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QUESTION: Is self help, media-based therapy effective for managing behaviour problems in children and adolescents?
Data sources
Studies were identified by searching Biological Abstracts, CINAHL, the Cochrane Controlled Trials Register, EMBASE/Excerpta Medica, Medline, SPECTR, PsycLIT, and Sociofile in 1999; scanning reference lists of articles; and contacting authors.
Study selection
Studies were selected if they were randomised or quasi-randomised controlled trials of self help, media based (eg, audiotape, book, computer, manual, videotape, or some combination of these) behavioural therapy for parents or caregivers of children or adolescents with behavioural disorders.
Data extraction
Data were extracted on patients, interventions, and outcomes. Authors were contacted to obtain missing data. The reviewer assessed the quality of study methods.
Main results
9 studies (1 unpublished; 7 randomised, 2 quasi-randomised) met the selection criteria. Follow up ranged from 6 weeks to 2.5 years. Sample sizes ranged from 32 to 160 participants. Sleep problems: 2 studies showed that conventional and booklet treatments were each effective for sleep problems in children. Enuresis: 1 study compared 3 groups: filmed training of behavioural instructions, live training, and a waiting list control. The face to face group had better outcomes than the film group. Another study compared 3 treatments: a urine alarm, a urine alarm plus instructions for parents to immediately reinforce the child awakening and using the toilet upon hearing the alarm, and a urine alarm plus instructions for parents to reinforce the child in the morning for a dry night. At 2.5 years, the treatment success rate was higher for immediate reinforcement than for a urine alarm alone. Pooled results for these 2 studies showed no difference in relapse or treatment failure rates. Attention deficit hyperactivity disorder: 1 small study (n=32) compared a booklet of behavioural management advice plus methylphenidate with methylphenidate alone, but 10 participants dropped out. Conduct disorder: 1 study compared 4 groups: individually administered videotape modelling, group discussion videotape modelling (1 video weekly), group discussion only, and a waiting list control for {10–12 wks}*. All 3 treatment groups showed fewer behaviour problems, more prosocial behaviours, and less spanking than the control group. Another study by the same authors showed that adding 2 hours of therapist time to an individually administered videotape parenting programme enhanced its effectiveness.
Conclusions
In children with behaviour problems, self help, media based behaviour therapy is more effective than no treatment. Results are inconclusive for comparisons with usual care or when added to medication.
*Webster-Stratton C, Kolpacoff M, Hollinsworth T. Self-administered videotape therapy for families with conduct-problem children: comparison with two cost-effective treatments and a control group. J Consult Clin Psychol 1988;56:558–66.
Commentary
Montgomery's systematic review presents the current evidence on the effectiveness of media based behavioural interventions for an array of child behavioural problems and reveals a paucity of randomised studies. An extensive search identified 1089 citations, but only 9 studies met the inclusion criteria, and 5 had adequate allocation concealment. The heterogeneity of the studies impeded comparative analysis. Vast differences existed in sample characteristics (eg, cognitive ability and age), behavioural conditions (eg, enuresis and conduct disorder), and media format (eg, audiotape, manual, or videotape). Although Montgomery concluded that media based interventions are clinically effective in improving child behavioural outcomes for specific cases, little evidence supports a unique effect when media interventions are combined with other treatments. Stronger evidence on specific media based interventions and child behavioural conditions is required before making decisions that influence practice.
Nurses in schools, child health clinics, and parenting classes are strategically poised to promote positive child behaviour and parenting. Media based approaches may be most appropriate for treatment of modifiable conditions such as sleep and enuresis problems. Video interventions may be especially suited to promote behaviour change as they have potential to provide information in a motivational and supportive manner while also augmenting face to face strategies. Early evidence suggests that video format is effective for nursing interventions such as promoting extended, long term breastfeeding among adolescent mothers.1 Research is necessary to guide the development of professional media based interventions and establish effectiveness for specific child and parent outcomes. Ultimately, it will be essential to determine the unique effect of a particular media production compared with the support and expertise of the nurse and/or healthcare professional.
References
Footnotes
Source of funding: National Health Services Executive Anglia and Oxford, UK.
For correspondence: Mr P Montgomery, University Section of Child and Adolescent Psychiatry, University of Oxford, Park Hospital for Children, Old Road, Headington, Oxford OX3 7LQ, UK. Fax +44 (0)1865 762 358.
A modified version of this abstract appears in Evidence-Based Mental Health.