Help those parents; help their children

What does parent training mean to you? Is it a self-help DVD or a group therapy, an instruction manual or a counseling session? Varied as the answers are likely to be, a consistent message from research worldwide is that parenting programs work and save governments money over the long-term. Why? Because they give parents the skills they need to manage and contain their children’s behavior.

Latest purveyors of the message are Janine Dretzke and colleagues including Jane Barlow of the University of Oxford, who were commissioned by NICE, the UK National Institute for Clinical Excellence, to investigate the effectiveness and cost-effectiveness of training programs for parents of children with conduct disorder.

Their findings reveal that training has a consistently positive impact up to four months after the training. The improvement the reseachers detected was statistically significant when compared to control groups of parents who did not receive training.

As for the question of whether different types of training had different effects, the results are perhaps counter-intuitive. The reviewers found no significant statistical difference between them, other than an indication that more intensive interventions (ie. those with a longer duration and more contact with a professional) were marginally more effective,

The findings emerged from a meta-analysis of 37 randomized controlled trials culled from medicine, social science and education. The 37 were whittled down from hundreds of studies by applying a series of exclusion and inclusion criteria. For example, to be included, a study had to have an RCT design with an exclusive focus on parents rather than on teachers or other agents.

Despite setting these fairly strict controls, Dretzke reports low levels of methodological rigor, based on the failure to report what parents in the control groups received (if anything) or how randomization was conducted and concealed.

The reviewers also say that the final choice included parents and children from a range of different backgrounds. All the children had conduct disorder but there were differences in how behavior was measured.

Establishing which treatments are effective is important, not only in relation to clinical practice but also for the potential benefit to those in a child’s wider environment - peers, family and teachers - who often fall victim to disorder-driven disruption and aggression.

Knowing that parent training is a good investment from those perspectives is one thing, but uncovering potential cost savings for the state can be the key to mobilizing widespread implementation.

Here Dretzke’s review failed to make any concrete long-term projections about cost-effectiveness due to a lack of data and research. However, her team acknowledges that the cost of treating individuals with conduct disorder is usually very high. By age 28 those costs are on average $120,000 and services from a variety of agencies are likely to appear on the account.

Parent training on the other hand can cost between $1,100 and $6,645. Financial savings vary depending on the type and intensity of parent training delivered; more intensive programs cost more to deliver.

As the reviewers say in their report, this broken string of calculations suggests a clear need for more research. We need to know more about the long-term impact of parent training on both outcomes and state spending and how the benefits break down according to program type.

Dretzke maintains, nevertheless, that the balance of evidence in this review points to parent training in all its forms being an effective and potentially cost-effective treatment for children with conduct disorder.

The report is shortly to be published as an academic paper in the Archives of Disease in Childhood.

• Barlow J, Dretzke J, Hyde C, Taylor R, Stewart-Brown S, Sandercock J, Bayliss S, Raftery J, (2008) “The clinical and cost-effectiveness of parent training programmes for children with behaviour problems: a systematic review and economic evaluation” Archives Of Disease In Childhood (in press).