This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
There is a lack of effectiveness studies when digital parent training programs are implemented in real-world practice. The efficacy of the internet-based and telephone-assisted Finnish Strongest Families Smart Website (SFSW) parent training intervention on the disruptive behavior of 4-year-old children was studied in a randomized controlled trial setting in Southwest Finland between 2011 and 2013. After that, the intervention was implemented nationwide in child health clinics from 2015 onwards.
The main aim of this study was to compare the treatment characteristics and effectiveness of the SFSW parent training intervention between the families who received the intervention when it was implemented as a normal practice in child health clinics and the families who received the same intervention during the randomized controlled trial.
The implementation group comprised 600 families who were recruited in the SFSW intervention between January 2015 and May 2017 in real-world implementation. The RCT intervention group comprised 232 families who were recruited between October 2011 and November 2013. The same demographic and child and parent measures were collected from both study groups and were compared using linear mixed-effect models for repeated measurements. The child psychopathology and functioning level were measured using the Child Behavior Checklist (CBCL) version 1.5-5 for preschool children, the Inventory of Callous-Unemotional Traits (ICU), and a modified version of the Barkley Home Situations Questionnaire. Parenting skills were measured using the 31-item Parenting Scale and the shorter 21-item Depression, Anxiety and Stress Scale (DASS-21). The estimated child and parent outcomes were adjusted for CBCL externalizing scores at baseline, maternal education, duration of the behavior problems, and paternal age. The baseline measurements of each outcome were used as covariates.
The implementation group was more likely to complete the intervention than the RCT intervention group (514/600, 85.7% vs 176/232, 75.9%, respectively;
The internet-based and telephone-assisted SFSW parent training intervention was effectively implemented in real-world settings. These findings have implications for addressing the unmet needs of children with disruptive behavior problems. Our initiative could also provide a quick socially distanced solution for the considerable mental health impact of the COVID-19 pandemic.
ClinicalTrials.gov NCT01750996; https://clinicaltrials.gov/ct2/show/NCT01750996
RR2-10.1186/1471-2458-13-985
There is mounting evidence from randomized controlled trials (RCTs) that parents can be trained to tackle and reduce children’s disruptive behavior and improve their parenting skills [
Digitally assisted interventions are becoming more common, as they can overcome the barriers associated with conventional programs [
RCT studies have shown that remote and digitally assisted parent training programs have worked well in clinical settings [
There has been growing interest in implementation research during the past 2 decades. Dissemination refers to how knowledge of new practices is actively and passively extended, and implementation refers to how new practices are incorporated into real-world environments. The term
This was the first study to report the effectiveness of the SFSW internet-based and telephone-assisted parent training program for preschool children when it was implemented in real-world settings. The intervention was put into practice after the population-based screening was used to identify children with disruptive behavior problems during routine visits to Finnish child health clinics at the age of 4 years. The primary aim was to report the changes in the children’s psychopathology and functioning level and any improvement in their families’ parenting skills. The children and their parents were followed up 6 months after the SFSW intervention was nationally implemented in Finnish primary care child health clinics. We compared the treatment characteristics and effectiveness between the families who received the SFSW intervention in these real-world settings from January 2015 to May 2017 and the families who received the intervention during the RCT from October 2011 to November 2013. Finally, we verified the findings by carrying out the following additional analyses. The first analysis excluded families who did not complete the parent training program. The second analysis excluded the Turku study site from the implementation study group because it was the only site that participated in both the RCT intervention and the implementation phases. In the third analysis, we compared the implementation and the RCT education control group. Our hypothesis was that the effectiveness of the SFSW intervention would be maintained if the protocol used in our previous RCT and the structured implementation plan were strictly adhered to.
This study was a longitudinal comparison of 2 parallel groups. The implementation group comprised 600 families who received the SFSW internet-based and telephone-assisted parent training program in the real-world setting between January 2015 and May 2017. The implementation phase covered 95 child health clinics in 12 administrative regions across Finland. The RCT intervention group comprised 232 families who had been recruited by 42 child health clinics in 7 administrative regions in Southwest Finland between October 2011 and November 2013. The administrative regions in both the RCT and implementation studies contained both urban and rural areas. Turku was the only region that participated in both studies.
There were both differences and similarities between the implementation and the RCT intervention studies. First, the implementation group received the intervention when it was integrated as a normal practice of the child health clinics, and therefore, all families who met the inclusion criteria were eligible to enter. In the implementation phase, both participants and the health care workers received information that the SFSW parent training intervention has been evaluated as an intervention with strong documented effects by the Finnish national evaluation and classification system for evidence-based interventions [
This study focused on the 6-month follow-up assessments of children who displayed a high level of disruptive behavior when they were screened at 4 years of age during routine child health clinic visits. The screening procedure in the implementation study followed the same principles that were used in the RCT study. It was integrated into the standard 4-year-old child health checkups carried out by the child health clinics in the participating administrative regions [
In the implementation group, the first 600 eligible parents who agreed to take part in the program received the SFSW parent training intervention. Initially, 8866 children were screened for highly disruptive behavior and 1099 (12.4%) met the screening criteria. The implementation group equated to 6.8% (600/8866) of the initial population-based sample and 54.6% (600/1099) of those who were eligible to take part. The reference group consisted of 232 families who were randomized to receive the intervention during the previous RCT study [
Flowchart of the families in the implementation and randomized controlled trial intervention groups.
The screening measures and enrollment criteria were identical for the implementation and RCT studies [
The participants in the implementation and RCT intervention study groups received the SFSW parent training program, which combines an interactive website with weekly telephone coaching [
The content and the conceptual framework of the skill training process of the Strongest Families Smart Website internet-based and telephone-assisted parent training intervention.
Session | Training components | Key training elements | Parental goals | Coaching elements | Parental action |
Introduction to the program | Telephone coaching | Set up the parents for success | Reorient the parents to “How to break the negative circle” | Working alliance |
Actively start to notice the good |
Notice the good | Web-based material (text, videos, audio clips) |
Positive and active |
Boost self-esteem of the child and parents and change the parents’ views of the child | Working alliance |
Notice good behavior often |
Spread attention around | Web-based material (text, videos, audio clips) |
Positive, impartial |
Strengthen child’s empathy skills | Same as above | Learn to spread attention actively |
Ignore whining and complaining | Web-based material (text, videos, audio clips) |
Positive, self-controlled parenting | Teaches parents self-regulation | Same as above | Use positive thinking to stay calm and in control of the situations |
Prepare for changes | Web-based material (text, videos, audio clips) |
Positive, proactive |
Reinforce good daily routines | Same as above | Warn that behavior must change |
Plan ahead at home | Web-based material (text, videos, audio clips) |
Positive, proactive |
Reinforce child’s active role and involve them in planning | Same as above | Listens to the child’s ideas, plans daily situations at home |
Reinforce by |
Web-based material (text, videos) |
Positive, active parenting | Involve the child in planning and reinforce good daily routines | Same as above | Understand realistic goal setting and how to use praises and rewards |
Plan ahead outside the home | Web-based material (text, videos) |
Positive, proactive |
Reinforce child’s active role and involve them in planning | Same as above | Listen to the child’s ideas |
Cooperate with day care | Web-based material (text, videos) |
Positive cooperation and communication between parent and day care | Help child to manage and succeed | Same as above | Set realistic goals and rewards |
Plan how to use time-out | Web-based material (text, videos) |
Positive, self-controlled parenting | Teach self-regulation and |
Reassure and use positive skills |
Learn to be consequent |
Revise: Problem-solving and future application of skills | Web-based material (text, videos) |
Positive daily parenting in future | Remind parents of positive proactive parenting skills | Ensure that parent is using all the skills and stays on track | Understand how using skills helps to prevent setbacks |
To ensure the integrity of the intervention and the accuracy of the data, several quality assurance measures were in effect during the implementation phase. These were similar to the quality assurance measures during the RCT study [
The outcome measures were the same in the implementation and RCT studies [
Daily activities were only assessed for the implementation study. Parents were asked to rate the impact of the child´s behavior during daily transitions, including getting dressed, getting ready for day care, during the evening meal, and getting ready for bed. It also covered social interactions, including playing with siblings and other children during a car or bicycle ride and in public places such as the supermarket. A Cronbach alpha of .64 was calculated using our implementation data. The questionnaire was adapted from the Barkley Home Situations Questionnaire, which asks the parent to rate whether the child’s behavior causes problems during specified daily routines [
The Parenting Scale, which is a 30-item questionnaire, was used to measure parenting skills [
The analyses compared the 600 families in the real-world implementation group to the 232 families in the RCT intervention group. Categorical demographic variables, including the child, parent, and family characteristics, are presented as numbers and percentages. Continuous demographic variables, including the parents’ age and duration of child’s behavioral problems, are presented as means and standard deviations. We explored any differences at baseline between the 2 groups by using Pearson chi-square test or Fisher exact test for the categorical variables and the two-tailed Student
The sensitivity analyses comprised the families who had completed the parent training program as well as the treatment comparisons. Turku was excluded from analysis, as it was the only site that had taken part in both the implementation and RCT intervention studies. As the study subjects in the implementation group were recruited from January 2015 to May 2017 and in the RCT intervention group from October 2011 to November 2013, we also tested the effect of the recruitment year on the CBCL externalizing score at baseline. The model included the effects of recruitment year, maternal education, and duration of behavior problems. The effect of the recruitment year was insignificant (
Ethical approval for the implementation study was received from the University of Turku (approval number: 18/2018). The parents provided written informed consent for both the implementation and the RCT studies.
The number of families who discontinued the program was 86 (14.3%) of the 600 families in the implementation group compared to 56 (24.1%) of the 232 families in the RCT intervention group. This meant that the odds ratio was 1.9 with a 95% CI of 1.3 to 2.8 (
Kaplan-Meier curves of families completing the program in the implementation and the randomized controlled trial intervention groups. RCT: randomized controlled trial, fixed axes according to editor comments.
Demographic characteristics of the families and treatment factors in the implementation and the randomized controlled trial intervention groups.
Demographics | Implementation group (n=600) | Randomized controlled trial |
||||||
|
||||||||
|
|
.54 | ||||||
|
|
Two biological parents | 489 (81.6) | 191 (83.5) |
|
|||
|
|
Single biological parent | 82 (13.7) | 24 (10.4) |
|
|||
|
|
Biological parent and foster parent | 19 (3.2) | 9 (3.9) |
|
|||
|
|
Other | 9 (1.5) | 5 (2.2) |
|
|||
|
|
|||||||
|
|
Maternal | 30.3 (4.8) | 30.5 (5.4) | .68 | |||
|
|
Paternal | 32.7 (5.7) | 33.2 (5.9) | .28 | |||
|
|
.046 | ||||||
|
|
Elementary school or less | 15 (2.5) | 13 (5.7) |
|
|||
|
|
Secondary education | 204 (34.2) | 85 (37) |
|
|||
|
|
College or university degree | 378 (63.3) | 132 (57.4) |
|
|||
|
|
.28 | ||||||
|
|
Elementary school or less | 27 (4.8) | 16 (7.4) |
|
|||
|
|
Secondary education | 280 (50.1) | 99 (45.8) |
|
|||
|
|
College or university degree | 252 (45.1) | 101 (46.8) |
|
|||
|
||||||||
|
|
.82 | ||||||
|
|
Female | 238 (39.7) | 90 (38.8) |
|
|||
|
|
Male | 362 (60.3) | 142 (61.2) |
|
|||
|
|
.29 | ||||||
|
|
Yes | 476 (79.9) | 192 (83.1) |
|
|||
|
|
No | 120 (20.1) | 39 (16.9) |
|
|||
|
|
.18 | ||||||
|
|
Minor | 301 (50.2) | 129 (55.6) |
|
|||
|
|
Definite | 252 (42) | 92 (39.7) |
|
|||
|
|
Severe | 47 (7.8) | 11 (4.7) |
|
|||
|
|
.004 | ||||||
|
|
<6 months | 193 (33) | 102 (45.1) |
|
|||
|
|
6-12 months | 155 (26.5) | 44 (19.5) |
|
|||
|
|
>12 months | 237 (40.5) | 80 (35.4) |
|
|||
|
||||||||
|
Total number of calls | 10.4 (2.5) | 10.1 (3.3) | .20 | ||||
|
Duration of calls for the 11 themes (min) | 37.3 (11.0) | 37.3 (13.5) | .96 | ||||
|
Duration of website access per theme (min) | 45.3 (19.3) | 47.8 (19.9) | .12 | ||||
|
Total duration of calls (h) | 6.5 (2.4) | 6.4 (3.3) | .65 | ||||
|
Total duration of website access (h) | 7.3 (2.8) | 7.5 (3.2) | .56 | ||||
|
Total duration of program (h) | 13.8 (4.3) | 14.1 (5.4) | .49 |
aMissing observations: implementation group (n=1); randomized controlled trial group (n=2).
bMissing observations: implementation group (n=3); randomized controlled trial group (n=2). Pairwise comparisons: elementary school or less versus secondary education (
cMissing observations: implementation group (n=41); randomized controlled trial group (n=1).
dMissing observations: implementation group (n=4); randomized controlled trial group (n=1).
eMissing observations: implementation group (n=15); randomized controlled trial group (n=6). Pairwise comparisons: <6 months versus 6-12 months (
In the implementation group, there were significant improvements from the baseline to the 6-month follow-up assessment in the primary outcome, which was the CBCL externalizing score. The same was true for the secondary outcomes: CBCL total and internalizing scores and the total scores of the ICU, Parenting Scale, and DASS-21 (
The additional analyses compared the changes in primary and secondary outcomes between the implementation and the RCT education control groups, as shown in Table S3 of
Change from baseline to 6 months in child psychopathology, parenting skills, and parents’ stress in the implementation group.
Variable | Baseline (n=600), meana (SE) | After 6 months (n=600), meana (SE) | Mean changeb (SE) | 95% CI | ||||||||
|
||||||||||||
|
|
|||||||||||
|
|
Child Behavior Checklist externalizing score | 21.1 (0.5) | 14.8 (0.5) | 6.2 (0.4) | 5.5 to 7.0 | <.001 | |||||
|
|
|||||||||||
|
|
Child Behavior Checklist Total score | 48.8 (1.2) | 33.6 (1.3) | 15.2 (1.0) | 13.3 to 17.2 | <.001 | |||||
|
|
Child Behavior Checklist Internalizing score | 12.1 (0.4) | 8.5 (0.5) | 3.6 (0.4) | 2.9 to 4.3 | <.001 | |||||
|
|
|
||||||||||
|
|
|
Aggression | 18.0 (0.4) | 12.5 (0.4) | 5.5 (0.3) | 4.9 to 6.1 | <.001 | ||||
|
|
|
Attention | 3.1 (0.1) | 2.4 (0.1) | 0.7 (0.1) | 0.6 to 1.0 | <.001 | ||||
|
|
|
Sleep | 4.0 (0.2) | 2.5 (0.2) | 1.5 (0.1) | 1.2 to 1.7 | <.001 | ||||
|
|
|
Withdrawn | 2.4 (0.1) | 1.6 (0.1) | 0.8 (0.1) | 0.6 to 1.0 | <.001 | ||||
|
|
|
Somatic | 2.9 (0.1) | 2.0 (0.2) | 0.8 (0.1) | 0.6 to 1.1 | <.001 | ||||
|
|
|
Anxious | 2.9 (0.1) | 2.0 (0.1) | 0.8 (0.1) | 0.6 to 1.0 | <.001 | ||||
|
|
|
Emotional | 3.9 (0.2) | 2.8 (0.2) | 1.2 (0.1) | 0.9 to 1.4 | <.001 | ||||
|
|
|
||||||||||
|
|
|
Affective problems | 3.3 (0.1) | 2.0 (0.2) | 1.3 (0.1) | 1.1 to 1.5 | <.001 | ||||
|
|
|
Anxiety problems | 4.2 (0.2) | 2.9 (0.2) | 1.4 (0.1) | 1.1 to 1.6 | <.001 | ||||
|
|
|
PDDd problems | 4.7 (0.2) | 3.3 (0.2) | 1.4 (0.2) | 1.1 to 1.7 | <.001 | ||||
|
|
|
ADHDe problems | 6.0 (0.2) | 4.5 (0.2) | 1.6 (0.1) | 1.3 to 1.8 | <.001 | ||||
|
|
|
ODDf problems | 6.5 (0.2) | 4.6 (0.2) | 1.9 (0.1) | 1.6 to 2.1 | <.001 | ||||
|
|
|
||||||||||
|
|
|
Total | 24.6 (0.5) | 20.6 (0.5) | 4.0 (0.4) | 3.2 to 4.7 | <.001 | ||||
|
|
|
Callousness | 8.3 (0.2) | 6.2 (0.2) | 2.2 (0.2) | 1.8 to 2.5 | <.001 | ||||
|
|
|
Uncaring | 13.2 (0.2) | 11.6 (0.3) | 1.6 (0.2) | 1.3 to 2.0 | <.001 | ||||
|
|
|
Unemotional | 3.1 (0.1) | 2.9 (0.1) | 0.2 (0.1) | –0.1 to 0.4 | .30 | ||||
|
||||||||||||
|
|
|||||||||||
|
|
Total | 3.2 (0.0) | 2.7 (0.0) | 0.6 (0.0) | 0.5 to 0.6 | <.001 | |||||
|
|
Laxness | 2.7 (0.0) | 2.2 (0.0) | 0.4 (0.1) | 0.4 to 0.5 | <.001 | |||||
|
|
Overreactivity | 3.9 (0.1) | 3.1 (0.1) | 0.8 (0.0) | 0.7 to 0.9 | <.001 | |||||
|
|
Hostility | 1.9 (0.0) | 1.6 (0.1) | 0.3 (0.1) | 0.3 to 0.4 | <.001 | |||||
|
|
|||||||||||
|
|
Total | 18.5 (1.1) | 12.1 (1.1) | 6.4 (0.8) | 4.9 to 7.9 | <.001 | |||||
|
|
Depression | 5.2 (0.5) | 3.1 (0.5) | 2.1 (0.3) | 1.4 to 2.7 | <.001 | |||||
|
|
Anxiety | 2.4 (0.3) | 1.4 (0.3) | 1.1 (0.2) | 0.7 to 1.4 | <.001 | |||||
|
|
Stress | 11.0 (0.5) | 7.7 (0.5) | 3.3 (0.4) | 2.6 to 4.0 | <.001 |
aLeast-squares means.
bChange from baseline to 6 months after providing informed consent.
cAdjusted with maternal education and duration of problems.
dPDD: pervasive developmental disorder.
eADHD: attention-deficit/hyperactivity disorder.
fODD: oppositional defiant disorder.
Mean changes from baseline to 6 months in child psychopathology, parenting skills, and parents’ stress in the implementation and randomized controlled trial intervention groups.
Variable | Mean (SE) change from baseline to 6 months | Implementation versus RCT intervention, mean (95% CI) | ||||||||
|
Implementation group (n=600), meana (SE) | RCTb intervention (n=232), meana (SE) |
|
|
||||||
|
||||||||||
|
|
|||||||||
|
|
Child Behavior Checklist externalizing score | 6.3 (0.4) | 6.1 (0.6) | –0.2 (–1.3 to 1.6) | .83 | ||||
|
|
|||||||||
|
|
Child Behavior Checklist total score | 15.3 (1.0) | 14.6 (1.6) | –0.7 (–3.0 to 4.5) | .70 | ||||
|
|
Child Behavior Checklist internalizing score | 3.7 (0.4) | 3.4 (0.6) | –0.3 (–1.0 to 1.6) | .64 | ||||
|
|
|||||||||
|
|
Aggression | 5.5 (0.3) | 5.5 (0.5) | –0.0 (–1.2 to 1.3) | .95 | ||||
|
|
Attention | 0.7 (0.1) | 0.6 (0.1) | –0.1 (–0.2 to 0.4) | .53 | ||||
|
|
Sleep | 1.5 (0.1) | 1.5 (0.2) | –0.0 (–0.5 to 0.5) | 1.0 | ||||
|
|
Withdrawn | 0.8 (0.1) | 0.5 (0.2) | –0.3 (–0.0 to 0.7) | .08 | ||||
|
|
Somatic | 0.8 (0.1) | 0.6 (0.2) | –0.2 (–0.2 to 0.7) | .29 | ||||
|
|
Anxious | 0.9 (0.1) | 1.0 (0.2) | –0.1 (0.5 to 0.3) | .62 | ||||
|
|
Emotional | 1.2 (0.1) | 1.3 (0.2) | –0.1 (–0.7 to 0.4) | .58 | ||||
|
|
|||||||||
|
|
Affective problems | 1.3 (0.1) | 1.3 (0.2) | 0.0 (–0.4 to 0.5) | .95 | ||||
|
|
Anxiety problems | 1.4 (0.1) | 1.5 (0.2) | –0.1 (–0.6 to 0.4) | .69 | ||||
|
|
PDDd problems | 1.4 (0.2) | 1.2 (0.3) | 0.2 (–0.3 to 0.8) | .41 | ||||
|
|
ADHDe problems | 1.6 (0.1) | 1.2 (0.2) | 3.5 (–0.2 to 0.9) | .17 | ||||
|
|
ODDf problems | 1.9 (0.1) | 2.2 (0.2) | –0.3 (–0.7– 0.2) | .26 | ||||
|
|
|||||||||
|
|
Total | 4.0 (0.4) | 4.3 (0.7) | –0.4 (–1.9 to 1.2) | .64 | ||||
|
|
Callousness | 2.0 (0.2) | 2.1 (0.3) | –0.1 (–0.7– 0.8) | .83 | ||||
|
|
Uncaring | 1.6 (0.2) | 1.9 (0.3) | –0.2 (–1.0 to 0.5) | .53 | ||||
|
|
Unemotional | 0.2 (0.1) | 0.3 (0.2) | –0.1 (–0.6 to 0.3) | .44 | ||||
|
||||||||||
|
|
|||||||||
|
|
Total | 0.6 (0.0) | 0.5 (0.0) | 0.0 (–0.1 to 0.1) | .50 | ||||
|
|
Laxness | 0.4 (0.0) | 0.4 (0.1) | 0.0 (–0.1 to 0.2) | .79 | ||||
|
|
Overreactivity | 0.8 (0.1) | 0.6 (0.1) | 0.2 (–0.0 to 0.4) | .07 | ||||
|
|
Hostility | 0.3 (0.0) | 0.3 (0.1) | 0.0 (–0.1 to 0.2) | .85 | ||||
|
|
|||||||||
|
|
Total | 6.4 (0.7) | 3.9 (1.1) | 2.5 (0.0 to 5.1) | .05 | ||||
|
|
Depression | 2.1 (0.3) | 1.0 (0.5) | 1.1 (0.1 to 2.2) | .036 | ||||
|
|
Anxiety | 1.0 (0.2) | 0.8 (0.3) | 0.3 (–0.4 to 0.1) | .44 | ||||
|
|
Stress | 3.3. (0.4) | 2.2 (0.6) | 1.1 (–0.2 to 2.4) | .09 |
aLeast-squares means.
bRCT: randomized controlled trial.
cAdjusted with maternal education and duration of problems.
dPDD: pervasive developmental disorder.
eADHD: attention-deficit/hyperactivity disorder.
fODD: oppositional defiant disorder.
This was the first population-based study to evaluate the effectiveness of an internet-based and telephone-assisted parent training intervention for children with behavior problems when it was implemented in real-world practice. The children’s psychiatric problems improved, including externalizing and internalizing problems and callousness. The findings were remarkable from the perspective of the children’s social development, as the program had significant effects on daily transitions and activities such as getting dressed, dining behavior, activities outside the home, and interactions with other people. Parents reported that their parenting skills had improved and they demonstrated less distress in dealing with their children at the 6-month follow-up. Most importantly, this study shows that the improvements that had been achieved were similar to those reported for the intervention group in the RCT. There was no difference in the changes in the children’s psychiatric problems or parenting skills when the implementation and RCT groups were compared. Furthermore, when changes between the implementation and RCT education control groups were compared, the implementation group showed significantly better improvements in the children’s externalizing and internalizing problems as well as in parenting skills and parents’ distress. In addition to the effectiveness of the treatment, the ability to engage and retain parents in the program is one of the keys to successful parent training interventions [
In order to successfully implement interventions, we need to know whether they work and
Several practical features of the program may have paved the way for positive outcomes during the real-world implementation. First, the program was much easier for the parents than face-to-face interventions because they did not need to leave home or work or make childcare arrangements. Second, the telephone coaching provided immediate problem-solving, which may have been more rewarding for the parents than communicating using emails or text messages. A recent meta-analysis showed that digital interventions that included support and guidance, such as telephone calls, had larger effect sizes on mental health outcomes than smartphone interventions without any personal support [
There were some limitations in our study. First, although the parental and child outcomes were measured using well-validated questionnaires, they were rated by the same person, namely, the parent. One parent was identified for each child, but they were also encouraged to get the child’s other parent involved in the program as much as possible. Further details on the level of parental involvement could have added to the richness of the data, but there were practical limitations to collecting this. To reduce the possibility of the common rater variance, observations by other informants such as day care personnel could have validated our findings. Second, we have discussed mechanisms that could have been responsible for the positive outcomes. However, there is very little empirical evidence on whether the effects of the intervention resulted from the internet sessions, the personal telephone coaching, parental motivation, or a combination of those factors. Further studies need to examine factors that explain these positive outcomes. Personalized medicine is increasingly being used to move away from one-size-fits-all interventions to those that are more tailored to individual needs. This approach could yield useful information on the mechanisms underlying interventions and enable more accurate targeting.
The target group, content, and effectiveness of the intervention were maintained when the implementation group results were compared with the findings of the RCT intervention. Internet-based telephone-assisted parent training interventions may have advantages over traditional group-based treatment approaches when the goal is to identify children at risk in the community at an early stage. This new approach can provide effective parent training for a large number of families, including many who would not normally participate in clinic-based services. Referring families who need parent training to clinical services often results in substantial delays and they need other support while they are waiting. Digitally delivered interventions move child mental health treatment outside traditional clinics and into people’s homes and schools, increasing access and reducing stigma. In addition, they can be increased to help more families, and parents are more likely to stay with the program until the end. There is a global shortage of skilled staff who can address child mental health problems in low- and high-income countries and even in countries with public health care [
Timeline of the randomized controlled trial and implementation studies.
Change from baseline to 6 months in child psychopathology, parenting skills and parents’ stress in the Implementation group for participants who completed the program.
Mean changes from baseline to 6 months in child psychopathology, parenting skills, and parents’ stress in the implementation and the randomized controlled trial intervention groups for participants who completed the program.
Mean changes from baseline to 6 months in child psychopathology, parenting skills, and parents’ stress in the implementation and randomized controlled trial educational control groups.
Change from baseline to 6 months in child psychopathology, parenting skills, and parents’ stress in the implementation and randomized controlled trial intervention groups. The city of Turku is excluded from the implementation data.
Change from baseline to posttreatment and 6 months in daily activities and social interactions in the implementation group (n=600).
Child Behavior Checklist
21-item Depression, Anxiety and Stress Scale
Inventory of Callous-Unemotional Traits
randomized controlled trial
Strongest Families Smart Website
We wish to thank the family coaches and Project Engineer Atte Sinokki from the Department of Child Psychiatry, University of Turku, as well as the public health directors and health nurses at the participating municipal child health clinics who made this study possible. This research was funded by the Academy of Finland Flagship Program Inequalities, Interventions, and a New Welfare State (decision 320162), the Academy of Finland Health from Cohorts and Biobanks Program (decision 308552), and the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant 101020767) (author AS).
AS is the founder and director of Digifamilies, which provides evidence-based treatments to Finnish public health services. The Strongest Families Institute (SFI) is a not-for-profit organization that delivers services to Canadian families. PJM is the cofounder and Chair of SFI Board of Directors. The other authors have no conflicts of interest to declare.