J Child Fam Stud (2016) 25:705719
DOI 10.1007/s10826-015-0284-6
ORIGINAL PAPER
Brief Parenting Interventions for Children at Risk
of Externalizing Behavior Problems: A Systematic Review
Lucy A. Tully1 Caroline Hunt1
Published online: 21 September 2015
Springer Science+Business Media New York 2015
Abstract We systematically reviewed the evidence for
the efficacy and effectiveness of brief parenting interven-
tions, defined as \8 sessions in duration, in reducing child
externalizing behaviors. While there is significant evidence
to support the efficacy of parenting interventions of 812
sessions in duration, the public health benefit of these
interventions is limited by low participation rates, high
attrition rates and the lack of implementation by a wide
range of practitioners. Brief parenting interventions have
the potential to extend the reach and impact of parenting
interventions and steer children away from a trajectory of
life course persistent behavior problems. A search of four
electronic databases was undertaken to identify RCTs
conducted on brief parenting interventions. The primary
outcome was child externalizing behaviors and secondary
outcomes included parenting skills, parental self-efficacy,
parental mental health and partner relationship functioning.
The heterogeneity of included studies prevented a meta-
analysis but characteristics of the studies were described.
Nine papers summarising the results of eight studies with
836 families in five countries met inclusion criteria. All
studies found significant improvements in parent-rated
child externalizing behaviors, parenting skills and parent-
ing self-efficacy, relative to control or comparison groups,
with findings maintained at follow-up. Less consistent
findings emerged for parental mental health and partner
relationship functioning. This review provides initial evi-
dence that brief parenting interventions may be sufficient to
& Lucy A. Tully
lucytully56@gmail.com
1
The University of Sydney, Sydney, Australia
reduce child externalizing behavior problems for some
families, however further research is needed.
Keywords Parenting
Brief parenting interventions

Parenting skills
Child externalizing behavior
Introduction
The prevalence estimates of childhood mental health
problems worldwide vary widely between 5 and 26 %
(Brauner and Stephens 2006) with recent estimates in the
US of approximately 18 % (Houtrow and Okumura 2011).
Childhood mental health problems are often separated into
internalizing and externalizing behavior problems. Exter-
nalizing problems describe behavior that is characterised
by aggression, defiance, hostility and poor impulse control
and these behaviors are the main reason for referral to child
and adolescent mental health services (Kazdin 2008).
While for some young children, externalizing behaviors are
transient and limited to a specific development stage; for
many, however, the behaviors persist throughout childhood
and place them at risk of long-term outcomes that are
significant and costly to society (e.g., Colman et al. 2009;
Fergusson et al. 2005).
There is significant evidence from the past 30 years that
parenting interventions based on social learning and cog-
nitive-behavior theory such as Triple P-Positive Parenting
Program (Sanders 1999), Incredible Years (Webster-Strat-
ton and Reid 2003), Parent Management Training Oregon
Model (PMTO; Patterson et al. 2002) and Parent Child
Interaction Therapy (PCIT; Eyberg et al. 1995) are effec-
tive in changing dysfunctional parenting and in improving
childrens externalizing problems in the short- and longer-
term (de Graaf et al. 2008a, b; Nowak and Heinrichs 2008;
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706
Eyberg et al. 2008; Thomas and Zimmer-Gembeck 2007).
However, there are low participation rates (Heinrichs et al.
2005) and high attrition rates (up to 60 %, Kazdin 1996;
Nowak and Heinrichs 2008) which limit the reach and
impact of parenting interventions. Low uptake rates and
high attrition rates may be due to the demands of partici-
pation in typical individual or group parenting interven-
tions, which are usually 812 sessions in duration (Bradley
et al. 2003; Lavigne et al. 2008), but can be as many as 24
sessions.
Lengthy parenting interventions are not only challeng-
ing for parents to attend in terms of organising childcare,
transport and competing family priorities (Kazdin and
Wassell 1999), but they are also resource-intensive, costly
and require significant clinician time through training and
supervision (OBrien and Daley 2011). According to the
RE-AIM framework, the impact of the intervention is a
function of five factors: Reach, Efficacy, Adoption,
Implementation and Maintenance (Glasgow et al. 1999).
This means that as well as reach and efficacy, interven-
tions need to be adopted, implemented and maintained
over time by a variety of health care professionals in a
range of settings. Primary care practitioners such as child
health nurses and general practitioners are often best
placed to provide interventions to families with young
children with externalizing behavior problems, but the
length of typical parenting interventions and the training
and supervision requirements are a significant barrier for
implementation.
There is growing recognition that in order to radically
extend the reach of parenting interventions and impact on
the prevalence of child externalizing problems, a range of
flexible low intensity or light touch interventions are Participants will be caregivers of children aged 28 years
required (Sanders and Kirby 2010). Low intensity inter-
ventions include brief individual or group interventions as
well as self-directed interventions, where parents work
through the materials on their own with minimal or no
therapist assistance. These can be offered as the first step as
part of a stepped-care approach, with more intensive
interventions offered to those who require more support
(Haaga 2000). However, in order for stepped care
approaches to be effective, low intensity interventions have
to produce equivalent outcomes to more intensive inter-
ventions for at least proportion of participants (Bower and
Gilbody 2005). There is increasing research on self-di-
rected parenting programs, where parents work through the
materials on their own with little or no therapist support,
and a recent meta-analysis found that they result in similar
outcomes compared with therapist-led interventions (Tar-
ver et al. 2014). While self-directed programs are low
intensity, they are not always brief in duration, so still may
be burdensome for families. Therefore, brief individual or
group interventions are required for families who would
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J Child Fam Stud (2016) 25:705719
prefer brief therapist support over a longer self-directed or
therapist-led program, and also to enable delivery by pri-
mary care practitioners.
Brief interventions aim to condense the key components
of effective parenting programs into a shorter program
length. While there is no accepted definition of what a
brief parenting intervention constitutes, since many par-
enting programs are between 8 and 12 sessions (Bradley
et al. 2003; Lavigne et al. 2008), brief can be defined as
\8 sessions in duration. Supporting this definition,
research on psychological interventions for adult mental
health disorders such as depression has also defined brief
interventions as \8 sessions in duration (e.g., Nieuwsma
et al. 2011). There already appears to be a trend towards
implementing brief interventions in publicly funded child
and adolescent mental health services, in order to cope with
the excessive demand for services (Perkins 2006). While
the efficacy of moderately intensive parenting programs
of 812 sessions has already been established (Lavigne
et al. 2008), it is now a priority to examine the effects of
brief parenting interventions in reducing child externaliz-
ing behavior problems and in improving parent and family
functioning. The aim of this systematic review is to assess
the evidence for the efficacy and effectiveness of brief (\8
sessions) individual or group parenting interventions for
reducing child externalizing behavior problems.
Method
Inclusion Criteria
who have either been diagnosed with Oppositional Defiant
Disorder; have elevated externalizing behaviors; who are at
risk of having elevated externalizing behaviors as a con-
sequence of presence of a family risk factor (e.g., parental
depression); or caregivers who are concerned about their
childs behavior. Thus, studies that use selected and tar-
geted interventions for child externalizing behaviors will
be included, but universal interventions that target an entire
population with the aim of preventing problems will not be
included. Studies that target children with ADHD, medical
health problems, and developmental delays or disabilities
will not be included. Studies including children younger
than 2 or older than 8 years will be included in the review
if the mean child age falls within the 28 year age range.
This age range was selected since there is evidence that
parenting interventions are less efficacious with parents of
children over 8 years (e.g., Ogden and Hagen 2008).
The review will include randomized controlled trials
(RCTs) that compare brief interventions with a control or
comparison group such as a waitlist control group, no
J Child Fam Stud (2016) 25:705719
interventions or treatment as usual. The articles need to be
published in English between 1992 and May 2015.
Parenting interventions of \8 sessions, delivered in
individual, group or telephone-assisted format will be
included. Parenting interventions should be based on social
learning theories since these interventions have substantial
research to support their efficacy (Chorpita et al. 2011) and
focus on modifying parenting skills in order to reduce child
externalizing behaviors. Studies that report on interven-
tions with self-directed sessions will be excluded (since
reviews already exist on self-directed interventions) as will
studies that examine multi-component interventions that
include parenting interventions as only one component of
the intervention.
Outcomes
The primary outcome for this study was measures of child
externalizing behaviors. Secondary outcomes include: (1)
parenting skills, practices or discipline style, (2) parental
self-efficacy, competence, confidence or satisfaction, (3)
parental mental health and (4) parental relationship func-
tioning (satisfaction or conflict).
Search Strategy
Keyword searches of the following electronic databases
were undertaken: PsychINFO, Medline, Sociological
Abstracts, Web of Science. There were two groups of
search terms. The first group related to the intervention and
included the terms: parent intervention, parent training,
parenting program, behavioral family therapy, parent sup-
port and positive parenting. The second group of search
terms related to child behavior and included the terms:
behavior problems, disruptive behavior, externalizing
behavior, conduct disorder, oppositional defiant disorder,
aggression and child mental health.
Study Selection
The initial literature search yielded 4061 articles. Article
titles were screened for eligibility by the first author (LT)
and the second author (CH) screened a random sample of
622 titles (15 %) with agreement of 96 %. Where agree-
ment was not reached, the abstract for the article was
reviewed by both authors. From the title search, 189 arti-
cles were selected for an abstract review by the first author
with the second author reviewing a random sample of 88
abstracts (47 %) with agreement of 91 %. Again, where
agreement was not reached between reviewers, the full
article was reviewed by both authors. As many abstracts
did not include information about the duration of the
intervention, this necessitated a review of the full article to
707
determine eligibility. In total, 64 articles were selected for
full review by both authors independently with nine
meeting inclusion criteria. These nine papers described the
results from eight studies. Figure 1 shows a flow chart of
article selection, including reasons for exclusion.
Data Extraction, Coding and Quality Assessment
For the nine articles describing eight studies, information
was independently abstracted from both authors on study
sample, recruitment and inclusion criteria; intervention;
design of study and retention rate; timing of measurement;
targeted outcomes and measures; and results including
statistical significance, effect size and clinical significance.
The articles were also independently reviewed for quality
using a modified version of the Quality Index (Downs and
Black 1998), a valid and reliable tool for measuring
methodological quality. The original 27-item Quality Index
was modified to exclude 4 items that were not relevant
including 2 items about blinding, 1 about allocation con-
cealment and 1 about adverse events. These items were
excluded as they are not relevant to studies of parenting
interventions since it is not possible to conceal allocation
from participant or blind them to condition, and adverse
events are usually not reported in these studies. The
remaining 23 items assessed: 9 items on reporting of the
study (e.g., were the interventions clearly described?), 3
items on external validity (e.g., were subjects who were
prepared to participate representative of the entire popu-
lation from which they were recruited?), 10 items on
internal validity (e.g., were the main outcome measures
accuratevalid and reliable?); and 1 item on power. Each
checklist item was scored 0 (no/unable to determine) or 1
(yes) with a maximum possible score of 23. The two
reviewers resolved disagreements regarding quality
assessment through discussion.
Table 1 summarises the abstracted information from the
nine articles and the Quality Index Score. Where statistical
analyses were conducted with MANOVAs, the results in
Table 1 include only the findings of the ANOVAs where
MANOVAs were significant. Only outcomes relevant to
the focus of this review are reported in the table. Due to the
small number of papers identified and significant variations
in interventions, child age, settings and outcomes, a formal
meta-analysis was not conducted.
Results
Participant Characteristics
All studies recruited parents of children who had concerns
or were seeking help about their childs behavior. The
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708
Title search of potentially relevant studies
(n = 4061)
Abstracts of studies retrieved and reviewed
(n = 189)
Papers selected for full review by two authors (n = 64)
Studies meeting inclusion criteria (n = 9)
Fig. 1 Flowchart of included and excluded studies and reasons for exclusion
focus was on parents of children in the pre-school or early
primary school age range, with the exception of Kjbli and
Odgen (2012) and Meija et al. (2015) who recruited parents
of 312 year olds. Joachim et al. (2010) recruited parents
who were concerned about problems on shopping trips
while Morawska et al. (2011) and Dittman et al. (2015)
recruited parents who were concerned about child disobe-
dience and Bradley et al. (2003) and Meija et al. (2015)
recruited parents having trouble managing their childs
behavior. For this latter study, children had to score above
the mean on the Eyberg Child Behavior Inventory (ECBI;
Eyberg and Pincus 1999). Studies predominantly recruited
families via community advertising except for Kjbli and
Odgen (2012) and Turner and Sanders (2006) who recrui-
ted parents of children seeking help from a primary care
agency and Meija et al. (2015) who recruited parents from
schools in disadvantaged neighbourhoods.
Types of Interventions
Of the eight studies, six used the Triple P system of
intervention (Sanders 1999). Triple P includes a tiered
system of support that increases in intensity from a uni-
versal communication strategy (Level 1), brief low-inten-
sity seminars, individual or group programs (Levels 2 and
3) to more intensive group and individual programs (Level
4 and 5). Triple P uses a self-regulatory framework where
parents are taught parenting skills and strategies to become
independent problem solvers. Level 3 includes information
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J Child Fam Stud (2016) 25:705719
Ineligible studies,
excluded on the basis
of title review
(n = 3872)
Ineligible studies,
excluded on the basis of
abstract review (n=125)
55 excluded:
Duration >7 sessions =
43
Universal intervention
=3
Multi-component = 5
Self-directed
components = 2
Not based on social
learning theory = 1
Children with medical
condition = 1
and advice for parents as well as active skills training
(DVD modelling of skills, roleplay, rehearsal, feedback
and group discussion). Five of the studies examined the
efficacy of different Triple P Discussion Groups (Dealing
with Disobedience, Hassle-free Shopping and Hassle
Free Mealtimes). These 2-h Triple P Discussion Group,
are a Level 3 intervention specifically designed for parents
of children with discrete behavior problems. Morawska
et al. (2011) and Meija et al. (2015) examined the Dealing
with Disobedience program plus two telephone sessions
while Dittman et al. (2015) examined the group program
only. Joachim et al. (2010) examined Hassle free Shop-
ping group program and Morawska et al. (2014) exam-
ined Hassle-free Mealtimes group program. Meija et al.
(2015) minimally adapted the Dealing with Disobedi-
ence group intervention for Spanish speaking parents by
using language translation and included two phone
sessions.
The final study to examine Triple P was an effectiveness
study in which child health nurses delivered the Primary
Care Triple P (also a Level 3 intervention) with three to
four (30 min) individual sessions (Turner and Sanders
2006). All of the studies were conducted in Australia with
the exception of Dittman et al. (2015) who recruited fam-
ilies from New Zealand as well as Australia and Meija
et al. (2015) who conducted the study in Panama City.
Kjbli and Odgen (2012) examined a brief version of
PMTO lasting 35 individual sessions in an effectiveness
study in Norway where the intervention was delivered by
 Table 1 Summary table of the design and results of the nine articles on brief parenting interventions included in the systematic review
Authors/country Study sample, Interventionname, Design of Timing of Targeted outcomes and Results including statistical Clinical significance Quality
recruitment format, duration and study (n) and measures measures significance (and effect sizes) and reliable change Index
and inclusion fidelity retention rate Score
criteria

Bradley et al. Parents of Brief behaviorally RCT Pre-post, Child behavior Child behavior CSC 14
(2003) 34 year olds oriented psycho- effectiveness 1 year month PBQ total, hyper/distractible, Intervention \ WL on PBQ total* Calculated on PS total at
Canada having trouble educational parenting study. Cluster FU. A sub- hostile/aggressive scales (0.40)a and hyper/distractible ** post. In intervention group
managing intervention. Four randomisation sample of (0.41)a at post. PBQ hostile/ 26 % in clinical range at
their childs group sessions (78 in blocks of intervention Parenting
aggressive NS. Improvements post vs 56 % in waitlist.
behavior. parents per group), six or ten. 198 group PS total, laxness, overreactivity maintained at follow-up for sub- Statistical significance not
Families 2 h per session. First families (n = 25) and verbosity scales sample of the intervention group. reported.
J Child Fam Stud (2016) 25:705719

recruited three sessions randomised to assessed at Parental mental health

through delivered weekly. intervention 1 year FU. Parenting
community Final booster session (n = 89) or BSI hostility scales Intervention group \ WL on PS
advertising. delivered 4 weeks three-month Only one parent completed total*** (0.89)a, laxness** (0.51)a,
after session 3. waitlist control measures (% mothers vs fathers Overreactivity *** (0.57)a and
Delivered in group not specified) verbosity *** (1.10)a.
community agencies (n = 109). Improvements maintained at FU.
by trained community 88 % retention at Parental mental health
staff facilitators. post (91 % in
Treatment fidelity not Intervention group \ WL on
intervention
reported group) BSI hostility** (0.44)a with
improvements maintained at FU.
ITT analysis
ITT analysis not reported
Dittman et al. Parents of Triple P-Positive RCT efficacy Pre-post, Child behavior Child behavior CSC 16
(2015) 35 year olds Parenting Program: study. 85 6 month FU. ECBI Intensity Score Intervention \ WL on ECBI Intensity Intervention [ WL in % of
Australia and New who were Parent Discussion families Only (0.86)*** at post. Improvements for children moved from
concerned Group focussing on randomised to intervention Parenting
Zealand intervention group maintained at clinical to non-clinical
about dealing with intervention group PS laxness, overreactivity and FU. range on ECBI Intensity**.
noncompliant disobedience. Two (n = 45) or assessed at verbosity Score Intervention [ WL in % of
behavior. hour group program 68 week 6 month FU Parenting
Parent conflict and relationship parents moved to non-
Parents were (average of 6 parents waitlist control satisfaction Intervention group \ WL on PS clinical range on PS
recruited per group). group Laxness* (0.57), Overreactivity* Laxness**,
through Intervention delivered (n = 40). PPCExtent Scale (0.52) & Verbosity** (0.69) with Overreactivity** and
community by psychologists. 73.3 % RQI improvements for intervention Verbosity*, and PTC
advertising. Treatment fidelity retention at Parenting self-efficacy group maintained at FU. Behavior & Setting NS.
monitored through post for Parenting conflict and relationship
session content intervention PTCBehavior and Setting Self- RCI
Efficacy Scales satisfaction
checklists but and 95.0 % Intervention [ WL reliable
adherence rates not control. 87 % Parental mental health Group differences NS change on ECBI
reported retention at DASS-21 depression, Anxiety Parenting self-efficacy intensity**, PS
follow-up for and Stress Scales Intervention group [ WL Overreactivity* and
intervention Verbosity* and PTC
group Only one parent completed on PTC behavior** (0.69) and PTC Setting*. PS Laxness and
measures (94 % mothers) setting* (0.45) at post. PTC Behavior NS
Improvements maintained at FU.
Parental mental health
Group differences NS.
ITT analysis
All analyses were ITT
709

123
 Table 1 continued
710

Authors/country Study sample, Intervention Design of Timing of Targeted outcomes and Results including statistical Clinical Quality
recruitment and name, format, study (n) and measures measures significance (and effect sizes) significance and Index

123
inclusion criteria duration and retention rate reliable change Score
fidelity

Joachim et al. Parents of a child aged Triple P-Positive RCT efficacy Pre-post, 6 month Child behavior Child behavior CSC 18
(2010) 26 years reporting Parenting study. 46 FU. Only ECBI Intensity and Problem Intervention \ WL on ECBI Intensity* Intervention [ WL in
Australia behavior problems on Program: Families intervention Score (0.75) and Problem Score** (0.92) at % of children
shopping trips. Parent randomised to group assessed at post. Improvements maintained at moving from clinical
Parents recruited Discussion intervention 6 month FU. Parenting
6 month FU. to non-clinical range
through community group (n = 26) or PS Total Score on ECBI Intensity*
advertising focussing on 4-week Parenting
Parent conflict not Problem Score.
managing child waitlist Intervention group \ WL on PS Total** Intervention [ WL
disruptive control group PPCProblem Scale and (0.72). Improvements were not
Extent Scale in % of parents
behavior on (n = 20). maintained at FU. moving from clinical
shopping trips. 87 % Parenting self-efficacy Parent conflict to non-clinical range
Two hour retention at PTC Behavior & Setting on PS Total**, PTC
group program post (88 % in Group differences NS.
Self-Efficacy Scales behavior* and PTC
(average of 10 intervention Parenting self-efficacy setting*.
parents per group). 92 % Parental mental health
Intervention group [ WL RCI
group). retention at DASS-21 Depression,
Treatment follow-up for Anxiety and Stress Scales on PTC behavior *** (1.07) and Setting Intervention [ WL
fidelity not intervention self-efficacy*** (1.26). Improvements reliable change on
Only one parent completed maintained at FU.
reported group measures (96 % mothers) ECBI problem** and
Parental mental health PTC behavior * but
Group differences NS. not ECBI Intensity,
PS Total or PTC
ITT analysis setting
All effects remained significant
Kjbli and Odgen Parents of children aged Brief Parent RCT Pre-post test design. Child behavior Parent report: Child behavior Not reported 15
(2012) 3 to 12 years (M = 7) Training (based effectiveness 6 month FU. Both ECBI Intensity & Problem Intervention \ comparison on ECBI
Kjbli and seeking help from on PMTO). study. 216 intervention and Scale, & HCSBS Intensity** at post and FU (0.43 & 0.33)
Bjrnebekk primary care agency Individual families comparison externalizing scale. and Problem Scale* (0.35 & 0.32),
(2013) for child conduct programs. randomised to assessed at FU Teacher report: HCSBS & HCSBS externalizing scale* (0.37 &
problems. 55.6 % at Lasts 35 intervention SSBS externalizing. 0.27). Teacher reports of child behavior
Norway or 90th percentile on sessions (n = 108) or Parenting NS at post and FU.
ECBI Intensity (M = 5.4 h). comparison
Scale Comparison group Parent report of parenting Parenting
received (n = 108). practices: PPI Positive Intervention [ comparison on Positive
regular 87 % Parenting, Harsh for age, Parenting*** at post and follow-up
services retention at Harsh discipline, (0.65 & 0.53).
delivered by post (88 % in Inconsistent discipline, Intervention \ comparison on Harsh
practitioners intervention Appropriate discipline, discipline* at post and FU (0.58 & 0.34)
from local group) and clear expectations and at post but not FU for Harsh for
community 80 % Parental mental health age* (0.32) and Inconsistent discipline
organisations. retention at SCL-5maternal distress (0.30)*. Appropriate discipline or clear
Treatment follow-up expectations NS at post and FU.
fidelity Only one parent completed
measures (% of mothers vs Parental mental health
reported by
parents with fathers not specified) No significant group differences at post.
mean of 4.5/5 Follow-up approached significance
(0.26)
ITT analysis
All analyses were ITT.
J Child Fam Stud (2016) 25:705719
 Table 1 continued
Authors/country Study sample, Interventionname, Design of Timing of Targeted outcomes and Results including statistical Clinical significance Quality
recruitment and format, duration and study (n) and measures measures significance (and effect sizes) and reliable change Index
inclusion criteria fidelity retention rate Score

Meija et al. (2015) Parents of 38 year olds Triple P-Positive RCT efficacy Pre-post test Child behavior Child behavior Not reported 16
Panama City who scored over the Parenting Program: pilot study. design. 3 ECBI Intensity and Problem Intervention \ control on ECBI
mean on ECBI. Parent Discussion 108 Families and 6 month Scale intensity*** at post (0.52),
Teachers selected group focussing on randomised to FU. Both 3 month FU (0.42) and 6 month
parents of children managing child intervention groups Parenting
FU (1.09) and on ECBI problem
with behavioral disobedience. Two (n = 54) or assessed at PS Total Score** at post (0.23), 3 month
difficulties for hour group program no all time Parental mental health FU (0.51) and 6 month FU (0.76).
invitation to the study. (average of 6 families intervention points
DASS21 Total Parenting
J Child Fam Stud (2016) 25:705719

Parents recruited from per group) plus two control group

public primary 20-min telephone (n = 54). Only one parent completed Intervention group \ control on PS
schools in low income sessions. Intervention 87 % measures (86 % mothers) Total** at post (0.19), 3 month
communities. translated into retention at FU** (0.15) and 6 month FU
Spanish. Treatment post (89 %in (0.59).
fidelity checks not intervention), Parental mental health
reported 81 % at
3 month FU Intervention group \ WL
(85 % in on DASS21** at post (0.32),
intervention) 3 month FU (0.40) and 6 month
and 70 % at FU (0.61).
6 month FU ITT analysis
(65 % in
intervention) All effects remained significant

Morawska et al. Parents of 25 year olds Triple P-Positive
(2014) concerned about child
Australia eating or mealtime
difficulties. Parents
recruited through
community
advertising.
RCT efficacy Pre-post, Child behavior Child behavior RCI 20
Parenting Program: study. 86 6-month FU. PAFTAchild frequency, child Intervention \ control on child Intervention [ WL on
Parent Discussion families Only problem. frequency *** (0.77), but not reliable change at post
group focussing on randomised to intervention child problem. Improvements on PAFTA Child
managing mealtime intervention group CAPESBehavioral and
Emotional Adjustment Scales maintained at FU for frequency. Frequency**, Parent
difficulties (Hassle (n = 44) or assessed at Confidence ** and
Free Mealtimes Triple waitlist 6-month FU Parenting No significant group differences on
CAPES behavioral and emotional strategies ** but not
P). Two hour group control group PAFASParenting Practices Child Problem.
program (average of 6 (n = 42). adjustment scales at post.
subscale
families per group). 86.0 % Parenting
Interventions retention at PAFTAParent Strategies scale
Intervention group [ control on
facilitated by post (82 % Parental Efficacy PAFTA Parent Strategies***
psychologists. retention in PAFTAParent Confidence (0.92) with improvements
Treatment fidelity intervention) scale maintained at FU but no
confirmed through differences for PAFAS Parenting
videotapes of group CAPESefficacy scale
Practices at post.
sessions (100 %) Only one parent completed
measures (86 % mothers) Parental Efficacy
Intervention group [ control on
PAFTA parent confidence***
(1.03) and CAPES Efficacy***
(0.73) at post with improvements
maintained at FU for PAFTA,
parent confidence and CAPES
efficacy.
ITT analysis
All effects remained significant
711

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 Table 1 continued
712

Authors/country Study sample, Interventionname, Design of Timing of Targeted outcomes and Results including statistical Clinical significance and Quality
recruitment format, duration and study (n) and measures measures significance (and effect reliable change Index

123
and inclusion fidelity retention rate sizes) Score
criteria

Morawska et al. Parents of Triple P-Positive RCT efficacy Pre-post, Child behavior Child behavior RCI 18
(2011) 25 year olds Parenting Program: study. 67 6-month FU. ECBI Intensity and Problem Intervention \ WL on ECBI Intervention [ WL on reliable
Australia who were Parent Discussion Families Only Scale Intensity** (1.17) & Problem change at post on ECBI
concerned group focussing on randomised to intervention Score** (1.07) at post. intensity* and problem score*
about child managing child intervention group Parenting
Improvements for intervention and PS overreactivity* but not
disobedience. disobedience. Two (n = 33) or assessed at PS total, laxness, overreactivity & group maintained at FU. laxness and verbosity
Parents hour group program waitlist control 6-month FU Verbosity Scales.
recruited (average of 6 families group Parenting
Parenting self-efficacy
through per group) plus two (n = 34). Intervention group \ WL on
community 20-min telephone 82 % retention PTCBehavior & Setting Self- Laxness** (0.51),
advertising. sessions. Intervention at post (82 % Efficacy Scales. Overreactivity*** (0.60) &
delivered by in intervention Partner support Verbosity*** (0.57) with
psychologist. Fidelity group). 77 % PESPartner Support scale improvements for intervention
recoded by protocol retention in group maintained at FU.
adherence checklists intervention Only one parent completed
measures (1 was a father) Parenting self-efficacy
(100 %) group at FU
Intervention group [ WL
on PTC Behavior*** (1.0) but no
differences on PTC Setting at
post. Improvements maintained
at FU
Partner support
Intervention [ WL on partner
support at post*** (0.16) with
improvements maintained at
follow-up.
ITT analysis
All effects remained significant
J Child Fam Stud (2016) 25:705719
 Table 1 continued
Authors/country Study sample, Interventionname, Design of Timing of Targeted outcomes and Results including statistical Clinical Quality
recruitment and format, duration and study (n) and measures measures significance (and effect sizes) significance and Index
inclusion criteria fidelity retention rate reliable change Score

Turner and Sanders Parents of 26 year olds Primary Care Triple P- RCT Pre-post, Child behavior Child behavior CSC 17
(2006) concerned about child Positive Parenting effectiveness 6-month FU. ECBI Intensity & Problem Score; Intervention \ WL in PDR Target Analysis of the
Australia behavior at Program. Three to study. 30 Only PDR Total Mean & Target Mean** (1.18)b & HCPC Home*** proportion of
Community Child four brief (30 min) Families intervention Mean score; HCPC Home & (1.25)b. No significant group participants in
Health Clinics in low- individual family randomised group Community Score. differences for ECBI Intensity, clinical range at post
income areas. consultations. to assessed at ECBI Problem, PDR Mean & calculated for PDR
Sessions once a week intervention 6-month FU. Parenting
HCPC Community. Improvements target mean only
for 3 weeks, with a (n = 16) or PS Laxness, Overreactivity & maintained at FU for intervention (only measure with
J Child Fam Stud (2016) 25:705719

break of 34 weeks waitlist Verbosity. group. means in clinical

before the final control group Parenting self-efficacy range at pre) show
session. Interventions (n = 14). Parenting
PSOC Satisfaction & Efficacy 7.7 % children in
delivered by child 8 week Intervention \ WL on Laxness* clinical range at post
health nurses. Fidelity waitlist Parental mental health (0.53)b, Overreactivity* (0.20)b & vs 61.5 % in
recoded by protocol period. DASS-21 Depression, Anxiety & Verbosity** (0.76)b at post. waitlist**.
adherence checklists 83.1 % Stress Scales Improvements maintained at FU on
(100 %) retention at Overreactivity & Verbosity but not RCI
post (81.1 % Observed ParentChild Laxness. Intervention [ waitlist
retention in Interaction on reliable change at
Parenting self-efficacy
intervention 15 min videotaped recording. post for HCPC
group). Coded for disruptive child Intervention [ WL on PSOC Home*, PSOC
100 % behavior & parent positive & Satisfaction** (1.02)b not Efficacy, Satisfaction**,
intervention aversive behavior using FOS. improvements maintained at FU. Verbosity** but not
families Only one parent completed Parental mental health for PDR Target
assessed at measures (1 was father) Intervention \ WL on Anxiety* mean, Laxness,
follow-up (0.61)b & Stress* (0.49)b not Overreactivity or
Depression at post, with DASS Stress.
improvements not maintained at
follow-up.
Observed ParentChild Interaction
Group differences NS.
ITT analysis
Effects remained significant except
for PS Laxness and DASS Stress
which were reduced to a trend

CAPES Child Adjustment and Parent Efficacy Scale, BSI Brief Symptom Inventory, CSC clinically significant change, DASS Depression, Anxiety and Stress Scale, ECBI Eyberg Child Behavior
Inventory, FOS Family Observation Scale, HCSBS Home and Community Social Behavior Scales, FU Follow-up, HCPC Home and Community Problem Checklist, ITT intention to treat, NS not
significant, PAFAS Parenting and Family Adjustment Scale, PAFTA Parent and Toddler Feeding Assessment, PBQ Preschool Behavior Questionnaire, PDR parent daily report, PES Parent
Experience Survey, PPC Parent Problem Checklist, PPI parent practices interview, PS Parenting Scale, PSOC Parenting Sense of Competence Scale, PTC Parent Task Checklist, RCI Reliable
Change Index, RQI Relationship Quality Inventory, SCL-5 Symptom Checklist-5, SSBS School Social Behavior Scales, TRF Teacher Report Form of Child Behavior Checklist, WL waitlist
* p \ .05; ** p \ .01, *** p \ .001
a
Bradley et al. (2003) reported effect sizes separately for intervention and control group for difference between pre and post. The effect sizes for pre-to-post differences for intervention group
only are reported here. Effect sizes for other studies report the difference between the intervention and control/comparison group
b
Turner and Sanders (2006) did not list effect sizes so these were calculated based on means and standard deviations in the article
713

123
714
primary care practitioners. PMTO is similar to Triple P in
that it aims to enhance parenting skills which are taught
through active skills training including roleplay and prob-
lem solving discussions. The final study was also an
effectiveness study of a psychoeducational parenting
intervention which involved four 2-h group sessions using
the videotape from the 123 Magic Program and was
delivered in community agencies by community facilitators
in Canada (Bradley et al. 2003). The intervention included
video demonstrations of skills, group discussion and cov-
ered key parenting strategies such as timeout and rewards
although it was not specified whether active skills training
such as roleplay and rehearsal were included in this
program.
Outcomes
Morawska et al. (2011) and Dittman et al. (2015) found the
Triple P Parent Discussion Group for Dealing with
Disobedience resulted in significantly lower parent-rated
child behavior problems at post-assessment when com-
pared with waitlist, with large effect sizes and changes
maintained at 6 month follow-up for the intervention
group. Similarly, the intervention groups in both studies
had significantly lower dysfunctional parenting and higher
parenting efficacy at post-assessment with moderate to
large effect sizes, and improvements maintained at follow-
up. The intervention groups also showed more clinically
significant change and reliable change across most mea-
sures of child behavior, dysfunctional parenting and par-
enting efficacy at post-assessment than waitlist (see
Table 1). No significant group differences emerged for the
measure of parental mental health or parental relationship
functioning at post (Dittman et al. 2015) but Morawska
et al. (2011) found the intervention group was significantly
higher than waitlist on partner support with small effects
and changes maintained at follow-up. Attrition rates for the
intervention group at post were 27 % (Dittman et al. 2015)
and 18 % (Morawska et al. 2011).
Meija et al. (2015) found the same intervention resulted
in significantly lower parent-rated child behavior problems
at post, 3 and 6 month follow-up relative to a no inter-
vention control, with moderate to large effect sizes (apart
from one measure of child behavior at post, which only
showed a small effect size). The effects of the intervention
increased over time. The intervention group also showed
significantly lower levels of dysfunctional parenting and
mental health problems than the control across all three
time points, with small to moderate effect sizes. The
attrition rate for the intervention group at post-assessment
was 11 %.
Joachim et al. (2010) found a similar pattern of findings
for the Parent Discussion Group which focussed on
123
J Child Fam Stud (2016) 25:705719
problems with shopping. The intervention group had sig-
nificantly fewer child behavior problems, less dysfunc-
tional parenting and greater parenting efficacy than the
waitlist control group at post-assessment with moderate to
large effect sizes. No significant group differences in par-
ental mental health emerged. The improvements in child
behavior and parenting efficacy but not parenting were
maintained at 6 month follow-up for the intervention
group. A greater proportion of children in the intervention
group were in the non-clinical range on one out of two
measures of child externalizing behavior as well as for
dysfunctional parenting and parental efficacy when com-
pared with waitlist. Greater reliable change was found for
one out of two measures of child behavior and parenting
efficacy at post-assessment, but not for dysfunctional par-
enting. The attrition rate for the intervention group was
15 % at post.
Focussing on problems at mealtimes, Morawska et al.
(2014) found the Parent Discussion Group resulted in sig-
nificantly reduced frequency of child mealtime difficulties
relative to the waitlist control at post-assessment, with
large effects, but there were no significant group differ-
ences for three other measures of child behavior. Signifi-
cant group differences were also found for one out of two
measures of parenting and both measures of confi-
dence/self-efficacy, with large effects. All improvements
were maintained at follow-up for the intervention group.
The intervention group showed significantly more reliable
change on one out of two measures of child behavior,
parenting and parenting confidence. The attrition rate was
18 % for the intervention group at post.
Turner and Sanders (2006) found Primary Care Triple P
resulted in significantly fewer child behavior problems
compared with the waitlist group on two out of six mea-
sures of child behavior, with large effect sizes and
improvements maintained at follow-up. At post-assess-
ment, 7.7 % of children in the intervention group were in
the clinical range versus 61.5 % in waitlist. The interven-
tion group had significantly lower ratings of dysfunctional
parenting, parental anxiety and stress (but not depression)
and higher ratings of parenting satisfaction (but not effi-
cacy) at post compared with waitlist, with improvements
maintained at follow-up for all measures except laxness,
anxiety and stress. This study also included a 15 min
observational parentchild interaction task that was coded
for child and parent aversive behavior and no group dif-
ferences in parent or child behavior emerged. The inter-
vention group had 19 % attrition at post.
Kjbli and Odgen (2012) and Kjbli and Bjrnebekk
(2013) found parents who received a brief version of
PMTO rated children as having significantly fewer
behavior problems compared with a treatment-as-usual
comparison group at post-assessment and 6 month follow-
J Child Fam Stud (2016) 25:705719
up, with small to moderate effect sizes. This study also
included teacher reports of child behavior but no significant
group differences were found. The intervention group
reported increased positive parenting, and reduced harsh
discipline at post-assessment and follow-up when com-
pared with the comparison group, with large effect sizes at
post-assessment which were low to medium at follow-up.
Significant group differences were found for post-assess-
ment but not follow-up for harsh discipline for age and
inconsistent discipline, but there were no significant dif-
ferences at post or follow-up for appropriate discipline or
clear expectations. There were no significant group dif-
ferences in ratings of parental mental health at post-
assessment, but differences approached significance by
6 month follow-up. There was 12 % attrition at post for the
intervention group.
Bradley et al. (2003) found that families who received a
brief psychoeducational parenting intervention reported
less child problem behavior problems when compared with
waitlist on two out of three measures at post-assessment,
with small effect sizes (effect sizes were reported sepa-
rately for experimental and control conditions). Improve-
ments were maintained for a subsample (fewer than one-
third of the intervention group) who returned question-
naires at one-year follow up. This subsample had higher
scores on dysfunctional parenting at pre-assessment. The
intervention group also reported significantly lower dys-
functional parenting and parental hostility than waitlist at
post-assessment with improvements again maintained at
follow-up. The attrition rate for the intervention group was
9 % at post.
Quality of Included Studies
The total mean score on the modified Quality Index
(Downs and Black 1998) was 16.8 out of 23 (range 1420).
The mean subscale scores were 8.3/9 for reporting (range
79), 8.2/10 for internal validity (range 710) and 0.3/3 for
external validity (range 01). Only two studies reported
sufficient details of a formal power calculation (Meija et al.
2015; Morawska et al. 2014); the rest scored 0/1 on this
subscale.
Discussion
Despite the large body of research on parenting interven-
tions over the past 30 years, this systematic review iden-
tified only identified nine articles describing eight studies
on brief parenting interventions that met inclusion criteria.
Most of these studies were conducted in the last few years,
despite the literature search spanning more than a 20 year
period. This is surprising and indicates that it is a topic that
715
requires more research, especially given that brief inter-
ventions may already be being delivered in clinical practice
(Perkins 2006). However, the findings from these nine
studies are promising and suggest that brief parenting
interventions may be effective in reducing child external-
izing behaviors and dysfunctional parenting for parents
seeking help for emerging problem behaviors in their
young children across a range of settings and problem
behaviors. Across all studies there were significant group
differences in parent reported externalizing behavior at
post-assessment relative to the control/comparison group
with changes maintained at follow-up. The findings for
dysfunctional parenting showed a similar pattern with
significant reductions at post-assessment which were
maintained at follow-up in all but one study (Joachim et al.
2010). Similarly, studies that included a measure of par-
ental self-efficacy or satisfaction found significant group
differences on this measure.
For this review, brief interventions were defined as \8
sessions in duration, but the interventions in the included
studies were very brief ranging from 1 session (2 h dura-
tion) to four sessions (8 h duration). Despite being very
brief, large effects sizes for group differences in child
externalizing behavior were found for studies on Triple P
Discussion Groups and Primary Care Triple P (Dittman
et al. 2015, Joachim et al. 2010; Morawska et al. 2011;
Morawska et al. 2014; Turner and Sanders 2006) with
smaller effects in for the studies on the psychoeducational
parenting intervention and PMTO (Bradley et al. 2003;
Kjbli and Odgen 2012). Smaller effects were also found
for the study examining a Triple P Discussion Group in
Panama (Meija et al. 2015). It should be noted that the two
studies that used either an active control group (Kjbli and
Odgen 2012) or a no intervention control (Meija et al.
2015) found smaller effect sizes than those using waitlist. It
is now established that waitlist control groups result in
larger effects than other control or comparison groups
including no intervention controls (e.g., Furukawa et al.
2014) which highlights the need to use alternatives to
waitlist control groups.
The improvements in measures of child behavior, par-
enting and parenting efficacy at post-assessment were lar-
gely maintained at follow-up. However, as the waitlist
control design used by most studies did not include a
control group at follow-up, the longer term effects of the
intervention could not be thoroughly assessed in all but two
studies. For Kjbli and Bjrnebekk (2013) the effects of the
intervention diminished over time but for Meija et al.
(2015) the effects of the intervention strengthened over
time relative to the no intervention control. Given the brief
nature of the intervention, efficacy may be enhanced with a
booster session delivered some weeks or months after the
intervention. Bradley et al. (2003) was the only study to
123
716
include a booster session which was delivered 4 weeks
after the final session (before post), but this did not result in
larger effects compared with the other studies. It is
imperative that future research use control or comparison
groups to enable the longer term effects of the intervention
to be thoroughly assessed.
Taken together, these findings suggest brief parenting
interventions may be sufficient to modify dysfunctional
parenting and in turn reduce emerging child behavior
problems, at least for some families. It should be noted,
however, that significant intervention effects did not
always emerge across all measures in each study. For
example, Turner and Sanders (2006) found significant
group differences on only 2 out of 6 child outcomes and
Morawska et al. (2014) found differences on one out of
four child outcomes. While relatively consistent findings
were seen for child externalizing behavior and parenting,
there were less consistent findings for measures of mental
health and parental relationship functioning. Six out of
eight studies included a measure of parental mental health,
and significant group differences were only identified for
three studies (Bradley et al. 2003; Meija et al. 2015; Turner
and Sanders 2006). For the three studies that used a mea-
sure of relationship functioning, only one found significant
group differences (Morawska et al. 2011). Participants in
some studies may have scored low on these measures at
pre-assessment, causing a floor effect, as was noted by
Joachim et al. (2010). However, it is also possible that brief
interventions may be insufficient to modify more distal
family risk factors. It is important to note that research has
found that a brief flexible parenting intervention that
addressed family risk (but did not meet inclusion criteria
for this study) led to reductions in child behavior regardless
of levels of maternal depression (Gardner et al. 2009),
suggesting that changes in these family risk variables may
not be necessary to achieve changes in child outcomes in a
brief intervention.
The attrition rates for the intervention groups across
studies ranged from 9 to 27 % (average of 16 %). A review
of 55 studies of more intensive formats of Triple P found
attrition rates in the intervention groups to vary widely
from 0 to 60 % with an average of 19 % (Nowak and
Heinrichs 2008), which was not greatly different to that
found in the present review. One of the key benefits
expected of brief interventions is the lower attrition rates,
due to the fewer demands made of families, so further
research is needed to quantify the attrition rates and to
determine whether they are significantly lower than more
intensive interventions.
Overall, the quality ratings for included studies were
adequate, although higher scores were obtained for the
reporting and internal validity subscales than for the
external validity subscale. In relation to external validity,
123
J Child Fam Stud (2016) 25:705719
most studies included in this review used community out-
reach campaigns to recruit families, so they were not able
to address the issue of representativeness. Wilson et al.
(2012) hypothesised that self-referred families may be
more motivated and compliant when compared with most
families in the population leading to a better than average
response to intervention. The two effectiveness studies
which did not rely on self-referred families also failed to
include information about representativeness of the sample
(that is, the characteristics of families who chose not to
participate). Thus, families included in these studies may
not be representative of families in the population eligible
to participate and as such, the findings may overstate the
impact of brief parenting interventions. It is difficult to
report representativeness of self-referred parents as infor-
mation is not usually available on the characteristics of
parents who do not participate. However, reporting on
sample representativeness may be possible when subjects
are drawn from a specific population (e.g., clinical referred
families) and future research should report this when pos-
sible. In relation to internal validity, only half of the studies
reported sufficient information on treatment fidelity (see
Table 1), so for the remaining studies it is not possible to
determine whether the interventions were delivered as
intended.
All included studies relied on parent-reports of child
behavior from one parent (usually the mother, although this
was not specified in all studies). Where teacher reports
(Kjbli and Bjrnebekk 2013; Kjbli and Odgen 2012) and
observational measures (Turner and Sanders 2006) were
used, results regarding child behavior were non-significant
although this may have been due to a floor effect for the
observational measures. Thus, there is currently no evi-
dence from any independent measure that brief parenting
interventions result in reductions in child externalising
behavior. Due to the potential biases of parent-report data,
it is important to include independent measures of child
behavior such as observational data. Also lacking from the
studies reviewed was father ratings on measures as well as
information about fathers involvement in the interventions
and recent reviews have highlighted the importance of
reporting this information (e.g., Fletcher et al. 2011; Smith
et al. 2012; Tiano and McNeil 2005). In addition, no study
compared a brief with a longer parenting intervention to
demonstrate equivalence and, according to Bower and
Gilbody (2005), this is critical in order to support a step-
ped-care model of service delivery. All studies recruited
parents of children concerned about or seeking help for
their childs behavior and none included children who were
diagnosed with ODD or in the clinical range for child
behavior problems (although just over half of Kjbli and
Ogdens sample were in the clinical range) so the effects of
brief parenting interventions for parents of children with
J Child Fam Stud (2016) 25:705719
more severe externalizing behaviors are unknown. It may
be that brief parenting interventions are best suited
towards families at low to moderate level of difficulty
(Sanders 2008). However, since there is some evidence
that they are already being implemented in child mental
health services (Perkins 2006), examining efficacy with
parents of children at higher levels of difficulty may be
warranted. Clearly, not all families will benefit from a
brief intervention and future research should aim to
examine the moderators or predictors of outcome. Even if
brief interventions are only effective with a small pro-
portion of families, their ease of dissemination and low
cost may mean that they are worthwhile alternative to
more intensive interventions (Kazdin 2008). Future
research should also aim to examine which strategies
contribute to the efficacy of parenting programs more
generally so these can be included in brief parenting
interventions. Leijten et al. (2015) highlighted the impor-
tance of conducting randomized microtrials to test the
efficacy of discrete parenting strategies, and this is a pri-
ority to maximise the efficacy of brief interventions.
Limitation of This Review
The key limitation of this review was the inability to
conduct a meta-analysis due the heterogeneity of included
studies, which meant the strength of the effects of brief
parenting interventions could not be quantified. In addition,
the restricted focus of the review meant that some articles
on brief interventions were not included. For example,
articles on the Family Check Up intervention (e.g., Dishion
et al. 2008) were not included since it was deemed a
multicomponent intervention of which parent training was
one component. Similarly, studies of brief interventions
focussing on certain populations, such as children with
birth complications (Schappin et al. 2013) were also not
included, nor were brief interventions examined through
study designs that were not RCTs (Axelrad et al. 2013).
Thus, the narrow focus of the review may have impacted
on the conclusions. Finally, the review included only
published articles in English language and there may have
been unpublished articles and articles in non-English-lan-
guage that may have been missed.
Given the lack of research on brief parenting interven-
tions, further research is needed and should aim to: com-
pare brief with longer interventions; include independent
measures of child outcomes; include control groups at
follow-up; include fathers in the parenting interventions
and report on father outcomes; include parents of children
with more severe externalizing behaviors; and examine
which discrete parenting strategies are associated with
intervention efficacy.
717
Acknowledgments We would like to thank the NSW Institute of
Psychiatry who provided a Training Fellowship in Research to the
first author.
Compliance with Ethical Standards
Conflict of interest None.
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