Disruptive behaviour problems (DPB) such as conduct problems or being oppositional and defiant affect a large proportion of young children. Many of these early behavioural problems predict negative outcomes such as underachieving at schools, future unemployment and criminal behaviour. Treatment of DPBs often begins during the school years once the condition is well-established, and when DPBs are still responsive to interventions.

Psychological treatments are usually regarded as the frontline treatment with younger children with DPB. Within this umbrella of treatments, parenting programmes are commonly used and have been shown to be largely effective at improving a number of outcomes including children’s behavioural problems and parents’ well-being. In these programmes, parents are taught a range of skills to promote positive interactions with their children, and more specifically, to reinforce appropriate behaviours from their children.

Implementation of parenting programmes has, however been challenging: many families with children who have DPBs decline to take part in available programmes, and even when families agree to take part, many drop out. These figures are worse for ‘hard to reach’ families, such as minority groups and those of lower socioeconomic status. Yet very little is known about the reasons for the low uptake and completion of programmes.

In this paper, a synthesis of qualitative studies (mainly interview studies or studies based on focus groups) was undertaken to determine the perceived barriers against attending and continuing parenting programmes and suggestions for how to facilitate better access.

Methods

Several search strategies were used to identify relevant studies. Initial searches produced 10,992 papers but after exclusion of studies that did not focus on treatment of child DBPs, 2,621 studies remained. These were subjected to further scrutiny on quality, broadly whether the research question was clearly stated, whether the method of analysis was appropriate, and whether there was demonstrated rigour in sampling, data collection and data analysis.

Twelve studies were included in the synthesis. These included studies conducted in the UK, Australia, US and Canada. Altogether, the views of 353 participants were represented: 171 parents/caregivers of children aged 2-17 years with DPB and 202 professionals involved in either the delivery of parenting programmes, worked in the health or social services, or worked with hard to reach families. An attempt was made to include views of hard to reach groups and families who had dropped out from programmes.

A thematic synthesis approach was used. This involved three stages: (i) line-by-line coding of the findings section, (ii) organisation of codes into ‘descriptive’ themes, and (iii) development of ‘analytic’ themes (which evolved with common descriptive themes across studies).

Results

Across studies, four main topics were covered. Briefly, these included: barriers to service access, barriers to continued engagement, how to facilitate service access and how to facilitate continued engagement.

Five major barriers to service access were identified:

1. Situational barriers: practical difficulties attending services and time constraints due to other commitments.
2. Psychological barriers: fears and worries, stigma and distrust
3. Lack of information/misconception about services: unawareness and misconceptions of services, general lack of advertising and beliefs that services are for others.
4. Availability of services: actual limited availability, long waiting times, needs not recognised by professionals, and the feeling that parents have to be assertive to get help.
5. Poor collaboration between those involved in care of child: disorganised and sometimes inappropriate referral routes and poor sharing of information or communication across professionals/agencies.

Four major barriers to continued service use were identified:

1. Dislike of group activities: feeling like an outsider in the group, finding it difficult to talk in front of a group and the inconsistent participation of other group members
2. Programme regarded as unhelpful: finding the programme stressful, disagreement with the strategies used and feeling that the recommended strategies had already been tried and used before by the parent
3. Difficulty following the programme: no support from other family members, not being able to fully understand the content and therefore finding it difficult to implement some of the exercises and strategies.
4. Change in circumstances: illness of another family member or a move to another area.

Three strategies for increasing access to services were identified:

1. Promoting services through effective advertisements: multiple methods of promotion, ensuring that content of the advert is clear and easy to understand, trying to specifically target hard to reach groups and offer other more fun activities or open events.
2. Direct recruitment of families: through personal contact with particular parents, or through word of mouth.
3. Better collaboration between professionals/agencies involved in child’s care: improve referral routes and train staff working in such agencies about other available services.

Two strategies for increasing continued engagement with services were identified:

1. Targeting the programme: ensuring that the programme actually targets the family’s needs, ensuring positive group experiences and considering additional contact outside of the parenting group sessions.
2. Targeting the therapist: emphasising to therapists the need to build good and non-judgemental relationships and rapport with parents, and continually training therapists in a wide range of skills.

Generally, parents and professionals converged on similar themes in terms of barriers to service engagement and continued usage (though there were some subtle differences in emphasis of specific factors/issues). However parents were far more vocal about their views on barriers than they were on strategies to improve their engagement with services.

Conclusions

Based on these findings, the authors emphasise that there is a clear need for assessment tools that can be used to collect information about specific barriers that families face when considering using or continuing to use services – and where possible, this information could bse used to tailor interventions towards individual families, in the manner of recent consumer modelling techniques.

In addition four specific recommendations are made regarding the development and delivery of parenting programmes:

1. Ensuring awareness and availability of services
2. Creating individually tailored support
3. Increasing therapist skills and matching them to programmes and families
4. Making group-based programmes more acceptable to parents and making available one-to-one versions of effective programmes

Finally, rather than narrowly focusing on the efficacy of the treatment, clinical guidelines such as NICE should also be aware of barriers and develop ways of targeting these barriers, when assessing parenting programmes for the early treatment of DPB.

Reference

Koerting J, Smith E, Knowles MM, Latter S, Elsey Hm McCann DC, Thompson M & Sonuga-Barke EJ.  Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents’ and professionals’ perceptions. Eur Child Adolesc Psychiatry, Published online 6th April 2013.