Yes | High |
| Mood disorders: internalising symptoms | 24 | Internalising, anxiety and depressive symptoms | 1 | 94 | 11 years (mean age) | Very limited | Yes | Low |
| 45 | Group interventions | 6 | 500 | 4–12 years | Limited | No | Critically low | |
| 42 | Online parenting interventions | 8 | 1282 | 2–12 years | Moderate | Yes | Critically low | |
| 49 | Refugees in low and middle income countries with early PTSD symptoms | 2 | 179 | 3–16 years | Very limited | Yes | Critically low | |
| Mood disorders: anxiety symptoms | 24 | Internalising, anxiety and depressive symptoms | 1 | 125 | 8–13 years | Very limited | Yes | Low |
| Disruptive behaviour disorders and ADHD | 45 | Group interventions | 13 | 1610 | 4–12 years | Moderate | Mixed | Critically low |
| 46 | Triple P interventions for externalising | 8 | 657 | 2–6 years | Limited | Yes | Critically low | |
| 17 | Externalising and disruptive (including ADHD) | 50 | 4989 | 1–12 | Large | Yes | Critically low | |
| 34 | Incredible Years | 8 | 1051 | 0–13 years | Moderate | Yes | Critically low | |
| 47 | Self-directed parenting interventions for externalising | 10 | 823 | 2–12 years | Limited | Yes (only parent-reported behaviours) | Critically low | |
| 42 | Online interventions for behavioural problems | 9 | 1416 | 2–12 years | Moderate | Mixed | Critically Low | |
| 48 | Brief interventions for externalising | 8 | 836 | 2–12 years | Limited | Mixed | Critically low | |
| 36 | Ethnic minorities | 4 | 410 | 1–13 years | Very limited | Yes | Critically low | |
| 49 | Refugees in low- and middle-income countries with early PTSD symptoms | 1 | 60 | 10–16 years | Very limited | Yes | Critically low | |
| Substance-use disorders (frequency) | 31 | Substance use | 3 | 416 | 12–21 years | Very limited | Mixed | Critically low |
Nine reviews focused on behavioural problems, six of which were in favour of indicated interventions in reducing disruptive behaviours including ADHD symptoms.17 34 36 46 47 49 These six reviews included 28 trials implementing the Triple P parenting intervention, 20 trials using the Incredible Years parenting programme for children with elevated disruptive behaviour symptoms. One review found that it reduced behavioural disorder and ADHD symptoms with a large amount of evidence and large effect size (d=0.55, (95% CI: 0.39 to 0.70); k=50).17 One review implementing Incredible Years found a moderate amount of evidence with mixed effect sizes (d=−0.02 to 0.48).34 One review included one trial implementing parent training to Syrian refugees with children displaying early signs of PTSD.49 They found a very limited amount of evidence for reducing disruptive behaviour problems. Likewise, a very limited amount of evidence with small to moderate effect sizes (d=0.15–0.76) was found for interventions targeting ethnic minorities.36 Self-directed (k=10) interventions were only effective in reducing parent-reported disruptive behaviour problems and not independently observed behaviour problems.47 Three reviews on behavioural problems found inconsistent results (50% to <75% of trials demonstrated effects).42 45 48
For internalising problems, three out of four reviews with very limited (<250) to moderate amount of evidence (1000–2500) demonstrated evidence in favour of the interventions.24 42 49 The meta-analysis with a moderate amount of evidence found that an online intervention was effective in reducing internalising symptoms with a small effect size (Hedges’ g=0.22 (95% CI: 0.13 to 0.31); k=8).42 One review focused on anxiety problems as a mental health outcome and found a very limited amount of evidence in favour of intervention.24
The high-quality review showed very limited evidence in reducing infant mental health problems.44 There was also a very limited amount of evidence suggesting a reduction in substance use.31
Quality appraisal
Two out of 32 (6.3%) reviews and meta-analyses were assigned a confidence of high, 5 (15.6%) were assigned low and 25 (78.1%) were critically low (online supplemental eTable 5). PICO components related to the research question were adequately stated in all reviews. Other domains addressed by the reviews included a comprehensive literature search, detailed description of the studies and reporting of conflicts of interest. Domains that were not adequately described included: (1) pre-registering of methods (critical item 2; 28% of reviews satisfied this domain), (2) providing a list of excluded studies and reasons for their exclusion (critical item 7; 9% of reviews satisfied this domain) and (3) reporting funding sources (non-critical item 10; also 9% of reviews satisfied this domain). Non-critical items, such as explaining the selection of study designs (item 3) and providing publication bias (item 15), were lacking in 50% or more of the reviews (online supplemental eTable 5).
Discussion
This meta-review examined universal, selective and indicated parenting interventions for preventing adverse mental health outcomes in children and adolescents. Across 32 reviews, consisting of 354 unique RCTs, we found consistent evidence for universal interventions in delaying alcohol and cannabis initiation, but limited effects for other outcomes. Selective interventions showed stronger effects in reducing symptoms of disruptive behavioural disorders than mood disorders. For specific at-risk groups (eg, disadvantaged families), selective parenting interventions reduced infant mental health problems. Indicated interventions had substantial evidence for addressing disruptive behavioural problems. However, more than 90% of the reviews were rated as low or critically low quality, requiring cautious interpretation.
Universal parenting interventions, which were effective in delaying alcohol and cannabis promoted limit-setting, parental warmth and improved parent–child communication. Effective selective and indicated parenting interventions such as the Incredible Years and Triple P used parent training with role-play, vignettes and reflective practices. Emotional socialisation approaches were also supported.28 45 One trial targeting fathers found a significant reduction in disruptive behaviour.28 Although the results are limited by a small sample size, it is promising as accumulating research shows that father involvement in parenting is associated with greater socioemotional competence.50 In sum, this meta-review demonstrates an extensive evidence base for selective and indicated interventions in preventing disruptive disorders and ADHD symptoms.
Children with early behavioural problems have an increased risk of being diagnosed with oppositional defiant and antisocial personality disorder in adulthood.51 These disorders have a high burden on society due to diminished social capital and maintenance of the criminal justice system.52 53 The effectiveness of indicated and selective interventions in preventing more severe disruptive behaviour problems is crucial, as remediation of these problems down the road can be difficult to access, require subspecialty professionals with long-waiting times, and this is not sustainable in society.
Demographic characteristics can influence the effectiveness of parenting interventions. Study findings remain mixed in regards to depressive and anxiety symptoms in children, and for specific risk groups (eg, familial risk). This may be due to substantial heterogeneity in mood disorders, particularly relating to their onset, phenotypic presentation and sex differences.54 55 In addition, parents with mental health disorders vary in their functional impairment. Findings for disruptive behaviour disorders are mixed in refugee and ethnic minority populations,35 36 possibly due to structural disadvantages and cultural beliefs that may hinder their engagement with the intervention.56 57 For infant mental health, we observe more consistent findings for interventions implemented for longer durations and/or after the age of 1. Infant experiences in the first year of life are highly shaped by contextual factors; as such, the effectiveness of interventions may be moderated by parental mental health and socioeconomic status.21
Although the quality of the reviews limits strong inferences, evidence supports the economic value of parenting interventions.24 58 59 Cost-benefit analyses report returns between US$6.48 and US$17.18 per dollar invested.58 59 While individual-level effects may be modest, their population-level impact can be substantial. It is estimated that parenting interventions have a number needed to treat of 10 for anxiety and 11 for depression.24 Therefore, modest prevention can reduce long-term costs in healthcare, social services, criminal justice and lost productivity.
Strengths and limitations
The main strength of our study is that it provides a comprehensive overview of evidence for the effectiveness of different levels of preventive parenting interventions, across a range of mental health outcomes, settings and populations. We reported data from RCTs, which are less likely to be subjected to bias as opposed to observational or quasi-experimental studies. However, our study also has limitations. As a meta-review, our study relied on the methods of the systematic reviews and meta-analyses, many of which are rated as low quality without meeting the expected critical domains in AMSTAR-2. The domains that were not adequately described include pre-registering the methods of the study and providing a list of excluded studies. This highlights the importance of improving methodological transparency in future research.60 A less stringent appraisal instrument such as the Joanna Briggs Institute Critical Appraisal Tool may change the quality assessments of the reviews.61 Importantly, the quality of these reviews does not necessarily reflect the quality of individual trials included in them. Instead, our findings indicate a necessity for higher-quality reviews, with the aim of summarising evidence for policymakers. Despite our methodological approach of addressing overlapping reviews, some interventions have appeared in more than one review. However, due to the relatively consistent findings between reviews, it is unlikely that the overlaps will produce meaningful changes to our results.
As for limitations of the meta-analyses reviewed, many are affected by selective reporting of outcome measures or assessments by unblinded raters. Interventions reviewed had short follow-up periods, which may not be maintained long-term, especially for interventions implemented before 1 year of age.11 12 15 Finally, there is considerable heterogeneity in the components of the parenting interventions (eg, duration of intervention), which complicates comparisons of their effectiveness. Therefore, our review does not allow for direct comparisons of the effect sizes for interventions at different levels of prevention, nor directly compare the different types of intervention. Despite these limitations, we found evidence favouring parenting interventions at the universal, selective and indicated levels of care.
Conclusions
A large number of systematic reviews and meta-analyses investigating the effectiveness of parenting interventions in reducing adverse youth mental health outcomes are presented. Effectiveness is demonstrated for universal programmes for substance abuse and for selective and indicated programmes in reducing sequelae of disruptive behaviour. The majority of the reviews have low or critically low quality, limiting our ability to make evidence-based recommendations for policy and underscoring the need for comprehensive systematic reviews. Nevertheless, we recognise that individual interventions are of high quality and support the continued provision of parenting interventions.
Supplementary material
Footnotes
Footnote Group
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
References
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Associated Data
Supplementary Materials
Data Availability Statement
Data sharing not applicable as no datasets generated and/or analysed for this study.