CONTEXT:

More than 4 decades of research indicate that parenting interventions are effective at preventing and treating mental, emotional, and behavioral disorders in children and adolescents. Pediatric primary care is a viable setting for delivery of these interventions.

OBJECTIVE:

Previous meta-analyses have shown that behavioral interventions in primary care can improve clinical outcomes, but few reviews have been focused specifically on the implementation of parenting interventions in primary care. We aimed to fill this gap.

DATA SOURCES:

We reviewed 6532 unique peer-reviewed articles published in PubMed, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo.

STUDY SELECTION:

Articles were included if at least part of the intervention was delivered in or through primary care; parenting was targeted; and child-specific mental, emotional, and behavioral health outcomes were reported.

DATA EXTRACTION:

Articles were reviewed in Covidence by 2 trained coders, with a third coder arbitrating discrepancies.

RESULTS:

In our review of 40 studies, most studies were coded as a primary. Few researchers collected implementation outcomes, particularly those at the service delivery system level.

LIMITATIONS:

Including only published articles could have resulted in underrepresentation of implementation-related data.

CONCLUSIONS:

Parenting interventions delivered and implemented with fidelity in pediatric primary care could result in positive and equitable impacts on mental, emotional, and behavioral health outcomes for both parents and their children. Future research on the implementation strategies that can support adoption and sustained delivery of parenting interventions in primary care is needed if the field is to achieve population-level impact.

Parenting interventions are considered best practice for preventing the most common mental and behavioral health disorders of childhood and adolescence, such as depression, anxiety, and externalizing disorders,18  while also promoting positive development and adaptation.9,10  However, parenting programs are not implemented widely in primary care, despite intuitive appeal and fit within this service context.9  In this review, we delve into the state of the literature on implementing parenting interventions in primary care to inform directions for taking these programs to scale.

The 2017 to 2018 National Survey of Children’s Health revealed that ∼1 in 5 children in the United States aged 3 to 17 years (21.9%) had a diagnosed mental, behavioral, or developmental disorder.11  Among youth with concerns severe enough to warrant intervention, <50% received treatment in the previous year, and significant disparities existed for ethnic minority youth, low-income families, and the uninsured.12  Four decades of research provide evidence that these interventions improve key parenting domains, such as positive behavior support, monitoring and limit setting, and family relationship building,13,14  which in turn prevent children’s emotional (eg, anxiety, depression)5  and behavioral disorders (eg, substance use, conduct problems),15  can mitigate the effects of socioeconomic adversity,16,17  and improve school readiness, positive peer relationships, and well-being.18  Parenting intervention effects are robust and often long- lasting across multiple health and developmental outcomes19,20  and have been shown to be acceptable and effective with racially and ethnically diverse families.21,22  Despite the strong evidence base, parenting interventions have not been taken to scale.14,23 

Pediatric primary care provides an opportune setting for parenting interventions aimed at improving children’s emotional and behavioral health.24  Beginning in infancy, most children in the United States receive primary health care. In the 2018 National Health Interview Survey, it was estimated that more than three-quarters of all children <18 years have had contact with a primary health care professional in the past 6 months.25  Thereby, primary health care is a compelling service context as it creates a tight net for reaching families in need of intervention. With the realization that children are nearly always accompanied by their parents to well-child visits, recommendations regarding child behavior are often given to parents in this context, engendering low stigma.9,26  In addition to child health, the health of caregivers is a growing focus within pediatric primary care. For example, postpartum depression screening, a known risk factor for adverse child outcomes across the life course, is now covered under children’s health insurance when delivered at well-child visits.27  This shift to supporting caregiver well-being provides an opening for the delivery of parenting programs in this context.

Parenting interventions can be delivered by using a variety of models appropriate for pediatric settings. Kolko and Perrin23  describe 5 evidence-based models of effective delivery of behavioral health services in pediatric primary care: (1) coordination with an external behavioral health clinician, (2) consultation between behavioral health and the primary care clinician, (3) training the primary care clinician in behavioral health interventions, (4) on-site intervention by behavioral health (often called co-located care), and (5) on-site collaborative and integrated care. With its success with adults, particularly for depression, collaborative care and medical home models for mental, emotional, and behavioral health in children have garnered recent attention. However, results are equivocal, and implementation is thus far limited.2830  It is unclear which of these care delivery models for parenting interventions are more common in primary care and which result in better implementation outcomes, which are defined as the effects of deliberate and purposive actions to implement new programs, practices, and services31  and include such common metrics as acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration and reach, and sustainability.31,32 

There has been limited implementation of empirically supported interventions that prevent mental and behavioral health disorders in pediatric primary care.15  This lack of uptake suggests a substantial infrastructure deficit as well as an area with tremendous growth potential.9,15,24,33  Primary care–based interventions have the potential to address health inequity by reaching families of socioeconomic and racial and ethnic diversity and marginalized populations who often have difficulty accessing specialized mental health care in other contexts or who tend to avoid specialty mental health care because of stigma.34  In the 2017 National Survey of Drug Use and Health, among adolescents aged 12 to 17 years who received behavioral health services, only 3.3% of youth reported receipt in primary care compared with 13.3% and 13.6% of services received in education or outpatient mental health settings, respectively.35 

Before parenting interventions can be implemented at scale in primary care, however, 4 major challenges need to be addressed. Such interventions must be feasible to deliver; integrated across and within existing primary care and child health care systems; culturally responsive21  to socioeconomically disadvantaged, historically marginalized, and underserved populations; and adaptable to different organizational structures and cultures.36  These challenges underscore the tension between health care infrastructure and the characteristics of interventions that, although being considered evidence based, may not be feasible for implementation in systems that are often resource scarce and can have incongruent priorities and funding sources.37  Adaptation of programs for delivery in the primary care context can increase feasibility but might not overcome all barriers to adoption and sustainment.38  Many examples exist of adapting evidence-based parenting interventions for racial and ethnic minority families to improve cultural responsivity,39  but few examples exist of adapting these programs for the primary care service context.38 

In recent meta-analytic studies, researchers have found that the effects of prevention programs targeting children and adolescents are significant when delivered in coordination with primary care. Asarnow et al40  reviewed controlled studies of treatment and prevention programs for child and adolescent mental health delivered as integrated behavioral health care compared with primary care services as usual. In the results from 31 included studies (n = 12 129 participants), a significant overall effect was indicated (d = 0.32; 95% confidence interval [CI], 0.2–0.44; P < .001). Effects were smaller but still significant for prevention programs compared with treatment programs that targeted youth with elevated symptoms. However, only 9 prevention trials met the authors’40  criteria, which included a rigorous randomized trial design. Relatedly, in a meta-analysis, Shah et al41  examined the effects of primary care–based interventions for the promotion of positive parenting for children enrolled at <3 years of age. Thirteen studies (n = 3807) were identified. Results were promising, with effects on parent-child interactions (d = 0.29; 95% CI, 0.06–0.52; P < .001) and participation in cognitively stimulating activities (d = 0.34; 95% CI, 0.03–0.54; P < .001). Authors of both these meta-analyses noted the need to better understand implementation of these effective practices, but neither group explicitly evaluated included studies for characteristics or outcomes related to intervention implementation.

A number of systematic reviews have also emerged in the literature recently, highlighting interest in this area. Brown et al42  found 44 studies of preventive interventions in primary care for children ages 0 to 5 years. Many had a parenting outcome but were not necessarily a formal parenting program. Rojas et al43  identified 19 preventive interventions for child and adolescent mental and behavioral health problems, 10 of which were considered parenting programs. Studies were focused mostly on school-aged children (n = 6) and adolescents (n = 8) compared with earlier ages (infancy: n = 2; preschool age: n = 3). They also noted that there was a low degree of involvement from the primary care practices themselves, meaning that primary care was primarily used as a recruitment source for services provided in other settings rather than as a context for integrated delivery. In these reviews, it is indicated that parenting interventions can be effective when delivered in coordination with primary care, but little attention was given to sustainable implementation, possibly contributing to the low uptake in regular practice.

We report the findings of a systematic review of peer-reviewed research on the use of parenting programs to improve child and adolescent mental, emotional, and behavioral health outcomes that were either delivered in the context of pediatric primary care or coordinated with primary care through systematic referrals to services provided in other settings. The findings of this review are placed in the framework of the intervention research translation pipeline,44  which describes the process of taking interventions to scale in a series of stages from preintervention, to testing interventions using efficacy and effectiveness designs, to dissemination and implementation research in real-world service delivery systems. With regard to parenting interventions, the field has provided sufficient evidence of efficacy and effectiveness already, so in our review, we follow the guidance of Glasgow et al45  to focus on data reported to inform implementation. As such, the aims are to provide (1) a comprehensive view of the state-of-the-knowledge concerning implementation of parenting interventions in conjunction with the primary health care system and (2) evidence-based guidance to inform the development of effective strategies to enhance the adoption and sustainment of parenting programs in pediatric primary care settings.46 

A comprehensive search of studies published since 1990 was undertaken in March 2018 in Google Scholar, PubMed, PsycInfo, and the Cumulative Index to Nursing and Allied Health Literature. Search terms included those related to child demographics, primary care (including family medicine, pediatric care, community health centers, federally qualified health centers), parental involvement in the intervention, and a range of mental, emotional, and behavioral health outcomes (see Supplemental Information for complete search strategy). A total of 6859 articles were returned, with 327 duplicates removed via Covidence47  review management software and manual review (6532 unique articles). After title and initial full-text review by 2 trained coders (G.H.C., L.M.R.) and arbitration of discrepancies by a third (J.D.S.), 676 articles were deemed eligible for full-text review. A total of 636 were excluded for various reasons presented in the preferred reporting items for systematic reviews and meta-analyses flow diagram (Fig 1), the most common of which were the intervention not occurring in primary care (n = 381) and either no child outcome was reported (n = 41) or the child outcome reported was not a mental, emotional, or behavioral health outcome (n = 74). The final sample included 40 articles (references for included articles are in Supplemental Information). Data extraction was completed by using a shared Excel template. Ratings of trial design quality were completed by 2 authors (J.D.S., G.H.C.) using an established 8-point scale: (1) aims stated clearly, (2) “randomized controlled trial” or a trial with a “comparable comparison group,” (3) intervention described sufficiently to be replicable, (4) number of recruited subjects provided, (5) preintervention data provided, (6) level of attrition discussed, (7) results of all measured outcomes discussed, and (8) postintervention results provided for all intervention groups.48  This study did not require institutional review board approval because it was not considered human subjects research.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Close modal

We included studies published in the English language of interventions that were targeting youth (birth to 18 years); explicitly targeting and reporting intervention effects on a child-level mental, emotional, and behavioral health outcome; and involving a distinct parental component to the intervention (defined as having at least one parent or caregiver being clearly identified as an intervention recipient, either individually or in a group setting; merely having a parent present while the child received an intervention or having the parent complete a questionnaire was not sufficient). Trials had to be quasi-experimental or fully randomized, have an appropriate comparison condition, and describe the location(s) at which the intervention was delivered. Multiple articles in which researchers reported on the same study were included if unique analyses were conducted (eg, mediation or moderation versus overall effect) or subgroups were assessed. Interventions that targeted parent behavior (eg, breastfeeding frequency) without a child mental, emotional, or behavioral target; targeted disease management behavior alone (eg, medication management); or did not include comparable pre- and postmeasures were excluded. Interventions in which teenage (<18 years old) mothers were targeted were excluded. Non–peer-reviewed publications, such as dissertations and conference proceedings, were excluded.

The interventions predominantly targeted infants (∼2 weeks) to preadolescents (12.9 years). Among the 40 studies, using the Ages and Stages of Child Development taxonomy,49  10 targeted babies, infants, and toddlers (birth to 3 years); 5 targeted toddlers to preschoolers (3–6 years); 7 targeted preschoolers only (5–6 years); 1 targeted preschool to school age (6–12 years); 1 targeted preschool to adolescent (13–18 years); 6 targeted school age only; 4 targeted school age and adolescent; and 2 solely targeted adolescents (Table 1).

TABLE 1

Study Characteristics

Source, YearSample SizeDevelopmental Stage(s)Delivery ModalityTarget Condition of InterventionClinician TypePrimary Care Physician InvolvementIntervention SettingType of IntegrationComparison ConditionDesign Quality Rating
Bauer et al,50  2015 29 families School age (6 y) to adolescent (18 y) (mean = 10.4 y) Parent and child separate Conduct or behavioral disorder Physician Delivery, full intervention Primary care Training the primary care clinician in mental health skills Services as usual 
Barlow et al,51  2007 131 women Infant (recruited at birth) Parent and child together Other Other Referral Home External mental health clinician Services as usual 
Bayer et al,52  2010 733 mothers Infant (6–7 mo) (mean = 7.0 mo) Parent group Conduct or behavioral disorder Physician Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Berkovits et al,53  2010 30 children Preschool (3–6 y) (mean = 4.3 y) Parent group Conduct or behavioral disorder Behavioral health specialist Referral Primary care External mental health clinician Active 
Borowsky et al,54  2004 224 children School age (7 y) to adolescent (15 y) (mean = 11.2 y) Individual parent Conduct or behavioral disorder Behavioral health specialist, physician Referral Phone Consultation with the primary care clinician Services as usual 
Chang et al,55  2015 501 mother–child pairs Infant (6–8 wk) (mean = 1.67 mo) Parent group Other Nurse Delivery, partial intervention Primary care Integrated care or on-site collaborative care Services as usual 
Chavira et al,56  2014 48 parents School age (8 y) to adolescent (13 y) (mean = 9.8 y) Parent and child together Anxiety Physician Referral Primary care Colocation, colocated care, on-site intervention Active 
Guilamo-Ramos et al,57  2011 264 mother–adolescent dyads School age (11 y) to adolescent (14 y) (mean = 12.9 y) Individual parent Other Physician, social worker Referral Primary care Colocation, colocated care, on-site intervention Services as usual 
Hiscock et al,58  2008 328 mothers School age (mean = 7.3 y) Individual parent Parent mental health and stress Nurse Delivery, partial intervention Primary care Integrated care, on-site collaborative care Services as usual 
Hiscock et al,59  2007 328 mothers Infant (mean = 7.3 mo) Individual parent Parent mental health and stress Nurse Delivery, partial intervention Primary care Integrated care, on-site collaborative care Services as usual 
Hiscock et al,60  2008 733 mothers Infant (6–7 mo) (mean = 7.0 mo) Parent group Conduct or behavioral disorder Nurse, group facilitation expert Delivery, full intervention Primary care Integrated care, on-site collaborative care Services as usual 
Iloabachie et al,61  2011 83 adolescents Adolescent (mean not reported) Individual parent Depression Physician Delivery, partial intervention Primary care Training the primary care clinician in mental health skills; referral Active 
Johnston et al,62  2006 439 mothers Toddler (mean = 2.0 y) Parent and child together Conduct or behavioral disorder Other (Head Start specialist) Delivery, full intervention Primary care Integrated care, on-site collaborative care Services as usual 
Kjøbli et al,63  2012 216 children School age (mean = 7.4 y) Individual parent Parenting skills Other (train primary care clinicians, staff in manualized intervention) Delivery, partial intervention Primary care Training the primary care clinician in mental health skills Active 
Kolko et al,64  2011 163 children School age (mean = 8.1y) Parent and child together Conduct or behavioral disorder Nurse Delivery, full intervention Primary care Integrated care, on-site collaborative care Active (enhanced usual care) 
Kolko et al,65  2014 321 caregivers School age (mean = 8.0 y) Parent and child together Conduct or behavioral disorder Behavioral health specialist, physician, physician assistant, nurse practitioner Delivery, partial intervention Primary care Integrated care, on-site collaborative care Active (enhanced usual care) 
Lavigne et al,66  2008 117 parents Preschool (3–6 y) (mean not reported) Parent and child together Conduct or behavioral disorder Behavioral health specialist, nurse Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Active 
Lavigne et al,67  2008 117 parents Preschool (mean = 4.6 y) Individual parent Conduct or behavioral disorder Researcher, nurse Delivery, partial intervention Primary care Colocation, colocated care, on-site intervention Active 
McFarlane et al,68  2005 233 women Toddler (18 mo) to adolescence (18 y) (mean not reported) Individual parent Parent mental health or stress Nurse Delivery, full intervention Primary care Integrated care, on-site collaborative care Services as usual 
Mendelsohn et al,69  2005 93 children Infant (newborns) Parent and child together Conduct or behavioral disorder Physician Delivery, partial intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Mendelsohn et al,70  2007 99 children Infant (newborns) Parent and child together Parenting skills Researcher Delivery, partial intervention Primary care Integrated care, on-site collaborative care Services as usual 
Minkovitz et al,71  2003 5565 children Infant (enrolled up to 4 wk old) Parent and child together Conduct or behavioral disorder Physician, nurse, health steps specialist Delivery, partial intervention Primary care Integrated care, on-site collaborative care Active 
Minkovitz et al,72  2007 5565 children Infant (enrolled up to 4 wk old) Parent and child together Conduct or behavioral disorder Physician, nurse, health steps specialist Delivery, partial intervention Primary care Integrated care, on-site collaborative care Unspecified 
Myers et al,73  2015 223 children School age (5.5–12 y) (mean = 9.3 y) Individual child Conduct or behavioral disorder Behavioral health specialist, physician Referral Web External mental health clinician Active 
Patterson et al,74  2002 116 parents Toddler (2 y) to school age (8 y) (mean not reported) Parent group Depression Nurse, other health professional (health visitor) Referral Colocated Colocation, colocated care, on-site intervention No intervention 
Perrin et al,75  2014 273 parents Toddler (2 y) to preschool (4 y) (mean = 2.8 y) Parent group Conduct or behavioral disorder Researcher Delivery, partial intervention Primary care Colocation, colocated care, on-site intervention Active (wait list) 
Reedtz et al,76  2011 186 children Toddler (2 y) to preschool (8 y) (mean = 3.9 y) Parent group Parenting skills Nurse Delivery, full intervention Primary care Colocation, colocated care, on-site intervention No intervention 
Reid et al,77  2013 178 parents Toddler (2 y) to preschool (5 y) (mean = 3.2 y) Individual parent Conduct or behavioral disorder Behavioral health specialist Delivery, partial intervention Phone External mental health clinician Services as usual 
Sanders et al,78  2008 3004 parents Preschool (4–7 y) (mean not reported) Individual parent Parenting skills Physician, nurse Delivery, partial intervention Home Training the primary care clinician in mental health skills Services as usual 
Saulsberry et al,79  2013 83 adolescents Adolescent (mean = 17.4 y) Individual parent Depression Physician, other health professional Delivery, partial intervention Primary care Training the primary care clinician in mental health skills Active 
Schappin et al,80  2013 67 children Preschool (mean = 3.7 y) Parent group Parenting skills Other primary care health professional Delivery, full intervention Primary care Training the primary care clinician in mental health skills Active (wait list) 
Schilling et al,81  2017 120 parents Preschool (2–6 y) (mean not reported) Parent group Parenting skills Behavioral health specialist Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Shaffer et al,82  2017 321 parent-child dyads Preschool (5 y) to school age (12 y) (mean = 8.0 y) Individual parent Conduct or behavioral disorder Behavioral health specialist, physician Referral Primary care External mental health clinician Active (enhanced usual care) 
Sourander et al,83  2016 464 parents Preschool (4 y) (mean not reported) Individual parent Conduct or behavioral disorder Behavioral health specialist, physician Referral Web External mental health clinician Active (education) 
Spijkers et al,84  2013 81 families School age (9–11 y) (mean = 10.6 y) Parent and child together Anxiety Nurse Delivery, full intervention Primary care Training the primary care clinician in mental health skills Services as usual 
Swift et al,85  2009 29 children Toddler (2 y) to school age (12 y) (mean = 7.0 y) Individual parent Conduct or behavioral disorder Behavioral health specialist Delivery, full intervention Phone Training the primary care clinician in mental health skills Active (wait list) 
Turner et al,86  2006 30 families Toddler (2 y) to preschool (<6 y) (mean = 3.1 y) Individual parent Conduct or behavioral disorder Nurse Delivery, full intervention Primary care Training the primary care clinician in mental health skills Active (wait list) 
Weisleder et al,87  2016 463 families Toddler (14 mo) to preschool (36 mo) (mean not reported) Individual parent Parenting skills Other health worker Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Wissow et al,88  2008 403 youth Preschool (5 y) to adolescence (16 y) (mean = 10.4 y) Parent and child together Anxiety Physician Delivery, full intervention Primary care Training the primary care clinician in mental health skills Unspecified 
Wissow et al,89  2011 403 youth Preschool (5 y) to adolescence (16 y) (mean = 10.4 y) Parent and child together Parenting skills Physician Delivery, full intervention Primary care Training the primary care clinician in mental health skills Services as usual 
Source, YearSample SizeDevelopmental Stage(s)Delivery ModalityTarget Condition of InterventionClinician TypePrimary Care Physician InvolvementIntervention SettingType of IntegrationComparison ConditionDesign Quality Rating
Bauer et al,50  2015 29 families School age (6 y) to adolescent (18 y) (mean = 10.4 y) Parent and child separate Conduct or behavioral disorder Physician Delivery, full intervention Primary care Training the primary care clinician in mental health skills Services as usual 
Barlow et al,51  2007 131 women Infant (recruited at birth) Parent and child together Other Other Referral Home External mental health clinician Services as usual 
Bayer et al,52  2010 733 mothers Infant (6–7 mo) (mean = 7.0 mo) Parent group Conduct or behavioral disorder Physician Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Berkovits et al,53  2010 30 children Preschool (3–6 y) (mean = 4.3 y) Parent group Conduct or behavioral disorder Behavioral health specialist Referral Primary care External mental health clinician Active 
Borowsky et al,54  2004 224 children School age (7 y) to adolescent (15 y) (mean = 11.2 y) Individual parent Conduct or behavioral disorder Behavioral health specialist, physician Referral Phone Consultation with the primary care clinician Services as usual 
Chang et al,55  2015 501 mother–child pairs Infant (6–8 wk) (mean = 1.67 mo) Parent group Other Nurse Delivery, partial intervention Primary care Integrated care or on-site collaborative care Services as usual 
Chavira et al,56  2014 48 parents School age (8 y) to adolescent (13 y) (mean = 9.8 y) Parent and child together Anxiety Physician Referral Primary care Colocation, colocated care, on-site intervention Active 
Guilamo-Ramos et al,57  2011 264 mother–adolescent dyads School age (11 y) to adolescent (14 y) (mean = 12.9 y) Individual parent Other Physician, social worker Referral Primary care Colocation, colocated care, on-site intervention Services as usual 
Hiscock et al,58  2008 328 mothers School age (mean = 7.3 y) Individual parent Parent mental health and stress Nurse Delivery, partial intervention Primary care Integrated care, on-site collaborative care Services as usual 
Hiscock et al,59  2007 328 mothers Infant (mean = 7.3 mo) Individual parent Parent mental health and stress Nurse Delivery, partial intervention Primary care Integrated care, on-site collaborative care Services as usual 
Hiscock et al,60  2008 733 mothers Infant (6–7 mo) (mean = 7.0 mo) Parent group Conduct or behavioral disorder Nurse, group facilitation expert Delivery, full intervention Primary care Integrated care, on-site collaborative care Services as usual 
Iloabachie et al,61  2011 83 adolescents Adolescent (mean not reported) Individual parent Depression Physician Delivery, partial intervention Primary care Training the primary care clinician in mental health skills; referral Active 
Johnston et al,62  2006 439 mothers Toddler (mean = 2.0 y) Parent and child together Conduct or behavioral disorder Other (Head Start specialist) Delivery, full intervention Primary care Integrated care, on-site collaborative care Services as usual 
Kjøbli et al,63  2012 216 children School age (mean = 7.4 y) Individual parent Parenting skills Other (train primary care clinicians, staff in manualized intervention) Delivery, partial intervention Primary care Training the primary care clinician in mental health skills Active 
Kolko et al,64  2011 163 children School age (mean = 8.1y) Parent and child together Conduct or behavioral disorder Nurse Delivery, full intervention Primary care Integrated care, on-site collaborative care Active (enhanced usual care) 
Kolko et al,65  2014 321 caregivers School age (mean = 8.0 y) Parent and child together Conduct or behavioral disorder Behavioral health specialist, physician, physician assistant, nurse practitioner Delivery, partial intervention Primary care Integrated care, on-site collaborative care Active (enhanced usual care) 
Lavigne et al,66  2008 117 parents Preschool (3–6 y) (mean not reported) Parent and child together Conduct or behavioral disorder Behavioral health specialist, nurse Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Active 
Lavigne et al,67  2008 117 parents Preschool (mean = 4.6 y) Individual parent Conduct or behavioral disorder Researcher, nurse Delivery, partial intervention Primary care Colocation, colocated care, on-site intervention Active 
McFarlane et al,68  2005 233 women Toddler (18 mo) to adolescence (18 y) (mean not reported) Individual parent Parent mental health or stress Nurse Delivery, full intervention Primary care Integrated care, on-site collaborative care Services as usual 
Mendelsohn et al,69  2005 93 children Infant (newborns) Parent and child together Conduct or behavioral disorder Physician Delivery, partial intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Mendelsohn et al,70  2007 99 children Infant (newborns) Parent and child together Parenting skills Researcher Delivery, partial intervention Primary care Integrated care, on-site collaborative care Services as usual 
Minkovitz et al,71  2003 5565 children Infant (enrolled up to 4 wk old) Parent and child together Conduct or behavioral disorder Physician, nurse, health steps specialist Delivery, partial intervention Primary care Integrated care, on-site collaborative care Active 
Minkovitz et al,72  2007 5565 children Infant (enrolled up to 4 wk old) Parent and child together Conduct or behavioral disorder Physician, nurse, health steps specialist Delivery, partial intervention Primary care Integrated care, on-site collaborative care Unspecified 
Myers et al,73  2015 223 children School age (5.5–12 y) (mean = 9.3 y) Individual child Conduct or behavioral disorder Behavioral health specialist, physician Referral Web External mental health clinician Active 
Patterson et al,74  2002 116 parents Toddler (2 y) to school age (8 y) (mean not reported) Parent group Depression Nurse, other health professional (health visitor) Referral Colocated Colocation, colocated care, on-site intervention No intervention 
Perrin et al,75  2014 273 parents Toddler (2 y) to preschool (4 y) (mean = 2.8 y) Parent group Conduct or behavioral disorder Researcher Delivery, partial intervention Primary care Colocation, colocated care, on-site intervention Active (wait list) 
Reedtz et al,76  2011 186 children Toddler (2 y) to preschool (8 y) (mean = 3.9 y) Parent group Parenting skills Nurse Delivery, full intervention Primary care Colocation, colocated care, on-site intervention No intervention 
Reid et al,77  2013 178 parents Toddler (2 y) to preschool (5 y) (mean = 3.2 y) Individual parent Conduct or behavioral disorder Behavioral health specialist Delivery, partial intervention Phone External mental health clinician Services as usual 
Sanders et al,78  2008 3004 parents Preschool (4–7 y) (mean not reported) Individual parent Parenting skills Physician, nurse Delivery, partial intervention Home Training the primary care clinician in mental health skills Services as usual 
Saulsberry et al,79  2013 83 adolescents Adolescent (mean = 17.4 y) Individual parent Depression Physician, other health professional Delivery, partial intervention Primary care Training the primary care clinician in mental health skills Active 
Schappin et al,80  2013 67 children Preschool (mean = 3.7 y) Parent group Parenting skills Other primary care health professional Delivery, full intervention Primary care Training the primary care clinician in mental health skills Active (wait list) 
Schilling et al,81  2017 120 parents Preschool (2–6 y) (mean not reported) Parent group Parenting skills Behavioral health specialist Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Shaffer et al,82  2017 321 parent-child dyads Preschool (5 y) to school age (12 y) (mean = 8.0 y) Individual parent Conduct or behavioral disorder Behavioral health specialist, physician Referral Primary care External mental health clinician Active (enhanced usual care) 
Sourander et al,83  2016 464 parents Preschool (4 y) (mean not reported) Individual parent Conduct or behavioral disorder Behavioral health specialist, physician Referral Web External mental health clinician Active (education) 
Spijkers et al,84  2013 81 families School age (9–11 y) (mean = 10.6 y) Parent and child together Anxiety Nurse Delivery, full intervention Primary care Training the primary care clinician in mental health skills Services as usual 
Swift et al,85  2009 29 children Toddler (2 y) to school age (12 y) (mean = 7.0 y) Individual parent Conduct or behavioral disorder Behavioral health specialist Delivery, full intervention Phone Training the primary care clinician in mental health skills Active (wait list) 
Turner et al,86  2006 30 families Toddler (2 y) to preschool (<6 y) (mean = 3.1 y) Individual parent Conduct or behavioral disorder Nurse Delivery, full intervention Primary care Training the primary care clinician in mental health skills Active (wait list) 
Weisleder et al,87  2016 463 families Toddler (14 mo) to preschool (36 mo) (mean not reported) Individual parent Parenting skills Other health worker Delivery, full intervention Primary care Colocation, colocated care, on-site intervention Services as usual 
Wissow et al,88  2008 403 youth Preschool (5 y) to adolescence (16 y) (mean = 10.4 y) Parent and child together Anxiety Physician Delivery, full intervention Primary care Training the primary care clinician in mental health skills Unspecified 
Wissow et al,89  2011 403 youth Preschool (5 y) to adolescence (16 y) (mean = 10.4 y) Parent and child together Parenting skills Physician Delivery, full intervention Primary care Training the primary care clinician in mental health skills Services as usual 

“Other” includes nonclinical staff in the primary care facility, such as administrative staff or study-trained interventionists whose roles were not otherwise specified, or external clinicians and staff who may have been responsible for partial intervention delivery, such as teachers. Design quality ratings are on an 8-point scale (described in Methods section).

Although we were not focused on intervention effects or synthesis of effect via meta-analysis in this review, we observed that the patterns of results on both child and parent outcomes were inconsistent, in that researchers of some studies reported immediate effects that trailed off and were not maintained, others did not have immediate effects but rather “sleeper effects”90  that emerged after completion of the intervention, and a small proportion reported immediate effects that were also sustained. Many studies had small effects on child, parent, or both outcomes. No study reported null effects on all outcomes. Authors of recent meta-analyses of the effectiveness of parenting interventions in general have reported small to medium effects (standardized mean differences range from 0.12 to 0.53), with significant heterogeneity across studies and outcomes and inconsistency in immediate versus follow-up effects.5,13,91,92  Effects reported for parenting interventions in primary care are similar in magnitude to those in general (standardized mean differences range from 0.29 to 0.34), but there are only 2 meta-analyses and far fewer total trials.40,41 

In our review, there was a high degree of heterogeneity among effects on targeted outcomes, which were most commonly disruptive behaviors (aggression, general externalizing behavior, conduct problems, or attention-deficit/hyperactivity disorder), followed by anxiety, depression, and developmental outcomes. Some studies had a primary focus on physical outcomes, such as sleep or well-child visit adherence, and studies in which researchers looked at infants or very young children examined temperament (but with a mental, emotional, and behavioral health outcome reported). Participant follow-up timeframes ranged from 2 weeks to 24 months, with the exception of the 1 population-level trial that had a 3-year follow-up.78  Comparison conditions were services as usual (n = 20) and active intervention (n = 15; such as educational materials = 1; wait list = 4; enhanced usual care = 4; evidence-based program = 6), and 5 were unspecified.

Parent outcomes were also highly variable. The most common pertained to maternal mental health, parenting stress, and parenting practices, such as harsh discipline. Researchers of some studies looked at specific types of parenting skills, such as parent behavior in response to child misbehavior,71,72  and understanding of child development and how to support their child.62,79  Researchers of one study examined overall parental well-being.59 

Several studies were conducted by using manualized interventions, including Incredible Years, Triple P, Primary Care Triple P, Child-Adult Relationship Enhancement, and the Strongest Families Telephone Program, whereas other programs were unnamed. Of those providing sufficient information, interventions were delivered to parents alone (n = 13), with their children present (n = 12), or in group format (n = 9). Five interventions had a home-visiting or take-home component, and 5 had technology-based components or primary delivery strategy, such as phone- or Web-based delivery. Interventions typically occurred over 1 to 12 sessions, with 1 or more sessions per week up to 12 weeks, although 3 studies intervened periodically over 2- and 3-year periods.51,55,87 

Researchers of approximately one-third of included studies described in detail how intervention deliverers and/or involved health care staff were trained. Among them, most provided training sessions beyond dissemination of training manuals (n = 10), and trainings lasted from 1 to 9 sessions (mode = 3) and took place over a few weeks or, in a few cases, several months. Most trainings involved some sort of manualized or discrete training protocol, followed by experiential training (eg, simulated patient interview).

Concerning program integration within primary care, involvement of the health care team was highly variable, including a pure integrative model (n = 8), co-located care (n = 9), and training the physician to deliver the program (n = 9). Researchers of 6 studies facilitated referrals to external mental health clinicians rather than delivering the intervention through primary care or in collaboration with primary care physicians. The variation in integration and delivery model adds to the difficulty of gauging program feasibility and sustainability in primary care. Model type was coded by using the Kolko and Perrin23  models of effective delivery of behavioral health services in pediatric primary care and is summarized in Table 1. Future researchers should test the relative advantages and feasibility of implementation between 2 or more models as is being done in other areas of child health care.93 

Program delivery was also highly variable, with physicians only (n = 6); physicians or other health care provider (eg, medical assistant) (n = 3); specialty behavioral health clinician only (n = 6); physician or behavioral health clinician (n = 3); nurse only (n = 9); the researchers themselves (n = 3); or some other combination of health care and behavioral health staff, nonclinical staff in the practice, or graduate students outside of the practice (n = 7) (see Table 1). In sum, physicians were included in 14 of the 40 trials, and other health care staff (nurse practitioners, physician assistants, nurses) were responsible for delivering the full intervention in 11 studies. In the remainder, clinicians were responsible for part of the program, typically a motivational interview or introduction to the intervention followed by referral. Those that did not involve the physician or a clinician most commonly referred participants to an outside behavioral health specialist or trained research staff (often graduate trainees). Carefully considering who will be responsible for delivering preventive services in primary care has been noted as a significant barrier to implementation because physicians’ time is severely limited for such activities.9  Furthermore, specialty behavioral health clinicians are in short supply nationally and remain a luxury in pediatric primary care practices.94  Greater attention to sustainable staffing models for parenting programs is sorely needed.95 

Implementation Outcomes

Fidelity was the most commonly measured and reported implementation outcome (n = 7), followed by parent’s or youth’s acceptability of the intervention (n = 5) (see Table 2). Among those reporting fidelity, researchers of 3 studies indicated that fidelity was assessed but did not report associated measures or outcomes52,77,80 ; researchers of other studies stated that fidelity was “achieved” or there was a “high-level of fidelity” but did not specify what constituted fidelity, how it was measured, or any criteria. Most study groups used study-specific fidelity measures. Thus, it is challenging to judge the validity and reliability of the measures used. Only 2 trials reported on cost of the intervention. No trials measured or reported other common implementation outcomes31 : acceptability of the intervention by the health care team, appropriateness, feasibility, reach and penetration rate, or program sustainability. Three studies reported on participation rate and dose of the intervention, which can be an indicator of implementation, but they did not interpret it in that context.

TABLE 2

Implementation Outcome Measurement and Analysis

Source, YearImplementation OutcomeMeasureComparisonResult or Finding
Hiscock et al,59  2007 Satisfaction (with and usefulness of each intervention component) (parents), Acceptability 10-cm visual analog scales (helpful to unhelpful; did not receive or do this) None Satisfied (median 7.7; IQR, 5.5–9.2), useful (median 7.3; IQR, 3.0–9.1) 
 Cost of intervention Per hour cost based on research budget Control Intervention £96.93 (SD 249.37) versus control £116.79 (SD 330.31); mean difference £19.44 (95% CI, 83.70–44.81), P = .55 
Hiscock et al,60  2008 Fidelity Checklist at end of each session (nurse reported) None Full program was delivered for 95% of group sessions 
Iloabachie et al,61  2011 Acceptability of program (adolescents) Survey developed for this study (9 items relevant to acceptability), parent interviews (qualitative analysis) None Before and after (baseline and 6–8 wk postintervention): Internet site preferences, adolescents reported greater importance of chatting online as part of the intervention after participation than before (P = .01) intervention format (wanting more interactive format) 
Kolko et al,64  2011 Fidelity Mean percentage of correctly administered content or procedures in the 2 treatment protocols (observer rated) None Average rating 91.4 (SD = 9.1); fidelity was unrelated to either child dysfunction or child health 
Mendelsohn et al,70  2007 Cost of intervention No measure reported None ∼$240 per child per year 
Minkovitz et al,72  2007 Satisfaction (parents), Acceptability Survey (no more details) Control Satisfaction was high 
 Fidelity Checklist Control Range: 48.2%–86.6%; higher in intervention than control 
Myers et al,73  2015 Fidelity Telepsychiatrists and therapists used checklists that outlined the essential treatment components to address during each session. All sessions were recorded, and sessions were randomly selected to rate the clinicians’ coverage of these components None High fidelity to protocols (other publications referenced but no results provided in this article) 
Perrin et al,75  2014 Fidelity Incredible Years program, Leader’s Process Checklist None Session activities were documented by group leaders after each session using the Incredible Years Leader’s Process Checklist and taped sessions that were randomly reviewed for fidelity. Over 90% of content and delivery components were delivered during each session. 100% of reviewed taped sessions had every parent speak at least once 
Sanders et al,78  2008 Clinician training, adoption 375 clinician trained over 21 courses None 73% of clinician became accredited 
 Participation and dosage (intervention elements used) N/A None 29 television programs, 48 radio broadcasts, 58 newspaper or magazine articles, and 1750 Web site hits 
 Participation and dosage (families) N/A Control group 7.5% of families participated in the program versus control (2.1%; χ2 = 48.93, P < .001) 
Schilling et al,81  2017 Participation and dosage (parents) N/A None 43% of intervention parents attended 3 or more sessions (of 6) 
 Fidelity Checklist (clinician report) None Clinicians received weekly oversight and documented session activities after each intervention session according to a fidelity checklist 
 Satisfaction (youth), Acceptability Likert scale surveys and qualitative exit interviews None 81% of youth completing the surveys reported being satisfied or very satisfied with the intervention. Qualitative analyses aligned with the survey results, expressing satisfaction with the intervention itself and with the delivery location (primary care) 
Turner et al,86  2006 Satisfaction (parents), Acceptability Client Satisfaction Questionnaire None Mothers reported high satisfaction (mean = 72.89; SD 11.48) 
Saulsberry et al,79  2013 Fidelity MI fidelity scale Control (brief advice) Clinicians in the treatment group had high fidelity (4.5 out of 5, SD = 0.83) to the MI model versus control fidelity to MI (1.02, SD = 0.07). Interviews were longer in the MI group (P = .002) 
Wissow et al,88  2008 Adoption N/A None 84% of eligible clinicians accepted and received training once a lead clinician was identified at each site. No attrition 
Source, YearImplementation OutcomeMeasureComparisonResult or Finding
Hiscock et al,59  2007 Satisfaction (with and usefulness of each intervention component) (parents), Acceptability 10-cm visual analog scales (helpful to unhelpful; did not receive or do this) None Satisfied (median 7.7; IQR, 5.5–9.2), useful (median 7.3; IQR, 3.0–9.1) 
 Cost of intervention Per hour cost based on research budget Control Intervention £96.93 (SD 249.37) versus control £116.79 (SD 330.31); mean difference £19.44 (95% CI, 83.70–44.81), P = .55 
Hiscock et al,60  2008 Fidelity Checklist at end of each session (nurse reported) None Full program was delivered for 95% of group sessions 
Iloabachie et al,61  2011 Acceptability of program (adolescents) Survey developed for this study (9 items relevant to acceptability), parent interviews (qualitative analysis) None Before and after (baseline and 6–8 wk postintervention): Internet site preferences, adolescents reported greater importance of chatting online as part of the intervention after participation than before (P = .01) intervention format (wanting more interactive format) 
Kolko et al,64  2011 Fidelity Mean percentage of correctly administered content or procedures in the 2 treatment protocols (observer rated) None Average rating 91.4 (SD = 9.1); fidelity was unrelated to either child dysfunction or child health 
Mendelsohn et al,70  2007 Cost of intervention No measure reported None ∼$240 per child per year 
Minkovitz et al,72  2007 Satisfaction (parents), Acceptability Survey (no more details) Control Satisfaction was high 
 Fidelity Checklist Control Range: 48.2%–86.6%; higher in intervention than control 
Myers et al,73  2015 Fidelity Telepsychiatrists and therapists used checklists that outlined the essential treatment components to address during each session. All sessions were recorded, and sessions were randomly selected to rate the clinicians’ coverage of these components None High fidelity to protocols (other publications referenced but no results provided in this article) 
Perrin et al,75  2014 Fidelity Incredible Years program, Leader’s Process Checklist None Session activities were documented by group leaders after each session using the Incredible Years Leader’s Process Checklist and taped sessions that were randomly reviewed for fidelity. Over 90% of content and delivery components were delivered during each session. 100% of reviewed taped sessions had every parent speak at least once 
Sanders et al,78  2008 Clinician training, adoption 375 clinician trained over 21 courses None 73% of clinician became accredited 
 Participation and dosage (intervention elements used) N/A None 29 television programs, 48 radio broadcasts, 58 newspaper or magazine articles, and 1750 Web site hits 
 Participation and dosage (families) N/A Control group 7.5% of families participated in the program versus control (2.1%; χ2 = 48.93, P < .001) 
Schilling et al,81  2017 Participation and dosage (parents) N/A None 43% of intervention parents attended 3 or more sessions (of 6) 
 Fidelity Checklist (clinician report) None Clinicians received weekly oversight and documented session activities after each intervention session according to a fidelity checklist 
 Satisfaction (youth), Acceptability Likert scale surveys and qualitative exit interviews None 81% of youth completing the surveys reported being satisfied or very satisfied with the intervention. Qualitative analyses aligned with the survey results, expressing satisfaction with the intervention itself and with the delivery location (primary care) 
Turner et al,86  2006 Satisfaction (parents), Acceptability Client Satisfaction Questionnaire None Mothers reported high satisfaction (mean = 72.89; SD 11.48) 
Saulsberry et al,79  2013 Fidelity MI fidelity scale Control (brief advice) Clinicians in the treatment group had high fidelity (4.5 out of 5, SD = 0.83) to the MI model versus control fidelity to MI (1.02, SD = 0.07). Interviews were longer in the MI group (P = .002) 
Wissow et al,88  2008 Adoption N/A None 84% of eligible clinicians accepted and received training once a lead clinician was identified at each site. No attrition 

IQR, interquartile range; MI, Motivational interview; N/A, not applicable.

The review also reveals a lack of evidence for sustainment of parenting interventions. The studies were focused almost exclusively on intervention effects, which is meaningful but not sufficient for understanding the impact of delivering these programs in primary care over the long-term. Transporting interventions that were largely developed and tested in laboratory-based settings to existing systems, such as pediatric primary care, can be a tremendous challenge, yet doing so is imperative to achieving a public health impact on children’s behavioral health.15  Additionally, there was no formal reporting of procedures used to adapt programs to the primary care settings. More studies are needed that focus on the context of implementation, the adaptations required for a protocol to fit with primary care, and the predictors of sustained adoption. Researchers should consider the use of implementation trial designs96,97  to place the focus on the system that is needed to support program adoption and delivery. Data obtained from such trials would inform translation of programs that show effects in primary care or have been found to be efficacious in other contexts.98  This research is imperative to advance parenting interventions in primary care from efficacy and effectiveness to wide-scale implementation. Taken together, parenting interventions for youth mental, emotional, and behavioral disorders have not been sufficiently tested in a way that shows they can be adopted and sustained in primary care. At least 2 trials99,100  that are known to the authors are underway in which researchers focus on both implementation and clinical effectiveness of a parenting program in primary care, known as a hybrid design,101  but more are needed.

Trial Quality

The included studies had the majority of the characteristics of a well-designed intervention study, as evidenced by ratings of 7 or above on all included studies (mean = 7.75). This indicated a high degree of scientific value.48  Importantly, all studies had clearly stated aims, a comparable comparison condition, and postintervention results provided for all conditions.

In this review, we add to the mounting evidence that parenting interventions can be effective at improving child mental, emotional, and behavioral health and parental outcomes when delivered in coordination with pediatric primary care. However, the way in which they are implemented matters, and this has not been the focus of research to date. Our findings also expose a pronounced lack of focus on implementation research methods and the context of implementation in the published literature. This is preventing the field from scaling up parenting intervention and achieving an equitable public health impact. There is sufficient evidence of effectiveness: it is time to research the implementation strategies that support adoption and sustained delivery of parenting interventions in primary care.

The results of this review should be considered with the following caveats. Our approach limiting the search to published articles only introduces the potential for underrepresenting the literature as a result of not contacting any study authors while conducting the search and preparing the article and not examining unpublished “gray” literature. Further publication bias is possible with what we perceive to be a preference for effectiveness study results among many journals, with perhaps less of an interest in implementation processes and outcomes (particularly when researchers in the study primarily aim to establish the effectiveness base for parenting interventions in primary care and secondarily aim to examine implementation). This suggests that implementation data may have been collected but were not included in the published results of the included studies in this review. We also noticed that few studies in this review were conducted outside of the United States. This could be a function of the search terms, such as primary care, which might not be the preferred term internationally, or our inclusion of only English language publications.

Drs Smith and Cruden contributed equally as first authors of this article, guiding the development of the research question, coding and arbitrating coding conflicts, and drafting the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; Dr Molleda contributed to the development of inclusion and exclusion criteria, was the second coder for all reviewed abstracts and full texts, and reviewed the manuscript critically for important intellectual content; Drs Ryzin and Davis contributed to drafting the manuscript and reviewed it critically for important intellectual content; Ms Fu was responsible for data checking and drafting sections of the manuscript and approved the version to be published; and Drs Landsverk and Brown guided the development of the research question and the inclusion and exclusion criteria and approved the version to be published; and all authors approved the final manuscript as submitted.

FUNDING: Supported by grant P30 DA027828 from the National Institute on Drug Abuse, awarded to Dr Brown. Additional support was provided by grant U18 DP006255 from the National Center for Chronic Disease Prevention and Health Promotion of the Centers of Disease Control and Prevention, under the Childhood Obesity Research Demonstration Project 2.0, awarded to Dr Smith and Cady Berkel, and by grant 2018-68001-27550 from the US Department of Agriculture, National Institute for Food and Agriculture, Agriculture and Food Research Initiative, awarded to Dr Smith and Cady Berkel. The opinions expressed in this article are the views of the authors and do not necessarily reflect the official policy or position of any other part of the US Department of Health and Human Services nor the US Department of Agriculture. Funded by the National Institutes of Health (NIH).

     
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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