Efficacy of a Self-help Parenting Program on Parental Outcomes: a Randomized Controlled Trial 

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R. C. de Jong, Barbara J. Hoofdakker, Lianne Veen-Mulders, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3973243/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The efficacy of our newly developed self-help parenting program on children’s externalizing behavior was recently shown. The present study investigated its efficacy on parental outcomes, which is understudied in clinical trials. Using a randomized controlled trial, 110 parents were allocated to an intervention condition (either with or without telephonic support) or a waitlist condition. Outcomes included the Parenting Practices Interview (PPI; positive and negative parenting practices), Parenting Sense of Competence Scale (PSOC), Parenting Stress Index (PSI) and Eyberg Child and Behavior Inventory - Problem Scale (ECBI-P; the number of child behaviors that parents perceive as troublesome). All measures were collected at baseline (T0) and post intervention (after 15 weeks, T2); PPI and ECBI-P were also collected at week 8 (T1) and 28 (T3). Using longitudinal multi-level regression analyses, we compared the intervention and waitlist condition at T2. Furthermore, the support and no support conditions were exploratively compared at T2 and T3. Comparing intervention to waitlist, results showed medium-sized effects on PPI and ECBI-P scores and a small-sized effect on PSI scores, and no differences between the conditions on PSOC scores. No differences were found between the support and the no-support condition. The results indicate that our self-help program improved parenting practices and parents’ perception of child behavior, in addition to previous findings on child outcomes. This confirms that self-help parenting programs may be a promising alternative to face-to-face programs, although future studies should focus on determining for whom and in which settings which parenting programs are most helpful.. externalizing behavior self-help intervention parents parenting practices parental well-being Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1. Introduction Parent training is an effective treatment for children with externalizing behavior, such as hyperactive and impulsive behavior, disobedience or temper tantrums (Groenman et al., 2021 ; Mingebach et al., 2018 ). In clinical practice, face-to-face parenting programs are commonly used (e.g., Incredible Years; Webster-Stratton & Reid, 2018 , Behavioral Parent Training Groningen; Van Den Hoofdakker et al., 2007 ), but these are not always easily accessible for parents (De Jong et al., 2023 ; Koerting et al., 2013 ). In contrast, self-help programs are widely accessible and have shown similar results (Tarver et al., 2014 ; Thongseiratch et al., 2020 ). In a recent study ( De Jong et al., 2023 ), we examined the efficacy of a newly developed self-help program for parents of children with externalizing behavior. The study showed that the program was efficacious in reducing children’s externalizing behavior (primary outcome measure) and that parental satisfaction was high. Because parent training programs are based on the assumption that changing parental behavioral is a prerequisite for changing child behavior (Forehand et al., 2014 ), changes in parenting practices, parental wellbeing (i.e., parenting sense of competence and stress), and perceptions are supposed to be crucial. However, these aspects are understudied in clinical trials, and are important in order to gain insight into possible working mechanisms. Changing parenting practices is one of the main targets of parent training, in which parents learn behavioral techniques to alter the behavior of their child (Daley et al., 2018 ). Both antecedent techniques, which aim at changing behaviors by manipulating their antecedents and consequent techniques, which aim at changing behaviors by manipulating the consequences of behavior (Dekkers et al., 2022 ; Leijten et al., 2019 ), have proven to be effective in changing the child’s behavior (Hornstra et al., 2021 ).Techniques that especially have proven to be effective in terms of positive effects on child outcomes include increasing positive interactions between child and parent, teaching parents to be consistent, and using mild discipline techniques, such as time out or planned ignoring (Hornstra et al., 2022 ; Kaminski et al., 2008 ). Meta-analytic evidence shows that parenting programs have a positive effect on parenting practices (Dekkers et al., 2022 ; Tarver et al., 2014 ; Weber et al., 2019 ). Regarding self-help parenting programs, a meta-analysis (eight studies), studying the effect of self-help parenting programs for externalizing child behavior on parenting practices, showed a medium sized reduction of negative parenting, i.e. harsh parenting practices and lax or permissive discipline (Tarver et al., 2014 ). For positive parenting, which was not studied in this meta-analysis, studies into self-help programs are scarce and results are mixed: some studies find an effect of a self-help parenting program on positive parenting (Franke et al., 2020 ; Kierfeld et al., 2013 ), while others do not (Dose et al., 2017 ; Dose et al., 2021 ). However, two meta-analyses on both face-to-face and self-help parenting programs for children with ADHD (Dekkers et al., 2022 ) and children with externalizing behavior (Weber et al., 2019 ) showed both medium-sized effects on positive parenting or a combined measure of positive and negative parenting. The meta analyses of (Dekkers et al., 2022 ) showed that teaching parents to use techniques focusing on reinforcement of desired behavior was in particular related to a decrease of negative parenting practices. Regarding parental wellbeing, parenting sense of competence has been shown to be positively related to parenting practices (i.e. more positive parenting practices), which may reduce child externalizing behavior (De Haan et al., 2009 ). Furthermore, it has been found that stress related to parenting has a transactional relationship with child externalizing behavior, such that child externalizing behavior can lead to more parenting stress and parenting stress in turn can lead to more child externalizing behavior. This is probably due to more negative parent-child interactions when parents experience stress (Mackler et al., 2015 ; Yan et al., 2021 ). Also, there is evidence that higher levels of parenting stress can lead to a distorted (more negative) perception of the child’s (externalizing) behavior (Van der Oord et al., 2006 ). A meta-analysis on self-help parenting programs showed a small effect on parenting stress and a large effect on parenting sense of competence (Tarver et al., 2014 ). A more recent meta-analysis on online self-help programs studied parental mental health and found small-sized improvements on a combined measure of parenting stress, parenting sense of competence and parenting practices (Thongseiratch et al., 2020 ). Taken together, these meta-analyses suggest that self-help parenting programs may have positive effects on parental wellbeing. Parent training might also influence parental perception of their child’s externalizing behavior. Studies showed that negative perceptions of problem behavior are associated with negative reactions to this type of child behavior (Dix et al., 1986 ; Mikami et al., 2015 ), which could lead to a negative vicious cycle. Randomized controlled trials into parent training showed that parents view disruptive behaviors as less problematic after the intervention (Baumel et al., 2016 ; De Graaf et al., 2008 ; Letarte et al., 2010 ; Tarver et al., 2014 ; Thongseiratch et al., 2020 ) Regarding the format of the training, some self-help parenting programs offer additional support during the program, for example by providing online feedback or supportive phone calls (Tarver et al., 2014 ; Thongseiratch et al., 2020 ). Such additions may impact the effectiveness of the program. The meta-analysis by Tarver and colleagues (Tarver et al., 2014 ) showed that after removing those studies that provided additional support, the effect of parenting programs on parenting stress remained unchanged. However, regarding parenting sense of competence, effect sizes reduced from large to medium, and the effect size for negative parenting practices became non-significant. These findings suggest that the effects of parenting programs on some parental outcomes can be enhanced by providing additional support. In our recent study examining efficacy on child outcomes (De Jong et al., 2023 ), we exploratively compared two versions of the self-help parenting program, one with and one without biweekly telephonic support. We found no differences in child externalizing behavior between the groups, although this might have been due to a lack of statistical power. The aim of the present study was to investigate the efficacy of our self-help program on parenting practices, parenting sense of competence, and parenting stress and on parental perception of their child’s behavior. We expected that, compared to waitlist, the self-help parenting program was efficacious in improving these parental outcomes (Tarver et al., 2014 ; Thongseiratch et al., 2020 ). Furthermore, we exploratively compared the self-help program with and without additional telephonic support. 2. Methods 2.1 Design and procedure Recruitment of parents took place through social media, schools, local child support facilities, and a parent association for children with developmental problems. Parents enrolled themselves for the intervention, without referral. We conducted a randomized controlled trial (RCT), see (De Jong et al., 2023 ), with three conditions: a) the parenting program with telephonic support (support condition); b) the parenting program without telephonic support (no support condition); and c) a waitlist control condition. The support and no support conditions were combined for the main analyses (referred to as the intervention condition). After providing consent and meeting full inclusion criteria, using a computer-generated random number list, parents were allocated to one of the three conditions (1:1:1 ratio) by blocked randomization, where inclusion time was divided in three equal time periods (resulting in three blocks). Allocation was done by one of the authors (ML) who did not have any contact with the participants. All measurements were assessed at baseline (T0) and immediately post-intervention at 15 weeks (T2). In addition, parenting practices and parental perception of their child’s externalizing behavior were also assessed eight weeks post baseline (T1) and at three months follow-up (T3). T3 measurements were omitted for participants in the waitlist condition, since they were offered the intervention after T2 and thus during T3. For a visual representation of the design, see Fig. 1 . The study was conducted between February 2019 and March 2021. Parents could start participation in the study at any week, except for the weeks in which measurements would take place during school holidays (although we decided that during the covid-19 lockdown, parents could start any week, as school- and holiday weeks were then approximately similar in terms of home situation). Parents could participate either alone or together with their partner, if being part of the same household. The primary parent (the parent mostly involved in the study) filled out the questionnaires, possibly together with their partner. After baseline, all participants were allowed to receive (additional) care as usual, if needed. Medical ethical approval of the study was waived for the medical research with human subjects act (WMO, 2018) by the Medical Ethical Committee of the VU Medical Centre (#2018.421). The trial was registered in the Netherlands Trial Register ( https://www.trialregister.nl/trial/8200 ). CONSORT guidelines were followed to describe the study (Schulz et al., 2010 ). 2.2 Participants Parents were included if fulfilling the following criteria: 1) they were seeking help for externalizing behavior displayed by their child; 2) their child was between 4 and 12 years old; 3) their child showed (sub)clinical levels of externalizing behavior at home, as indicated by a) a score above the 80th percentile (i.e. score > 6 for children aged 4 or 5 year, or > 7 for children aged 6 to 12) on the externalizing behavior scale of the Strengths and Difficulties Questionnaire (SDQ; Maurice-Stam et al., 2018 ; Van Widenfelt et al., 2003 ), and b) a (sub)clinical score on the ADHD hyperactivity and/or inattention scale ( ≥ three symptoms subclinical, ≥ six symptoms clinical) or the ODD scale ( ≥ two symptoms subclinical, ≥ four symptoms clinical) of the Diagnostic Interview Schedule for Children fourth edition (DISC-IV; Anderson et al., 2017 ; Park et al., 2015 ; Shaffer et al., 2004 ); 4) their child suffered from impairment due to the child’s externalizing behavior, as indicated by a score of 4 or higher on one of the domains of the Impairment Rating Scale (IRS; Fabiano et al., 2006 ). Parents were excluded if: 1) they were receiving other parent training during the study or in the preceding six months (we defined parent training as a training aimed at modifying the child’s behavior, involving several meetings, teaching the parent techniques and including homework assignments); 2) they had planned to receive other parent counseling or coaching during the study directed at externalizing behavior of the child at home; 3) their child started psychotropic medication or changed medication dose up to three months prior to the study (to rule out any changes in the child’s behavior as a result of changes in the use of medication); 4) parents’ Dutch reading ability was not sufficient to fully understand the program materials; 5) parents went on holiday during the study for more than two weeks (in order to maintain feasibility of completing the program in 15 weeks). Figure 2 displays the flow chart of participant inclusion. 2.3 Materials Intervention The 15-week self-help parenting program consists of a manual and online program divided in 11 modules. It includes psycho-education regarding externalizing behavior and provides parents with behavioral parenting techniques to modify the externalizing behavior of their child (Dekkers et al., 2022 ; Hornstra et al., 2022 ; Kaminski et al., 2008 ). In depth guidance is provided on the behavioral techniques with detailed description of praising, playing with your child in a positive way, providing structure in time and in the child’s environment, setting and maintaining clear rules and providing clear instructions, providing rewards, ignoring unwanted behavior, mildly punishing unacceptable behavior, and coping with temper tantrums. The online platform is used to provide examples of the techniques, test parents’ knowledge and guide parents in making a plan to implement the techniques. The online program starts with parents selecting child behavior that they perceive as most severe. These problem behaviors remain focus of the self-help parenting program. Furthermore, parents monitor progress, by reporting on their child’s behavior and their own parenting confidence, which is visually presented at the start of each module. Two versions of the parenting program were developed: a version without additional support, and a version with additional support, where parents received manualized, telephonic coaching biweekly. During these phone calls, parents were motivated and monitored and could ask question or discuss problems with implementing the techniques. These phone calls were conducted by trained psychologists (for a description of the intervention in more detail, De Jong et al., 2023 ). Screening measures and participant characteristics First, the Externalizing scale of the parent-rated Strengths and Difficulties Questionnaire (Van Widenfelt et al., 2003 ) was used to screen children for eligibility prior to further assessment. The reliability of the externalizing scale is considered acceptable (Di Riso et al., 2010 ; Maurice-Stam et al., 2018 ). Second, the ADHD and ODD part (module E) of the DSM-IV based structured Diagnostic Interview Schedule for Children (DISC; Shaffer et al., 2004 ) was administered to parents (which we slightly adjusted to be in line with DSM-5 criteria by adding the question whether the child was spiteful or vindictive at least twice within the last six months). Psychometric properties of the ADHD and ODD modules of the DISC are considered good (McGrath et al., 2004 ; Schwab-Stone et al., 1996 ). Furthermore, the parent-rated Impairment Rating Scale (IRS; Fabiano et al., 2006 ) was used to assess functional impairment. The IRS consists of eight 11-point Likert scaled items asking parents to what degree the child’s behavior problems influence their child’s daily life (0 = no impact, 10 = extreme impact) with higher scores indicating more impairment. Psychometric properties of the IRS are considered good (Fabiano et al., 2006 ). Baseline demographic factors (i.e. parent’s age, sex, education level) were assessed with a custom made questionnaire (based on guidelines for reporting education level; CBS, 2016 ). Outcome measures Parenting practices were measured using the Parenting Practice Interview questionnaire (PPI; Webster-Stratton, 2001 ). Parents were asked to indicate on a 7-point Likert scale the degree to which they would use a certain parenting practice (for example ‘giving the child a brief time out’ or ‘praising the child’), when the child acts in a certain way (for example ‘misbehaves’ or ‘doing a good job’). To assess positive parenting (PPI positive), we combined the scores on the subscales Appropriate Discipline (12 items), Positive Verbal Discipline (9 items), Praise and Incentives (11 items), and Clear Expectations (6 items), by averaging the mean scores on these subscales. To assess negative parenting (PPI negative), we used the subscale Harsh and Inconsistent Discipline (15 items). The subscales Monitoring and Physical Punishment were omitted, because monitoring was not part of the parenting program and physical punishment showed little variation, because it rarely occurred in our sample ( M = 1.23 out of 7, SD = 0.39). PPI positive and PPI negative could vary between 1 and 7, with higher scores indicating more positive or negative parenting practices. Internal consistency of the two newly formed subscales in the current sample was good for PPI positive ( α = 0.83) and acceptable for PPI negative ( α = 0.79). To our knowledge, the validity and reliability of the PPI has not been studied so far. Parenting sense of competence was measured with the Parenting Sense of Competence Scale (PSOC; Johnston & Mash, 1989 ). The PSOC consists of 16 statements (e.g., ‘Being a parent is manageable, and any problems are easily solved.’) divided over the Satisfaction and Efficacy scale, on which parents evaluate their agreement on a 6-point Likert scale (1 = strongly agree, 6 = strongly disagree), where higher total scores represent higher sense of competence. Reliability of the two subscales was acceptable to good, internal consistency of both subscales and concurrent validity of the total PSOC was shown to be acceptable to good (Johnston & Mash, 1989 ; Ohan et al., 2000 ); internal consistency in the current sample was α = 0.82. Parenting stress was measured with the Parenting Stress Index-short form (PSI; Abidin, 1995 ), consisting of 36 items (e.g., ‘Have some doubts about my ability to handle stuff.’) divided over three 12-itemed subscales: Parental Distress, Parent-Child Dysfunctional Interactions and Difficult Child. Parents are asked to evaluate their agreement on a 5-point Likert scale (mostly: 1 = totally disagree, 5 = totally agree; and some alternative answer options), where higher total scores indicate higher parenting stress. Internal consistency was shown to be good to excellent (Abidin, 1995 ) and validity was high (Loyd & Abidin, 1985 ); internal consistency in the current sample was α = 0.87. Parental perception of their child’s externalizing behavior, i.e. the number of behaviors that parents perceived as troublesome, was assessed with the Problem scale of the Eyberg Child Behavior Inventory (ECBI-P; Eyberg, 1999 ; Webster-Stratton, 2001 ), filled out by parents. This scale contains 36 items (e.g., ‘Refuses household chores.’) stating a certain problem behavior. Parents are asked to indicate whether they perceived this behavior as problematic (0 = no, 1 = yes). Psychometric properties of the Problem Scale were shown to be good (Abrahamse et al., 2015 ); internal consistency in the current sample was α = 0.83. 2.4 Data analyses Data were analyzed based on intention-to-treat. Statistical analyses were performed with the Statistical Package for Social Sciences (SPSS version 26; Statistics, 2013 )) and STATA (version 16; StataCorp, 2019 ). In case more than ten percent of the scores on a (sub)scale was missing, the subject was omitted for that (sub)scale. Normality and heterogeneity of the data were inspected visually. Outliers were winsorized if they exceeded three standard deviations from the mean (Blaine, 2018 ). Possible differences in demographic factors at baseline were assessed with univariate ANOVA’s or t-tests (for continuous and ordinal data, respectively) or Fisher’s exact tests (for categorical data). Using regression analyses, data collected from participants assigned to the intervention condition (combined support and no support condition) were compared to data from those assigned to the waitlist condition. Scores on PPI positive and negative and ECBI were analyzed using longitudinal multiple regressions, with observations (level 1) nested within participants (level 2), condition (intervention, waitlist) as between subject variable, and time (T1-T2) as within subject variable. To examine longer term changes, the difference between T2 and T3 was assessed within the intervention condition using within group linear regressions for both scores on PPI and ECBI (because there were no T3 measurements for PSOC and PSI, we could not assess differences between the intervention and waitlist condition at that timepoint). Scores on the PSI and PSOC were analyzed with linear multiple regressions with condition (intervention, waitlist) as independent variable and T2 measurements as outcome measures (as there were no T1 measures for these outcomes). To adjust for scores at baseline, baseline measurements (T0) were added as fixed factor in the (longitudinal) regressions. Effect sizes were calculated by dividing the b-coefficients of the effect by the pooled standard deviation of the outcome measure (Cohen’s d; Cohen, 1992 ). To exploratively compare the self-help program with and without additional support, between group analyses were repeated comparing the support versus the no support condition at T2 and T3. Significance levels were set at α = .05 for all analyses, except for the analyses regarding the two PPI scales, where a significance level of α = .025 was used, to correct for multiple testing (Bonferroni correction; Abdi, 2007 ). For an a priori power analysis of the multi-level regressions with three time points and two conditions, with a medium effect size, a total sample size of 113 was needed (see De Jong et al., 2023 ). 3. Results 3.1 Participants Primary parents had a mean age of 40.56 years ( SD = 5.31) and 101 (91.8%) of them were female. Mean age of the children on whom the parenting program was focused was 8.17 years ( SD = 2.29) and 80 of them were boys (72.7%). Primary parent and child characteristics per condition are depicted in Table 1 . No significant differences were found in primary parent and child characteristics between the intervention and waitlist condition p > .054 (nor between the support and the no support condition, p >. 281; See Online Resource 1, Table S1 ). Table 1 Primary Parent and Child Characteristics per Condition Intervention condition ( n = 74) Waitlist condition ( n = 36) Condition comparisons Baseline child characteristics Age in years, M (SD) 8.24 (2.32) 8.14 (2.26) t (108) = − 0.22, p = .829 Sex: boys, n (%) 50 (67.6) 30 (83.3) Fishers’s exact: p = .110 SDQ externalizing, M (SD) a 12.01 (2.24) 11.14 (2.17) t (107) = -1.94, p = .054 ADHD (DISC-IV), n (%) Clinical Subclinical Nonclinical 55 (74.3) 18 (24.3) 1 (1.4) 31 (86.1) 5 (13.9) 0 (0) Fishers’s exact: p = .352 ODD (DISC-IV), n (%) Fishers’s exact: p = .403 Clinical 57 (77.0) 31 (86.1) Subclinical 14 (18.9) 3 (8.3) Nonclinical 3 (4.1) 2 (5.6) Impairment, M (SD) b 6.23 (1.56) 5.93 (1.38) t (108) = -0.25, p = .579 Psychotropic medication, n (%) c 16 (21.6) 12 (33.3) Fishers’s exact: p = .244 Baseline primary parent characteristics Age in years, M (SD) 40.68 (4.88) 40.32 (6.21) t (101)=-0.32, p = .747 Sex: females, n (%) 68 (91.9) 33 (91.7) Fishers’s exact: p = 1.000 Education Level, M (SD) d 5.15 (1.04) 4.88 (1.07) t (103) = -1.25, p = .215 Household composition: single parent, n (%) 8 (10.8) 2 (5.6) Fishers’s exact: p = .493 ADHD = attention-deficit/hyperactivity disorder, DISC-IV = Diagnostic Interview Schedule for Children fourth edition, ODD = oppositional defiant disorder, SDQ = Strength and Difficulties Questionnaire , a range: 0–10 b range: 0–20 c intervention condition : 13 methylphenidate, 1 dexamphetamine, 1 lisdexamphetamine, 1 aripiprazole; Waitlist condition : 12 methylphenidate; d percentage of parents with: no education or primary education 1.9% ; lower or upper secondary education: 26.7%,; (under)graduate or post graduate: 71.4%. 3.2 Main analyses (parenting program versus waitlist condition) Means and standard deviations of the outcomes per time point and condition are shown in Online Resource 2, Table S2. Results regarding parental outcomes are displayed in Fig. 3 – 6 . Regarding PPI, compared to parents in the waitlist condition, parents in the intervention condition scored significantly higher on PPI positive ( B(SE) = 0.25 (0.07), p = .001) and significantly lower on PPI negative ( B(SE)= - 0.35 (0.09), p < .001) at T2, translating in a medium effect size ( d = 0.53 and d = -0.61 respectively). This indicates that the self-help parenting program led to an increase in positive and a decrease in negative parenting practices. PPI scores of parents in the intervention condition showed no significant changes between T2 and T3 for PPI positive ( B(SE) = -0.06, (0.06), p = .271) nor for PPI negative ( B(SE) = 0.07 (0.08), p = .378), indicating persistence of the changes. PSOC scores of parents in the intervention condition did not significantly differ from scores of parents in the waitlist condition ( B(SE) = 2.16 (1.50), p = .153, d = 0.22) at T2, meaning that the self-help parenting program did not influence parenting sense of competence. Regarding PSI, compared to waitlist, parents in the intervention condition showed a lower score at T2 ( B(SE) = -5.02 (2.28), p = .030), translating in a small effect size ( d = -0.28). This indicates that the self-help parenting program led to a decrease in parenting stress. ECBI-p scores of parents in the intervention conditions, compared to parents in the waitlist condition, were lower at T2 ( B(SE) = -3.72, (1.19), p = .002) translating in a small effect size ( d = -0.45), indicating a decrease in the amount of behaviors parents perceived as troublesome. ECBI-p scores of parents in the intervention condition did not significantly change between T2 and T3 ( B(SE) = -1.26 (0.85), p = .138), indicating persistence of the change. Explorative comparisons between the support and no support conditions (see Online Resource 3: Table S3 and Figure S1 -S4) showed no significant differences on any of the outcome measures at T2 (PPI, ECBI, PSOC and PSI; p ≥ .145) nor at T3 (PPI and ECBI; p ≥ .555). 4. Discussion The present study aimed to investigate the efficacy of a newly developed self-help parenting program on parental outcomes. Our results showed that the program improved parenting practices (i.e. let to more positive and less negative parenting practices; medium effect sizes), improved parental perceptions of their child’s externalizing behavior (small effect size), and reduced parenting stress (small effect size). No significant effect was found on parenting sense of competence. Improvements in parenting practices and parental perceptions of their child’s externalizing behavior remained stable up to three months after the intervention period, suggesting perseverance of intervention gains. Additional bi-weekly protocolized telephonic support yielded no differences in outcomes as compared to the self-help program without support. Our finding that the intervention has positive effects on parenting practices is in line with previous research on self-help parenting programs, which mainly studied the use of negative parenting practices such as harsh discipline, overreactivity and laxness (Tarver et al., 2014 ; Thongseiratch et al., 2020 ). Studies on face-to-face parenting programs showed, in line with our findings, medium sized improvements in negative parenting as well as positive parenting (Dekkers et al., 2022 ; Weber et al., 2019 ). Showing that a parenting program elicits changes in parenting practices is important, as in parent training, parents are the proposed mediators of changes in child externalizing behaviors (Forehand et al., 2014 ; Gardner et al., 2006 ; Van der Oord & Tripp, 2020 ). In contrast to previous research (Tarver et al., 2014 ), our study showed no beneficial effects of the self-help parenting program on parenting sense of competence. This might be explained by the group of parents included in the current study, who were self-enrolled in the intervention and already showed relatively high levels of confidence about their parenting before the start of the program (scores were comparable or higher than those of parents in a normative sample (Johnston & Mash, 1989 ; Ohan et al., 2000 ). These high levels may have limited the ‘room for improvement’, although this was also the case in other studies regarding self-help parenting programs (e.g. Daley & O’Brien, 2013 ; Markie-Dadds & Sanders, 2006 ) and in face-to-face programs (e.g. Bodenmann et al., 2008 ; Cunningham et al., 1995 ; Lange et al., 2018 ). Possibly, high parenting sense of competence may have motivated these parents to seek for self-help. Indeed, a previous study on a face-to-face parenting program showed that parent training was more effective, when parents had higher parenting sense of competence before they received the training (van den Hoofdakker et al., 2010 ). Further research should study whether parenting sense of competence influences the efficacy of a self-help parenting program. Our findings regarding parenting stress (small effect) did confirm earlier findings regarding positive effects on parenting stress after a self-help parenting program (Tarver et al., 2014 ) and face-to-face parent training (Dekkers et al., 2022 ; Lundahl et al., 2006 ). Our findings should, however, be interpreted with caution as beneficial effects were only obtained on one of the three subscales of the PSI, assessing child problem behavior (subscale ‘difficult child’). The improvement on parenting stress might therefore primarily reflect an improvement in child problem behavior, rather than the more broad concept of parenting stress (Abidin, 1995 ). The absence of effect on the subscales ‘parental stress’ and ‘parent-child dysfunctional interactions’ could not be explained by initial stress levels, because relatively high stress levels were observed in our study as compared to other populations of parents of children with externalizing behavior (Mackler et al., 2015 ), and observed stress levels were comparable to clinically referred children with externalizing behavior (Jones et al., 2017 ). Reducing parenting stress is important, because parenting stress and child behavioral problems seem bidirectionally related (Neece et al., 2012 ; Theule et al., 2013 ), and parenting stress is negatively related to parent-child interaction (Farmer & Lee, 2011 ) which can lead to a negative vicious cycle. It might be speculated that a reduction in parental stress may take more time and will only become evident sometime after behavioral problems are reduced. Improvement in parental perceptions of their child’s externalizing behavior in our study is in line with previous studies on self-help parenting programs (Baumel et al., 2016 ; De Graaf et al., 2008 ; Letarte et al., 2010 ). Improvement of parental perceptions are important, because negative perceptions are associated with negative parenting and with parenting stress (Dix et al., 1986 ; Mikami et al., 2015 ; Van der Oord et al., 2006 ). However, the perception of whether child behavior is perceived as problematic is also dependent on the occurrence of this behavior, which decreased significantly after parents followed the self-help program (De Jong et al., 2023 ). This interpretation is confirmed by a validation study of the ECBI (Abrahamse et al., 2015 ), that showed a correlation of 0.62–0.67 between the ECBI problem scale, which we used to measure parental perception of externalizing child behavior, and the ECBI intensity scale, which measures the severity of behavior problems. Thus, further studies are needed to investigate if self-help parenting programs change parents’ general attitudes towards the child, not only towards problem behavior (see for example Renk et al., 2007 ). No differences on any of the parenting outcomes were found between the format with and without additional telephonic support, which was in line with our findings on child outcomes ( De Jong et al., 2023 ). Previous studies, however, suggested a beneficial effect of additional support on both parenting practices and parental wellbeing (Tarver et al., 2014 ). Additional support in those studies was provided in terms of online feedback, supportive phone calls or automatic reminders (Tarver et al., 2014 ; Thongseiratch et al., 2020 ). A stronger improvement on parenting practices and decrease in parental stress after additional support might have been expected in our study, because during the supportive phone calls parents were motivated, could ask questions and were given support with some critical aspects of the parenting program. Limitations and further research Some limitations should be discussed. First, the PPI might be susceptible to expectancy effects in the intervention conditions, because most techniques included in the questionnaire were addressed in the parenting program. It might therefore be that parents in the intervention condition reported more positive and less negative parenting practices than parents in the waitlist condition because parents in the waitlist condition were not familiar with the techniques before. Alternatively, including objective (observational) measures of parenting practices was considered too invasive for the current study, given the easily accessible nature of the training program. Future research might include an (online) observation of parenting behavior (e.g., Oliver & Pike, 2021 ). Second, it might be that the absence of a difference in efficacy between the two versions of our program is related to a lack of statistical power for this head-to-head comparison. Power calculations to determine sample size were based on medium effect sizes, which were expected for the intervention versus waitlist comparison, but not for the comparison between the intervention with versus without telephonic support. For this explorative comparison no power analysis was performed. Further research should study the differences between the two formats in a larger sample. Third, results of the follow-up measurements (T3) of the ECBI and PPI should be interpreted with caution, because a relatively high proportion of data was missing and the results on this time point could not be compared to waitlist. Future research should replicate the longer term findings. Fourth, the specific characteristics of our sample, might limit generalization of the findings. Our sample was relatively highly educated, which is not representative for parents of children with externalizing behavior (McGrath & Elgar, 2015 ); had mainly a non-migration background and consisted mostly of mothers. These factors could have influenced effectivity of our program (Daglar et al., 2011 ; Nauck & Lotter, 2015 ; Salami et al., 2017 ). Furthermore, parents were self-enrolled in the study, and showed high levels of confidence regarding their parenting, which might have resulted in a sample of highly motivated and self-efficacious parents. Future research should aim to include broader samples of parents in terms of education and migration background. Also, studies examining whether similar effects are obtained when offering the program in clinical mental health settings are warranted. Lastly, thus far, we studied child outcomes and parental outcomes separately. Future research, may study the changes in parental outcomes as a mediator for changes in child outcomes and may look at possible moderators that influence this mediating role, to be able to better understand the possible mechanisms underlying improvements in child behavior. Previous studies found that either changes in parenting practices (Forehand et al., 2014 ) or parenting sense of competence (Rimestad et al., 2020 ) mediated improvements in child externalizing behavior after parent training. Implications/Conclusion We showed that a newly developed self-help program improved parenting practices, in particular increasing the use of positive and reducing the use of negative parenting skills, and improving parental perception of their child’s externalizing behavior. These findings are in addition to improvements in child behavior, as found in our previous study (De Jong et al., 2023 ), and highly comparable to previous findings regarding self-help parenting programs (Tarver et al., 2014 ; Thongseiratch et al., 2020 ), as well as face-to-face parenting programs (Dekkers et al., 2022 ; Kaminski et al., 2008 ; Lundahl et al., 2006 ). Exploratively analyses showed no differences between the program offered with and without additional support (biweekly phone calls), although these findings should be interpreted with caution due to a possible lack of power. Based on our findings, self-help parenting programs may be a promising alternative for face-to-face programs to improve parental outcomes, although future studies should focus on determining for whom and in which settings which parenting programs are most helpful. Declarations Conflicts of interest Barbara van den Hoofdakker receives royalties as one of the editors of “Sociaal Onhandig” (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training. She is and has been involved in the development and evaluation of several parent and teacher training programs, without financial interests; she is and has been a member of Dutch ADHD guideline and practice standard groups. Marjolein Luman is and has been involved in the development and evaluation of parent and teacher training programs, without financial interests, and has been an advisor for the Dutch ADHD guideline and practice standard group. Betty Veenman has been involved in the development and evaluation of parent and teacher training programs, without financial interests. Lianne van der veen-Mulders receives royalties as one of the editors of “Sociaal Onhandig” (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training. Suzanne de Jong and Jaap Oosterlaan have no relevant financial or non-financial interest to disclose. Funding This work was supported by The Netherlands Organization for Health Research and Development (ZonMw), grant number 737200015, and by Stichting Kinderpostzegels. Author Contributions Study conceptualization and design was performed by Suzanne de Jong, Marjolein Luman, Barbara van den Hoofdakker and Jaap Oosterlaan. Intervention development was done by Suzanne de Jong, Marjolein Luman, Barbara van den Hoofdakker, Betty Veenman and Lianne van der Veen Mulders. Data collection was performed by Suzanne de Jong. Analyses were performed by Suzanne de Jong, under supervision of Marjolein Luman, Barbara van den Hoofdakker and Jaap Oosterlaan. The first draft of the manuscript was written by Suzanne de Jong and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Abdi, H. (2007). Bonferroni and Šidák corrections for multiple comparisons. Encyclopedia of measurement and statistics , 3 , 103-107. Abidin, R. (1995). Parenting Stress Index (PSI) manual 3rd edition. Odessa, FL: Psychological Assessment Resources . Abrahamse, M. E., Junger, M., Leijten, P. H., Lindeboom, R., Boer, F., & Lindauer, R. J. (2015). Psychometric properties of the Dutch Eyberg Child Behavior Inventory (ECBI) in a community sample and a multi-ethnic clinical sample. Journal of Psychopathology and Behavioral Assessment , 37 (4), 679-691. Anderson, D., Lord, C., Risi, S., DiLavore, P., Shulman, C., Thurm, A., & Pickles, A. (2017). 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Wet medisch-wetenschappelijk onderzoek met mensen (WMO, 2018), retrieved from: https://wetten.overheid.nl/BWBR0009408/2021-07-01 at March 29, 2023 Yan, N., Ansari, A., & Peng, P. (2021). Reconsidering the relation between parental functioning and child externalizing behaviors: A meta-analysis on child-driven effects. Journal of Family Psychology , 35 (2), 225. Additional Declarations Competing interest reported. Barbara van den Hoofdakker receives royalties as one of the editors of “Sociaal Onhandig” (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training. She is and has been involved in the development and evaluation of several parent and teacher training programs, without financial interests; she is and has been a member of Dutch ADHD guideline and practice standard groups. Marjolein Luman is and has been involved in the development and evaluation of parent and teacher training programs, without financial interests, and has been an advisor for the Dutch ADHD guideline and practice standard group. Betty Veenman has been involved in the development and evaluation of parent and teacher training programs, without financial interests. Lianne van der veen-Mulders receives royalties as one of the editors of “Sociaal Onhandig” (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training. Suzanne de Jong and Jaap Oosterlaan have no relevant financial or non-financial interest to disclose. Supplementary Files ESM1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3973243","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274052084,"identity":"7c56e7a8-f0a2-43ef-b5ae-e272ebcf9c71","order_by":0,"name":"S. R. 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Schulz et al., 2010)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/3fb797a91f4799609fcb3228.jpg"},{"id":51562103,"identity":"d87efe6a-ace6-4c61-8ae6-d4796f8cddaf","added_by":"auto","created_at":"2024-02-23 18:29:46","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20568,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig 3a\u003c/strong\u003e \u003cem\u003eMean PPI Positive Scores for the Intervention and Waitlist Conditions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: PPI = Parenting Practices Interview, range: 1-7, error bars show standard error, corrections for baseline were not taken account in this graph.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3a.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/e68ddbea0f08cb87031b878d.jpg"},{"id":51562107,"identity":"8b890958-f1a9-4b0f-86c1-271497e47339","added_by":"auto","created_at":"2024-02-23 18:29:46","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21298,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig 3b\u003c/strong\u003e \u003cem\u003eMean PPI Negative Scores for the Intervention and Waitlist Conditions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: PPI = Parenting Practices Interview, range: 1-7, error bars show standard error, corrections for baseline were not taken account in this graph.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3b.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/2810f0bab8cfbb6e908d0366.jpg"},{"id":51562105,"identity":"5f05dce4-5cd8-4d4a-a63e-6beab959b3bc","added_by":"auto","created_at":"2024-02-23 18:29:46","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":23779,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig 4\u003c/strong\u003e \u003cem\u003eMean PSOC Scores for the Intervention and Waitlist Conditions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: PSOC = Parenting Sense of Competence Scale, range: 16-96, error bars show standard error, corrections for baseline were not taken account in this graph.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/b15610dd4b604726154e3460.jpg"},{"id":51562102,"identity":"c5e8d522-b67a-4848-b728-5879dc03fbbc","added_by":"auto","created_at":"2024-02-23 18:29:46","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":24070,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig 5\u003c/strong\u003e \u003cem\u003eMean PSI Scores for the Intervention and Waitlist Conditions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: PSI = Parenting Stress Index, range: 0-144, error bars show standard error, corrections for baseline were not taken account in this graph.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/b86fca9e34167dd86c44483e.jpg"},{"id":51562104,"identity":"ac316945-70d7-4040-934d-adf46024bdca","added_by":"auto","created_at":"2024-02-23 18:29:46","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":20948,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig 6\u003c/strong\u003e \u003cem\u003eMean ECBI Problem Scores for the Intervention and Waitlist Conditions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: ECBI = Eyberg Child Behavior Inventory, range: 0-36, error bars show standard error, corrections for baseline were not taken account in this graph.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/3485a0042ba1577c812ea92c.jpg"},{"id":52994929,"identity":"9e4e2ac4-c174-42b7-87ae-d10a84e27a80","added_by":"auto","created_at":"2024-03-19 13:02:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":517766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/9d8e3010-7862-46aa-a990-0e58550fe7af.pdf"},{"id":51562106,"identity":"1c01e5e7-5673-4752-be2f-a97f0a9b7495","added_by":"auto","created_at":"2024-02-23 18:29:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":57123,"visible":true,"origin":"","legend":"","description":"","filename":"ESM1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3973243/v1/75d66de5befe5e4c0cd48574.docx"}],"financialInterests":"Competing interest reported. Barbara van den Hoofdakker receives royalties as one of the editors of “Sociaal Onhandig” (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training. She is and has been involved in the development and evaluation of several parent and teacher training programs, without financial interests; she is and has been a member of Dutch ADHD guideline and practice standard groups. \nMarjolein Luman is and has been involved in the development and evaluation of parent and teacher training programs, without financial interests, and has been an advisor for the Dutch ADHD guideline and practice standard group.\nBetty Veenman has been involved in the development and evaluation of parent and teacher training programs, without financial interests.\nLianne van der veen-Mulders receives royalties as one of the editors of “Sociaal Onhandig” (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training.\nSuzanne de Jong and Jaap Oosterlaan have no relevant financial or non-financial interest to disclose.","formattedTitle":"Efficacy of a Self-help Parenting Program on Parental Outcomes: a Randomized Controlled Trial ","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eParent training is an effective treatment for children with externalizing behavior, such as hyperactive and impulsive behavior, disobedience or temper tantrums (Groenman et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mingebach et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In clinical practice, face-to-face parenting programs are commonly used (e.g., Incredible Years; Webster-Stratton \u0026amp; Reid, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, Behavioral Parent Training Groningen; Van Den Hoofdakker et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), but these are not always easily accessible for parents (De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Koerting et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). In contrast, self-help programs are widely accessible and have shown similar results (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In a recent study ( De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), we examined the efficacy of a newly developed self-help program for parents of children with externalizing behavior. The study showed that the program was efficacious in reducing children\u0026rsquo;s externalizing behavior (primary outcome measure) and that parental satisfaction was high. Because parent training programs are based on the assumption that changing parental behavioral is a prerequisite for changing child behavior (Forehand et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), changes in parenting practices, parental wellbeing (i.e., parenting sense of competence and stress), and perceptions are supposed to be crucial. However, these aspects are understudied in clinical trials, and are important in order to gain insight into possible working mechanisms.\u003c/p\u003e \u003cp\u003eChanging parenting practices is one of the main targets of parent training, in which parents learn behavioral techniques to alter the behavior of their child (Daley et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Both antecedent techniques, which aim at changing behaviors by manipulating their antecedents and consequent techniques, which aim at changing behaviors by manipulating the consequences of behavior (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Leijten et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), have proven to be effective in changing the child\u0026rsquo;s behavior (Hornstra et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).Techniques that especially have proven to be effective in terms of positive effects on child outcomes include increasing positive interactions between child and parent, teaching parents to be consistent, and using mild discipline techniques, such as time out or planned ignoring (Hornstra et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kaminski et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Meta-analytic evidence shows that parenting programs have a positive effect on parenting practices (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Weber et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Regarding self-help parenting programs, a meta-analysis (eight studies), studying the effect of self-help parenting programs for externalizing child behavior on parenting practices, showed a medium sized reduction of negative parenting, i.e. harsh parenting practices and lax or permissive discipline (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). For positive parenting, which was not studied in this meta-analysis, studies into self-help programs are scarce and results are mixed: some studies find an effect of a self-help parenting program on positive parenting (Franke et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kierfeld et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), while others do not (Dose et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Dose et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, two meta-analyses on both face-to-face and self-help parenting programs for children with ADHD (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and children with externalizing behavior (Weber et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) showed both medium-sized effects on positive parenting or a combined measure of positive and negative parenting. The meta analyses of (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) showed that teaching parents to use techniques focusing on reinforcement of desired behavior was in particular related to a decrease of negative parenting practices.\u003c/p\u003e \u003cp\u003eRegarding parental wellbeing, parenting sense of competence has been shown to be positively related to parenting practices (i.e. more positive parenting practices), which may reduce child externalizing behavior (De Haan et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Furthermore, it has been found that stress related to parenting has a transactional relationship with child externalizing behavior, such that child externalizing behavior can lead to more parenting stress and parenting stress in turn can lead to more child externalizing behavior. This is probably due to more negative parent-child interactions when parents experience stress (Mackler et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Yan et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Also, there is evidence that higher levels of parenting stress can lead to a distorted (more negative) perception of the child\u0026rsquo;s (externalizing) behavior (Van der Oord et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). A meta-analysis on self-help parenting programs showed a small effect on parenting stress and a large effect on parenting sense of competence (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). A more recent meta-analysis on online self-help programs studied parental mental health and found small-sized improvements on a combined measure of parenting stress, parenting sense of competence and parenting practices (Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Taken together, these meta-analyses suggest that self-help parenting programs may have positive effects on parental wellbeing.\u003c/p\u003e \u003cp\u003eParent training might also influence parental perception of their child\u0026rsquo;s externalizing behavior. Studies showed that negative perceptions of problem behavior are associated with negative reactions to this type of child behavior (Dix et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1986\u003c/span\u003e; Mikami et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), which could lead to a negative vicious cycle. Randomized controlled trials into parent training showed that parents view disruptive behaviors as less problematic after the intervention (Baumel et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; De Graaf et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Letarte et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRegarding the format of the training, some self-help parenting programs offer additional support during the program, for example by providing online feedback or supportive phone calls (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Such additions may impact the effectiveness of the program. The meta-analysis by Tarver and colleagues (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) showed that after removing those studies that provided additional support, the effect of parenting programs on parenting stress remained unchanged. However, regarding parenting sense of competence, effect sizes reduced from large to medium, and the effect size for negative parenting practices became non-significant. These findings suggest that the effects of parenting programs on some parental outcomes can be enhanced by providing additional support. In our recent study examining efficacy on child outcomes (De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), we exploratively compared two versions of the self-help parenting program, one with and one without biweekly telephonic support. We found no differences in child externalizing behavior between the groups, although this might have been due to a lack of statistical power.\u003c/p\u003e \u003cp\u003eThe aim of the present study was to investigate the efficacy of our self-help program on parenting practices, parenting sense of competence, and parenting stress and on parental perception of their child\u0026rsquo;s behavior. We expected that, compared to waitlist, the self-help parenting program was efficacious in improving these parental outcomes (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Furthermore, we exploratively compared the self-help program with and without additional telephonic support.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Design and procedure\u003c/h2\u003e \u003cp\u003e Recruitment of parents took place through social media, schools, local child support facilities, and a parent association for children with developmental problems. Parents enrolled themselves for the intervention, without referral. We conducted a randomized controlled trial (RCT), see (De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), with three conditions: a) the parenting program with telephonic support (support condition); b) the parenting program without telephonic support (no support condition); and c) a waitlist control condition. The support and no support conditions were combined for the main analyses (referred to as the intervention condition). After providing consent and meeting full inclusion criteria, using a computer-generated random number list, parents were allocated to one of the three conditions (1:1:1 ratio) by blocked randomization, where inclusion time was divided in three equal time periods (resulting in three blocks). Allocation was done by one of the authors (ML) who did not have any contact with the participants.\u003c/p\u003e \u003cp\u003eAll measurements were assessed at baseline (T0) and immediately post-intervention at 15 weeks (T2). In addition, parenting practices and parental perception of their child\u0026rsquo;s externalizing behavior were also assessed eight weeks post baseline (T1) and at three months follow-up (T3). T3 measurements were omitted for participants in the waitlist condition, since they were offered the intervention after T2 and thus during T3. For a visual representation of the design, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe study was conducted between February 2019 and March 2021. Parents could start participation in the study at any week, except for the weeks in which measurements would take place during school holidays (although we decided that during the covid-19 lockdown, parents could start any week, as school- and holiday weeks were then approximately similar in terms of home situation). Parents could participate either alone or together with their partner, if being part of the same household. The primary parent (the parent mostly involved in the study) filled out the questionnaires, possibly together with their partner. After baseline, all participants were allowed to receive (additional) care as usual, if needed.\u003c/p\u003e \u003cp\u003eMedical ethical approval of the study was waived for the medical research with human subjects act (WMO, 2018) by the \u003cem\u003eMedical Ethical Committee of the VU Medical Centre\u003c/em\u003e (#2018.421). The trial was registered in the \u003cem\u003eNetherlands Trial Register\u003c/em\u003e (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.trialregister.nl/trial/8200\u003c/span\u003e\u003cspan address=\"https://www.trialregister.nl/trial/8200\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). CONSORT guidelines were followed to describe the study (Schulz et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003e Parents were included if fulfilling the following criteria: 1) they were seeking help for externalizing behavior displayed by their child; 2) their child was between 4 and 12 years old; 3) their child showed (sub)clinical levels of externalizing behavior at home, as indicated by a) a score above the 80th percentile (i.e. score\u0026thinsp;\u0026gt;\u0026thinsp;6 for children aged 4 or 5 year, or \u0026gt;\u0026thinsp;7 for children aged 6 to 12) on the externalizing behavior scale of the Strengths and Difficulties Questionnaire (SDQ; Maurice-Stam et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Van Widenfelt et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), and b) a (sub)clinical score on the ADHD hyperactivity and/or inattention scale (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;three symptoms subclinical, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e six symptoms clinical) or the ODD scale (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;two symptoms subclinical, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e four symptoms clinical) of the Diagnostic Interview Schedule for Children fourth edition (DISC-IV; Anderson et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Park et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Shaffer et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2004\u003c/span\u003e); 4) their child suffered from impairment due to the child\u0026rsquo;s externalizing behavior, as indicated by a score of 4 or higher on one of the domains of the Impairment Rating Scale (IRS; Fabiano et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Parents were excluded if: 1) they were receiving other parent training during the study or in the preceding six months (we defined parent training as a training aimed at modifying the child\u0026rsquo;s behavior, involving several meetings, teaching the parent techniques and including homework assignments); 2) they had planned to receive other parent counseling or coaching during the study directed at externalizing behavior of the child at home; 3) their child started psychotropic medication or changed medication dose up to three months prior to the study (to rule out any changes in the child\u0026rsquo;s behavior as a result of changes in the use of medication); 4) parents\u0026rsquo; Dutch reading ability was not sufficient to fully understand the program materials; 5) parents went on holiday during the study for more than two weeks (in order to maintain feasibility of completing the program in 15 weeks). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e displays the flow chart of participant inclusion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Materials\u003c/h2\u003e \u003cp\u003e \u003cb\u003eIntervention\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe 15-week self-help parenting program consists of a manual and online program divided in 11 modules. It includes psycho-education regarding externalizing behavior and provides parents with behavioral parenting techniques to modify the externalizing behavior of their child (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hornstra et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kaminski et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). In depth guidance is provided on the behavioral techniques with detailed description of praising, playing with your child in a positive way, providing structure in time and in the child\u0026rsquo;s environment, setting and maintaining clear rules and providing clear instructions, providing rewards, ignoring unwanted behavior, mildly punishing unacceptable behavior, and coping with temper tantrums. The online platform is used to provide examples of the techniques, test parents\u0026rsquo; knowledge and guide parents in making a plan to implement the techniques.\u003c/p\u003e \u003cp\u003e The online program starts with parents selecting child behavior that they perceive as most severe. These problem behaviors remain focus of the self-help parenting program. Furthermore, parents monitor progress, by reporting on their child\u0026rsquo;s behavior and their own parenting confidence, which is visually presented at the start of each module.\u003c/p\u003e \u003cp\u003e Two versions of the parenting program were developed: a version without additional support, and a version with additional support, where parents received manualized, telephonic coaching biweekly. During these phone calls, parents were motivated and monitored and could ask question or discuss problems with implementing the techniques. These phone calls were conducted by trained psychologists (for a description of the intervention in more detail, De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eScreening measures and participant characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFirst, the Externalizing scale of the parent-rated Strengths and Difficulties Questionnaire (Van Widenfelt et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) was used to screen children for eligibility prior to further assessment. The reliability of the externalizing scale is considered acceptable (Di Riso et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Maurice-Stam et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Second, the ADHD and ODD part (module E) of the DSM-IV based structured Diagnostic Interview Schedule for Children (DISC; Shaffer et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) was administered to parents (which we slightly adjusted to be in line with DSM-5 criteria by adding the question whether the child was spiteful or vindictive at least twice within the last six months). Psychometric properties of the ADHD and ODD modules of the DISC are considered good (McGrath et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Schwab-Stone et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). Furthermore, the parent-rated Impairment Rating Scale (IRS; Fabiano et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) was used to assess functional impairment. The IRS consists of eight 11-point Likert scaled items asking parents to what degree the child\u0026rsquo;s behavior problems influence their child\u0026rsquo;s daily life (0\u0026thinsp;=\u0026thinsp;no impact, 10\u0026thinsp;=\u0026thinsp;extreme impact) with higher scores indicating more impairment. Psychometric properties of the IRS are considered good (Fabiano et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBaseline demographic factors (i.e. parent\u0026rsquo;s age, sex, education level) were assessed with a custom made questionnaire (based on guidelines for reporting education level; CBS, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eOutcome measures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParenting practices were measured using the Parenting Practice Interview questionnaire (PPI; Webster-Stratton, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Parents were asked to indicate on a 7-point Likert scale the degree to which they would use a certain parenting practice (for example \u0026lsquo;giving the child a brief time out\u0026rsquo; or \u0026lsquo;praising the child\u0026rsquo;), when the child acts in a certain way (for example \u0026lsquo;misbehaves\u0026rsquo; or \u0026lsquo;doing a good job\u0026rsquo;). To assess positive parenting (PPI positive), we combined the scores on the subscales Appropriate Discipline (12 items), Positive Verbal Discipline (9 items), Praise and Incentives (11 items), and Clear Expectations (6 items), by averaging the mean scores on these subscales. To assess negative parenting (PPI negative), we used the subscale Harsh and Inconsistent Discipline (15 items). The subscales Monitoring and Physical Punishment were omitted, because monitoring was not part of the parenting program and physical punishment showed little variation, because it rarely occurred in our sample (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.23 out of 7, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.39). PPI positive and PPI negative could vary between 1 and 7, with higher scores indicating more positive or negative parenting practices. Internal consistency of the two newly formed subscales in the current sample was good for PPI positive (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.83) and acceptable for PPI negative (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.79). To our knowledge, the validity and reliability of the PPI has not been studied so far.\u003c/p\u003e \u003cp\u003eParenting sense of competence was measured with the Parenting Sense of Competence Scale (PSOC; Johnston \u0026amp; Mash, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1989\u003c/span\u003e). The PSOC consists of 16 statements (e.g., \u0026lsquo;Being a parent is manageable, and any problems are easily solved.\u0026rsquo;) divided over the Satisfaction and Efficacy scale, on which parents evaluate their agreement on a 6-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly agree, 6\u0026thinsp;=\u0026thinsp;strongly disagree), where higher total scores represent higher sense of competence. Reliability of the two subscales was acceptable to good, internal consistency of both subscales and concurrent validity of the total PSOC was shown to be acceptable to good (Johnston \u0026amp; Mash, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; Ohan et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2000\u003c/span\u003e); internal consistency in the current sample was \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.82.\u003c/p\u003e \u003cp\u003eParenting stress was measured with the Parenting Stress Index-short form (PSI; Abidin, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), consisting of 36 items (e.g., \u0026lsquo;Have some doubts about my ability to handle stuff.\u0026rsquo;) divided over three 12-itemed subscales: Parental Distress, Parent-Child Dysfunctional Interactions and Difficult Child. Parents are asked to evaluate their agreement on a 5-point Likert scale (mostly: 1\u0026thinsp;=\u0026thinsp;totally disagree, 5\u0026thinsp;=\u0026thinsp;totally agree; and some alternative answer options), where higher total scores indicate higher parenting stress. Internal consistency was shown to be good to excellent (Abidin, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) and validity was high (Loyd \u0026amp; Abidin, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1985\u003c/span\u003e); internal consistency in the current sample was \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.87.\u003c/p\u003e \u003cp\u003eParental perception of their child\u0026rsquo;s externalizing behavior, i.e. the number of behaviors that parents perceived as troublesome, was assessed with the Problem scale of the Eyberg Child Behavior Inventory (ECBI-P; Eyberg, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Webster-Stratton, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), filled out by parents. This scale contains 36 items (e.g., \u0026lsquo;Refuses household chores.\u0026rsquo;) stating a certain problem behavior. Parents are asked to indicate whether they perceived this behavior as problematic (0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes). Psychometric properties of the Problem Scale were shown to be good (Abrahamse et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e); internal consistency in the current sample was α\u0026thinsp;=\u0026thinsp;0.83.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data analyses\u003c/h2\u003e \u003cp\u003eData were analyzed based on intention-to-treat. Statistical analyses were performed with the Statistical Package for Social Sciences (SPSS version 26; Statistics, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2013\u003c/span\u003e)) and STATA (version 16; StataCorp, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In case more than ten percent of the scores on a (sub)scale was missing, the subject was omitted for that (sub)scale. Normality and heterogeneity of the data were inspected visually. Outliers were winsorized if they exceeded three standard deviations from the mean (Blaine, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Possible differences in demographic factors at baseline were assessed with univariate ANOVA\u0026rsquo;s or t-tests (for continuous and ordinal data, respectively) or Fisher\u0026rsquo;s exact tests (for categorical data).\u003c/p\u003e \u003cp\u003eUsing regression analyses, data collected from participants assigned to the intervention condition (combined support and no support condition) were compared to data from those assigned to the waitlist condition. Scores on PPI positive and negative and ECBI were analyzed using longitudinal multiple regressions, with observations (level 1) nested within participants (level 2), condition (intervention, waitlist) as between subject variable, and time (T1-T2) as within subject variable. To examine longer term changes, the difference between T2 and T3 was assessed within the intervention condition using within group linear regressions for both scores on PPI and ECBI (because there were no T3 measurements for PSOC and PSI, we could not assess differences between the intervention and waitlist condition at that timepoint). Scores on the PSI and PSOC were analyzed with linear multiple regressions with condition (intervention, waitlist) as independent variable and T2 measurements as outcome measures (as there were no T1 measures for these outcomes). To adjust for scores at baseline, baseline measurements (T0) were added as fixed factor in the (longitudinal) regressions. Effect sizes were calculated by dividing the b-coefficients of the effect by the pooled standard deviation of the outcome measure (Cohen\u0026rsquo;s d; Cohen, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1992\u003c/span\u003e). To exploratively compare the self-help program with and without additional support, between group analyses were repeated comparing the support versus the no support condition at T2 and T3. Significance levels were set at α\u0026thinsp;=\u0026thinsp;.05 for all analyses, except for the analyses regarding the two PPI scales, where a significance level of α\u0026thinsp;=\u0026thinsp;.025 was used, to correct for multiple testing (Bonferroni correction; Abdi, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor an a priori power analysis of the multi-level regressions with three time points and two conditions, with a medium effect size, a total sample size of 113 was needed (see De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participants\u003c/h2\u003e \u003cp\u003ePrimary parents had a mean age of 40.56 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.31) and 101 (91.8%) of them were female. Mean age of the children on whom the parenting program was focused was 8.17 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.29) and 80 of them were boys (72.7%). Primary parent and child characteristics per condition are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No significant differences were found in primary parent and child characteristics between the intervention and waitlist condition \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.054 (nor between the support and the no support condition, \u003cem\u003ep\u003c/em\u003e \u0026gt;. 281; See Online Resource 1, Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePrimary Parent and Child Characteristics per Condition\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention condition\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWaitlist\u003c/p\u003e \u003cp\u003econdition\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCondition comparisons\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBaseline child characteristics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years, \u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.24 (2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.14 (2.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e (108)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex: boys, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50 (67.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eFishers\u0026rsquo;s exact: p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ externalizing, \u003cem\u003eM (SD)\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.01 (2.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.14 (2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e (107) = -1.94, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD (DISC-IV), \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003cp\u003eClinical\u003c/p\u003e \u003cp\u003eSubclinical\u003c/p\u003e \u003cp\u003e Nonclinical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (74.3)\u003c/p\u003e \u003cp\u003e18 (24.3)\u003c/p\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (86.1)\u003c/p\u003e \u003cp\u003e5 (13.9)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eFishers\u0026rsquo;s exact: p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eODD (DISC-IV), \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eFishers\u0026rsquo;s exact: p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (77.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (86.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubclinical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonclinical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpairment, \u003cem\u003eM (SD)\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.23 (1.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.93 (1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et (108) =\u003c/em\u003e -0.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.579\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychotropic medication, \u003cem\u003en\u003c/em\u003e (%)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eFishers\u0026rsquo;s exact: p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBaseline primary parent characteristics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years, \u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.68 (4.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.32 (6.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e (101)=-0.32, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex: females, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eFishers\u0026rsquo;s exact: p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level, \u003cem\u003eM (SD)\u003c/em\u003e\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.15 (1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.88 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e (103) = -1.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold composition: single parent, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eFishers\u0026rsquo;s exact: p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.493\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eADHD\u0026thinsp;=\u0026thinsp;attention-deficit/hyperactivity disorder, DISC-IV\u0026thinsp;=\u0026thinsp;Diagnostic Interview Schedule for Children fourth edition, ODD\u0026thinsp;=\u0026thinsp;oppositional defiant disorder, SDQ\u0026thinsp;=\u0026thinsp;Strength and Difficulties Questionnaire\u003c/em\u003e, \u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e \u003cem\u003erange: 0\u0026ndash;10\u003c/em\u003e \u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003erange: 0\u0026ndash;20\u003c/em\u003e \u003csup\u003e\u003cem\u003ec\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eintervention condition\u003c/em\u003e: 13 methylphenidate, 1 dexamphetamine, 1 lisdexamphetamine, 1 aripiprazole; \u003cem\u003eWaitlist condition\u003c/em\u003e: 12 methylphenidate; \u003csup\u003e\u003cem\u003ed\u003c/em\u003e\u003c/sup\u003e\u003cem\u003epercentage of parents with: no education or primary education 1.9% ; lower or upper secondary education: 26.7%,; (under)graduate or post graduate: 71.4%.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Main analyses (parenting program versus waitlist condition)\u003c/h2\u003e \u003cp\u003eMeans and standard deviations of the outcomes per time point and condition are shown in Online Resource 2, Table S2. Results regarding parental outcomes are displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Regarding PPI, compared to parents in the waitlist condition, parents in the intervention condition scored significantly higher on PPI positive (\u003cem\u003eB(SE)\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.25 (0.07), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001) and significantly lower on PPI negative (\u003cem\u003eB(SE)= -\u003c/em\u003e0.35 (0.09), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) at T2, translating in a medium effect size (\u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.53 and \u003cem\u003ed\u003c/em\u003e = -0.61 respectively). This indicates that the self-help parenting program led to an increase in positive and a decrease in negative parenting practices. PPI scores of parents in the intervention condition showed no significant changes between T2 and T3 for PPI positive (\u003cem\u003eB(SE)\u003c/em\u003e = -0.06, (0.06), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.271) nor for PPI negative (\u003cem\u003eB(SE)\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.07 (0.08), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.378), indicating persistence of the changes. PSOC scores of parents in the intervention condition did not significantly differ from scores of parents in the waitlist condition (\u003cem\u003eB(SE)\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.16 (1.50), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.153, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.22) at T2, meaning that the self-help parenting program did not influence parenting sense of competence. Regarding PSI, compared to waitlist, parents in the intervention condition showed a lower score at T2 (\u003cem\u003eB(SE)\u003c/em\u003e = -5.02 (2.28), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.030), translating in a small effect size (\u003cem\u003ed\u003c/em\u003e = -0.28). This indicates that the self-help parenting program led to a decrease in parenting stress. ECBI-p scores of parents in the intervention conditions, compared to parents in the waitlist condition, were lower at T2 (\u003cem\u003eB(SE)\u003c/em\u003e = -3.72, (1.19), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002) translating in a small effect size (\u003cem\u003ed\u003c/em\u003e = -0.45), indicating a decrease in the amount of behaviors parents perceived as troublesome. ECBI-p scores of parents in the intervention condition did not significantly change between T2 and T3 (\u003cem\u003eB(SE)\u003c/em\u003e = -1.26 (0.85), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.138), indicating persistence of the change.\u003c/p\u003e \u003cp\u003eExplorative comparisons between the support and no support conditions (see Online Resource 3: Table S3 and Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e-S4) showed no significant differences on any of the outcome measures at T2 (PPI, ECBI, PSOC and PSI; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;.145) nor at T3 (PPI and ECBI; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;.555).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e \u003c/p\u003e \u003cp\u003eThe present study aimed to investigate the efficacy of a newly developed self-help parenting program on parental outcomes. Our results showed that the program improved parenting practices (i.e. let to more positive and less negative parenting practices; medium effect sizes), improved parental perceptions of their child’s externalizing behavior (small effect size), and reduced parenting stress (small effect size). No significant effect was found on parenting sense of competence. Improvements in parenting practices and parental perceptions of their child’s externalizing behavior remained stable up to three months after the intervention period, suggesting perseverance of intervention gains. Additional bi-weekly protocolized telephonic support yielded no differences in outcomes as compared to the self-help program without support.\u003c/p\u003e \u003cp\u003eOur finding that the intervention has positive effects on parenting practices is in line with previous research on self-help parenting programs, which mainly studied the use of negative parenting practices such as harsh discipline, overreactivity and laxness (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Studies on face-to-face parenting programs showed, in line with our findings, medium sized improvements in negative parenting as well as positive parenting (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Weber et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Showing that a parenting program elicits changes in parenting practices is important, as in parent training, parents are the proposed mediators of changes in child externalizing behaviors (Forehand et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Gardner et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Van der Oord \u0026amp; Tripp, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast to previous research (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), our study showed no beneficial effects of the self-help parenting program on parenting sense of competence. This might be explained by the group of parents included in the current study, who were self-enrolled in the intervention and already showed relatively high levels of confidence about their parenting before the start of the program (scores were comparable or higher than those of parents in a normative sample (Johnston \u0026amp; Mash, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; Ohan et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). These high levels may have limited the ‘room for improvement’, although this was also the case in other studies regarding self-help parenting programs (e.g. Daley \u0026amp; O’Brien, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Markie-Dadds \u0026amp; Sanders, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) and in face-to-face programs (e.g. Bodenmann et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Cunningham et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Lange et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Possibly, high parenting sense of competence may have motivated these parents to seek for self-help. Indeed, a previous study on a face-to-face parenting program showed that parent training was more effective, when parents had higher parenting sense of competence before they received the training (van den Hoofdakker et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Further research should study whether parenting sense of competence influences the efficacy of a self-help parenting program.\u003c/p\u003e \u003cp\u003eOur findings regarding parenting stress (small effect) did confirm earlier findings regarding positive effects on parenting stress after a self-help parenting program (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and face-to-face parent training (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lundahl et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Our findings should, however, be interpreted with caution as beneficial effects were only obtained on one of the three subscales of the PSI, assessing child problem behavior (subscale ‘difficult child’). The improvement on parenting stress might therefore primarily reflect an improvement in child problem behavior, rather than the more broad concept of parenting stress (Abidin, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). The absence of effect on the subscales ‘parental stress’ and ‘parent-child dysfunctional interactions’ could not be explained by initial stress levels, because relatively high stress levels were observed in our study as compared to other populations of parents of children with externalizing behavior (Mackler et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), and observed stress levels were comparable to clinically referred children with externalizing behavior (Jones et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Reducing parenting stress is important, because parenting stress and child behavioral problems seem bidirectionally related (Neece et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Theule et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), and parenting stress is negatively related to parent-child interaction (Farmer \u0026amp; Lee, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) which can lead to a negative vicious cycle. It might be speculated that a reduction in parental stress may take more time and will only become evident sometime after behavioral problems are reduced.\u003c/p\u003e \u003cp\u003eImprovement in parental perceptions of their child’s externalizing behavior in our study is in line with previous studies on self-help parenting programs (Baumel et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; De Graaf et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Letarte et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Improvement of parental perceptions are important, because negative perceptions are associated with negative parenting and with parenting stress (Dix et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1986\u003c/span\u003e; Mikami et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Van der Oord et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). However, the perception of whether child behavior is perceived as problematic is also dependent on the occurrence of this behavior, which decreased significantly after parents followed the self-help program (De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This interpretation is confirmed by a validation study of the ECBI (Abrahamse et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), that showed a correlation of 0.62–0.67 between the ECBI problem scale, which we used to measure parental perception of externalizing child behavior, and the ECBI intensity scale, which measures the severity of behavior problems. Thus, further studies are needed to investigate if self-help parenting programs change parents’ general attitudes towards the child, not only towards problem behavior (see for example Renk et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo differences on any of the parenting outcomes were found between the format with and without additional telephonic support, which was in line with our findings on child outcomes ( De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Previous studies, however, suggested a beneficial effect of additional support on both parenting practices and parental wellbeing (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Additional support in those studies was provided in terms of online feedback, supportive phone calls or automatic reminders (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A stronger improvement on parenting practices and decrease in parental stress after additional support might have been expected in our study, because during the supportive phone calls parents were motivated, could ask questions and were given support with some critical aspects of the parenting program.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and further research\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSome limitations should be discussed. First, the PPI might be susceptible to expectancy effects in the intervention conditions, because most techniques included in the questionnaire were addressed in the parenting program. It might therefore be that parents in the intervention condition reported more positive and less negative parenting practices than parents in the waitlist condition because parents in the waitlist condition were not familiar with the techniques before. Alternatively, including objective (observational) measures of parenting practices was considered too invasive for the current study, given the easily accessible nature of the training program. Future research might include an (online) observation of parenting behavior (e.g., Oliver \u0026amp; Pike, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Second, it might be that the absence of a difference in efficacy between the two versions of our program is related to a lack of statistical power for this head-to-head comparison. Power calculations to determine sample size were based on medium effect sizes, which were expected for the intervention versus waitlist comparison, but not for the comparison between the intervention with versus without telephonic support. For this explorative comparison no power analysis was performed. Further research should study the differences between the two formats in a larger sample. Third, results of the follow-up measurements (T3) of the ECBI and PPI should be interpreted with caution, because a relatively high proportion of data was missing and the results on this time point could not be compared to waitlist. Future research should replicate the longer term findings. Fourth, the specific characteristics of our sample, might limit generalization of the findings. Our sample was relatively highly educated, which is not representative for parents of children with externalizing behavior (McGrath \u0026amp; Elgar, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2015\u003c/span\u003e); had mainly a non-migration background and consisted mostly of mothers. These factors could have influenced effectivity of our program (Daglar et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Nauck \u0026amp; Lotter, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Salami et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Furthermore, parents were self-enrolled in the study, and showed high levels of confidence regarding their parenting, which might have resulted in a sample of highly motivated and self-efficacious parents. Future research should aim to include broader samples of parents in terms of education and migration background. Also, studies examining whether similar effects are obtained when offering the program in clinical mental health settings are warranted. Lastly, thus far, we studied child outcomes and parental outcomes separately. Future research, may study the changes in parental outcomes as a mediator for changes in child outcomes and may look at possible moderators that influence this mediating role, to be able to better understand the possible mechanisms underlying improvements in child behavior. Previous studies found that either changes in parenting practices (Forehand et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) or parenting sense of competence (Rimestad et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) mediated improvements in child externalizing behavior after parent training.\u003c/p\u003e "},{"header":"Implications/Conclusion","content":"\u003cp\u003eWe showed that a newly developed self-help program improved parenting practices, in particular increasing the use of positive and reducing the use of negative parenting skills, and improving parental perception of their child’s externalizing behavior. These findings are in addition to improvements in child behavior, as found in our previous study (De Jong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and highly comparable to previous findings regarding self-help parenting programs (Tarver et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Thongseiratch et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), as well as face-to-face parenting programs (Dekkers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kaminski et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Lundahl et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Exploratively analyses showed no differences between the program offered with and without additional support (biweekly phone calls), although these findings should be interpreted with caution due to a possible lack of power. Based on our findings, self-help parenting programs may be a promising alternative for face-to-face programs to improve parental outcomes, although future studies should focus on determining for whom and in which settings which parenting programs are most helpful.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBarbara van den Hoofdakker receives royalties as one of the editors of \u0026ldquo;Sociaal Onhandig\u0026rdquo; (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training. She is and has been involved in the development and evaluation of several parent and teacher training programs, without financial interests; she is and has been a member of Dutch ADHD guideline and practice standard groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMarjolein Luman is and has been involved in the development and evaluation of parent and teacher training programs, without financial interests, and has been an advisor for the Dutch ADHD guideline and practice standard group.\u003c/p\u003e\n\u003cp\u003eBetty Veenman has been involved in the development and evaluation of parent and teacher training programs, without financial interests.\u003c/p\u003e\n\u003cp\u003eLianne van der veen-Mulders receives royalties as one of the editors of \u0026ldquo;Sociaal Onhandig\u0026rdquo; (published by Van Gorcum), a Dutch book for parents of children with ADHD or PDD-NOS that can be used in parent training.\u003c/p\u003e\n\u003cp\u003eSuzanne de Jong and Jaap Oosterlaan have no relevant financial or non-financial interest to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by The Netherlands Organization for Health Research and Development (ZonMw), grant number 737200015, and by Stichting Kinderpostzegels.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conceptualization and design was performed by Suzanne de Jong, Marjolein Luman, Barbara van den Hoofdakker and Jaap Oosterlaan. Intervention development was done by Suzanne de Jong, Marjolein Luman, Barbara van den Hoofdakker, Betty Veenman and Lianne van der Veen Mulders. Data collection was performed by Suzanne de Jong. Analyses were performed by Suzanne de Jong, under supervision of Marjolein Luman, Barbara van den Hoofdakker and Jaap Oosterlaan. The first draft of the manuscript was written by Suzanne de Jong and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdi, H. (2007). Bonferroni and \u0026Scaron;id\u0026aacute;k corrections for multiple comparisons. \u003cem\u003eEncyclopedia of measurement and statistics\u003c/em\u003e,\u003cem\u003e 3\u003c/em\u003e, 103-107. \u003c/li\u003e\n\u003cli\u003eAbidin, R. (1995). 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Reconsidering the relation between parental functioning and child externalizing behaviors: A meta-analysis on child-driven effects. \u003cem\u003eJournal of Family Psychology\u003c/em\u003e,\u003cem\u003e 35\u003c/em\u003e(2), 225. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"externalizing behavior, self-help intervention, parents, parenting practices, parental well-being","lastPublishedDoi":"10.21203/rs.3.rs-3973243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3973243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe efficacy of our newly developed self-help parenting program on children\u0026rsquo;s externalizing behavior was recently shown. The present study investigated its efficacy on parental outcomes, which is understudied in clinical trials. Using a randomized controlled trial, 110 parents were allocated to an intervention condition (either with or without telephonic support) or a waitlist condition. Outcomes included the Parenting Practices Interview (PPI; positive and negative parenting practices), Parenting Sense of Competence Scale (PSOC), Parenting Stress Index (PSI) and Eyberg Child and Behavior Inventory - Problem Scale (ECBI-P; the number of child behaviors that parents perceive as troublesome). All measures were collected at baseline (T0) and post intervention (after 15 weeks, T2); PPI and ECBI-P were also collected at week 8 (T1) and 28 (T3). Using longitudinal multi-level regression analyses, we compared the intervention and waitlist condition at T2. Furthermore, the support and no support conditions were exploratively compared at T2 and T3. Comparing intervention to waitlist, results showed medium-sized effects on PPI and ECBI-P scores and a small-sized effect on PSI scores, and no differences between the conditions on PSOC scores. No differences were found between the support and the no-support condition. The results indicate that our self-help program improved parenting practices and parents\u0026rsquo; perception of child behavior, in addition to previous findings on child outcomes. This confirms that self-help parenting programs may be a promising alternative to face-to-face programs, although future studies should focus on determining for whom and in which settings which parenting programs are most helpful..\u003c/p\u003e","manuscriptTitle":"Efficacy of a Self-help Parenting Program on Parental Outcomes: a Randomized Controlled Trial ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-23 18:29:41","doi":"10.21203/rs.3.rs-3973243/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"295604fd-c3b4-46ea-a41d-996b7f221c19","owner":[],"postedDate":"February 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-19T12:54:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-23 18:29:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3973243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3973243","identity":"rs-3973243","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}