Two-year Follow-up of Internet-based Parent Training with Telephone Coaching Aimed at Treating Child Disruptive Behaviors in a Clinical Setting during the COVID-19 Pandemic

Two-year Follow-up of Internet-based Parent Training with Telephone Coaching Aimed at Treating Child Disruptive Behaviors in a Clinical Setting during the COVID-19 Pandemic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Two-year Follow-up of Internet-based Parent Training with Telephone Coaching Aimed at Treating Child Disruptive Behaviors in a Clinical Setting during the COVID-19 Pandemic Saana Sourander, Minja Westerlund, Amit Baumel, Susanna Hinkka-Yli-Salomäki, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4170561/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 Background: There is a lack of studies examining the long-term outcomes of internet-based parent training programs implemented in clinical settings during the COVID-19 pandemic. Objective: To study two-year outcomes of families with 3–8-year-old children referred from family counseling centers to the Finnish Strongest Families Smart Website (SFSW), which provides digital parent training with telephone coaching aimed at treating child disruptive behaviors. Methods Counseling centers in Helsinki identified 50 3–8-year-old children with high levels of disruptive behavioral problems. Child psychopathology and functioning as well as parenting styles and parental mental health were reported by parents at baseline, posttreatment and at 6-, 12- and 24-month follow-ups. Results The SFSW program had positive long-term effects on child psychopathology and parenting skills. Improvements in child psychopathology, including Strengths and Difficulties Questionnaire (SDQ) total score (Cohen’s d = 0.47, p < .001), SDQ conduct scores (Cohen’s d = 0.65; p < .001) and Affective Reactivity Index (ARI) irritability scores (Cohen’s d = 0.52; p < .001) were maintained until the 24-month follow-up. Similarly, treatment effects of parenting skills measured with the Parenting Scale, including overreactivity (Cohen’s d = 0.41; p = .001) and laxness (Cohen’s d = 0.26; p = .021), were maintained until the 24-month follow-up. Parent training did not have a long-term effect on parental hostility (Cohen’s d = − 0.04; p = .70). Conclusions: The study shows that the SFSW parent training program can yield significant long-term benefits. Findings indicate that the benefits of the treatment may vary between different parenting profiles, which is important to consider when developing more personalized parenting interventions. parent training disruptive behavior child psychopathology child functioning internet-based family counseling Figures Figure 1 Introduction There is growing evidence from randomized controlled trials (RCTs) that parents can be trained to intervene and reduce child disruptive behaviors and improve their parenting skills [ 1 – 3 ]. Parent training has been found to be the most effective way to prevent and treat disruptive behaviors among children [ 4 – 6 ] and is considered one of the most-validated therapeutic techniques in child mental health [ 7 ]. In the face of the unmet need for accessible evidence-based treatment programs to tackle early-onset childhood disruptive behaviors, digitally administered remote treatments provide solutions that require fewer personnel, that may be less stigmatizing and that can reach geographically remote areas [ 8 , 9 ]. Examining long-term outcomes of an intervention is an essential step in ensuring the sustainability of its effects. However, to our knowledge, there are no long-term follow-ups (i.e., more than 12 months) of digital parent training interventions in clinical settings. The Finnish Strongest Families Smart Website (SFSW) intervention is an 11-week program that includes parent training delivered through an interactive online platform and assisted by weekly telephone coaching. Previously, we conducted a randomized controlled trial (RCT), screening families at regular health check-ups for 4-year-old children, targeting children who had parent-reported high levels of disruptive behavior. The sample included 232 children in each study group, an intervention group and an educational control group. At a 24-month follow-up after randomization, the results maintained efficacy in reducing a wide range of child psychopathology (e.g., The Child Behavior Checklist externalizing score Cohen’s d = 0.22; p < .001) and improving parenting skills (e.g., parental laxness Cohen’s d = 0.33; p < .001; parental overreactivity Cohen’s d = 0.26; p < .001) [ 10 ]. The present study extends the current knowledge on the long-term effects by evaluating the outcomes of families participating in the SFSW parent training program in a clinical setting at baseline and at 12- and 24-months after baseline. A unique aspect of this study is that the SFSW parent training program was administered to the study cohort during the worst phase of the COVID-19 pandemic, when the Helsinki capital region was partially isolated from other parts of Finland. Other services were severely limited, albeit the need of services was great. Due to the crisis, it was considered ethically inappropriate to conduct a randomized controlled study design in this study. The 6-month follow-up findings of this program were very promising and have been reported previously [ 11 ]. There were significant changes in most of the child psychopathology measures, including the CBCL externalizing score (95% CI 4.9–9.0; P < .001), and when parenting skills were measured with the Parenting Scale (PS), the results showed significant changes in the total score (095% CI 0.4–0.7; P < .001) [ 11 ]. Our aim with this paper is to report long-term changes in children’s functioning, psychopathology levels, parenting skills and wellbeing from baseline until the 24-month follow-up. We hypothesized that the previously reported positive effects of the SFSW at the 6-month follow-up [ 11 ] would be at least partly maintained at the 24-month follow-up. Methods Study Population The study focused on families with children between the ages of 3 and 8 years who exhibited elevated levels of disruptive behavior when screened by professionals from eight different family counseling centers in Helsinki. Family counseling centers operate under social services and provide low-threshold services. The centers contribute to child development by reinforcing parenting skills and family relationships. They provide direct support, offer advice to assisting services, and facilitate referrals to specialized services. At family counseling centers, parent training that addresses child-rearing challenges is offered through individual or group sessions. During the pandemic lockdowns, face-to-face sessions were not possible, underscoring the importance of remote support methods. Professionals from the counseling centers selected families suitable for the remotely administered SFSW parent training program. Study design Ethical approval for the study was received from the University of Turku, and the study also received a research permit from the city of Helsinki. This is a single-group study design with repeated measurements. Parents completed questionnaires at baseline, posttreatment and at 6, 12 and 24 months after starting the program. The study encompassed 50 families and took place from May 2020 to November 2022. Earlier findings comparing baseline, posttreatment and 6-month follow-up results have been reported previously [ 11 ]. Recruitment, eligibility and procedure The professionals identified children with high levels of disruptive behavior problems. In addition, parents completed the Strengths and Difficulties Questionnaire (SDQ) [ 12 , 13 ] and were included if their child had a high level of conduct problems (≥ 5 points in the SDQ Conduct scale) and if the parents perceived their child to have difficulties concerning emotions, behavior or social interactions based on one item inquiring parents about these aspects. Additionally, inclusion in the study required at least one parent to be a native Finnish or Swedish speaker with access to both a telephone and a device with Internet connectivity. Exclusion criteria were if a child had been diagnosed with autism, Down syndrome, fetal alcohol syndrome, an intellectual disability or severe mental disorders. Eligible families were invited to participate. Commencing with the completion of baseline questionnaires, participants progressed through SFSW. Intervention The SFSW parent training program utilized interactive online materials and telephone coaching. The program focused on enhancing skills to improve parent-child relationships, complemented by weekly telephone sessions conducted by trained family coaches—licensed health care professionals, including nurses and public health nurses. All coaching calls were systematically recorded and subjected to random audits by the coach supervisor. Table 1 includes an outline of the weekly themes covered in SFSW. The primary goal was for parents to recognize positive behaviors in their child and respond positively. The second aim was to apply learned skills in everyday situations, utilizing positive methods to reinforce the child’s positive behavior. The end of the program focused on solidifying the application of newfound positive parenting skills in daily life to support the child’s positive behavior. Parents practiced these skills with their child and discussed their progress during weekly telephone calls with their family coach, which were scheduled aiming to ensure sustainability beyond the program’s completion. Table 1 Themes of the SFSW a Internet-based parent training program for children with behavioral problems. Session Goals 1. Notice the good Boost the child’s self-esteem, boost the parent’s self-esteem and change the parent’s view of their child 2. Spread attention around Strengthen the child’s empathy skills 3. Ignore whining and complaining Teach parents self-regulation 4. Prepare for changes Reinforce good daily routines 5. Plan ahead at home Boost the self-esteem of the child and parent and involve the child in planning 6. Chart and stickers Involve the child in planning and reinforce good daily routines 7. Plan ahead outside the home Boost the self-esteem of child and parent and involve the child in planning 8. Working with daycare Help the child to manage and succeed 9. Time out Teach self-regulation and consistency 10. & 11. Problem solving revision and future application of skills Teach parents skills to support child development and prepare for future challenges Booster Remind parents of positive proactive parenting skills a SFSW: Strongest Families Smart Website. Measurements The parents completed online questionnaires at baseline, after the program and at 6-, 12- and 24- months after they had started the program. In addition, demographic details of the family, children, and parents were collected during the screening phase. All of the measurements used in this study have demonstrated adequate reliability and criterion validity metrics and are described more extensively in our previous paper [ 11 ]. For brevity, we mention them briefly below while a comprehensive description is provided as a supplementary material (Appendix A ). Child psychopathology and functioning Child psychopathology was assessed using the Finnish version of the 25-item SDQ [ 12 , 13 ], which measures challenges the child experiences in emotions, behavior, or social interactions [ 14 ]. Perceived difficulties were gauged through a single question regarding challenges in emotions, behavior or social interactions, with response options ranging from no difficulties to severe difficulties. Disruptive behavior was gauged by the externalizing subscale of the Child Behavior Checklist – Parent Report Form (CBCL) for ages 1.5–5 years (99 items) [ 15 ], focusing on an externalizing subscale with 24 items related to attention issues and aggressive behavior along with the CBCL’s total score. Child irritability was measured by the Affective Reactivity Index (ARI), which includes six irritability symptom items and one impairment item [ 16 ]. A 17-item questionnaire, derived from Barkley’s Home Situations Questionnaire [ 17 ], measured the parents’ experiences of their child’s functioning and behavior in daily situations. We used the 24-item Inventory of Callous-Unemotional Traits (ICU) [ 18 ] to assess three precursors of child psychopathy: callousness, uncaring and unemotional traits [ 19 , 20 ]. Parenting, parental mental health and satisfaction The Parenting Scale (PS), a 30-item tool, was used to evaluate three dysfunctional parenting discipline styles: laxness, overreactivity, and verbosity; reflecting rule enforcement, responses to mistakes, and lengthy verbal reactions, respectively [ 21 , 22 ]. We used the 21-item Depression, Anxiety, and Stress Scale (DASS-21) to assess parental stress, anxiety and depression symptoms in the past week [ 23 ]. Statistical analysis Descriptive statistics include numbers and percentages for categorical variables and means and standard deviations for continuous variables. We analyzed the outcome variables using linear mixed-effect models for repeated measurements with time as a within-factor. We used linear contrasts to estimate changes from baseline to 12 and 24 months as well as changes from 12 to 24 months. We included the sex, age and maternal education of the children as covariates in all models. McNemar’s test was applied to test the change in the number of children with a total SDQ score above the 90th percentile (i.e., abnormal range) at baseline and at the 24-month follow-up. The effect sizes of all outcome variables were calculated as T-test effect sizes using Cohen’s d. The statistical analyses were performed using SAS statistical software, version 9.4 (SAS Institute Inc.). RESULTS Participant Characteristics The study comprised 50 families, of which 44 (88%) completed the whole 11-week SFSW program. Twenty-four-month follow-up assessments were obtained from 37 (74%) subjects. As shown in Table 2 , 37 (74%) of the 50 children were boys. Forty-eight (96%) children had definitive or severe behavioral problems at baseline, and only 2 (4%) had minor behavioral problems based on a single item in parent report, “Overall, do you think that your child has difficulties in one or more of the following areas: emotions, behavior or being able to get on with other people?”. In terms of program use, the mean duration of website access per theme was 48.0 minutes (SD 25.6), and the mean duration of the telephone coaching calls per theme was 35.3 minutes (SD 8.8). The total mean duration of the program per theme, including both online materials and telephone coaching, was 83.3 minutes (SD 28.0). Table 2 also presents a comparison between the families who completed the 24-month follow-up and those who did not. The table shows the difference in maternal education—in the non-completer group, mothers were less educated. Table 2 Demographics of enrolled families, and comparison between families completing and those not completing the 24-month follow-up measurements. Demographics All families (n = 50) Families completing the 24-month follow-up (n = 37) Families not completing 24-month follow-up (n = 13) P-value a Parent and Family Characteristics Family structure, n (%) Biological parents 38 (76) 30 (81) 8 (62) .21 One biological parent 11 (22) 6 (16) 5 (38) Other 1 (2) 1 (3) 0 (0) Age (years), mean (SD) Maternal 31.9 (4.3) 31.9 (3.5) 31.6 (6.2) .86 Paternal 32.8 (3.7) 32.3 (3.6) 34.5 (3.7) .10 Maternal educational level b , n (%) College or university degree 38 (78) 31 (86) 7 (54) .047 Lower 11 (22) 5 (14) 6 (46) Paternal educational level c , n (%) College or university degree 32 (70) 23 (66) 9 (82) .46 Lower 14 (30) 12 (34) 2 (18) Mother’s native language, n (%) Finnish 45 (90) 34 (92) 11 (85) .55 Swedish 3 (6) 2 (5) 1 (8) Other 2 (4) 1 (3) 1 (8) Father’s native language d , n (%) Finnish 37 (80) 29 (83) 8 (73) .21 Swedish 3 (7) 1 (3) 2 (18) Other 6 (13) 5 (14) 1 (9) Child Characteristics Sex, n (%) Female 13 (26) 12 (32) 1 (8) .14 Male 37 (74) 25 (68) 12 (92) Age (years), n (%) 3–5 30 (60) 24 (65) 6 (46) .33 6–8 20 (40) 13 (35) 7 (54) Behavioral problems, n (%) Minor 2 (4) 2 (5) 0 (0) .43 Definite 30 (60) 20 (54) 10 (77) Severe 18 (36) 15 (41) 3 (23) a refers to statistical test comparing families completing the 24-month follow-up to those who did not. b 1 missing observation. c 4 missing observations. d 4 missing observations. Long-term Changes in Child and Parenting Measures Descriptive statistics of child psychopathology, child function level, parental skills and parental mental health at baseline and 12 months and 24 months after baseline are presented in Table 3 . A statistical comparison of the different time-points is presented in Table 4 . In terms of child psychopathology, significant improvements between baseline and the 12-month follow-up as well as between baseline and the 24-month follow-up were found in CBCL total scores and externalizing scores; SDQ total scores and most sub-scales (emotional, conduct, hyperactivity and peer and problems); and irritability measured with the ARI scale. At the same time, there was a significant deterioration in CBCL total and externalizing scores and SDQ prosocial behavior scores between the 12-month and 24-month follow-ups. We conducted an additional analysis of 37 (74%) of the 50 parents who completed the SDQ questionnaire both at baseline and at the 24-month follow-up as well as the parent training program. This analysis showed that 30 (81%) of the 37 children had a total SDQ score above the 90th percentile (i.e., abnormal range) at baseline, while only 14 (38%) remained in the abnormal range at the 24-month follow-up (P < .001, McNemar’s test), based on the population sample of 4–16-year-old children [ 12 ]. When using the 80th percentile cut-off point (i.e., abnormal or border range), 36 (97%) children were above the cut-off point at baseline, while the respective figure at the 24-month follow up was 23 (62%), indicating a highly significant change (P < .001, McNemar’s test). When parents were asked about perceived difficulties regarding their child’s behavior problems with a single question—“Overall, do you think that your child has difficulties in one or more of the following areas: emotions, behavior or being able to get on with other people?”—at baseline, 2 (5%) out of 37 had no or minor problems, 20 (54%) had definite problems and 15 (41%) had severe problems. The respective figures at the 24-month follow-up were 14 (38%), 14 (38%) and 9 (24%) (P = .001, McNemar-Bowker test). Among the child psychometric measures, callousness and uncaring improved between baseline and the 12-month follow-up. However, uncaring deteriorated between the 12-month and the 24-month follow-up, and no significant improvement was found between baseline and 24 months. The SFSW parent training program did not have any significant positive association with unemotional traits at the 12-month or the 24-month follow-up. Child functioning in everyday situations (e.g., transitions, dining, home and outside home activities) improved significantly between baseline and both follow-up points. No significant change was observed between the 12- and 24-month follow-up comparisons. Table 3 Child psychopathology, child functioning level, parental skills and parental mental health at baseline and 12 months and 24 months after the baseline (n = 50). Variable Baseline a Mean d (SE) 12 months b Mean (SE) 24 months c Mean (SE) Child psychopathology SDQ e Total 19.8 (1.1) 14.4 (1.3) 15.3 (1.3) Emotional symptoms 3.5 (0.5) 2.1 (0.5) 2.7 (0.5) Conduct problems 7.3 (0.4) 5.1 (0.4) 5.2 (0.5) Hyperactivity 6.8 (0.6) 5.5 (0.7) 5.7 (0.7) Peer problems 2.1 (0.4) 1.5 (0.4) 1.5 (0.5) Prosocial behavior 5.6 (0.5) 6.4 (0.5) 5.8 (0.5) Impact 3.2 (0.4) 2.0 (0.4) 2.7 (0.4) ARI f Irritability 9.3 (0.8) 6.2 (0.8) 6.4 (0.8) CBCL/1.5-5 g Total 61.8 (5.5) 43.8 (5.8) 50.2 (5.9) Externalizing 25.5 (1.9) 18.0 (2.2) 20.2 (2.2) ICU h Total 25.9 (1.8) 22.5 (2.0) 24.1 (2.0) Callousness 8.1 (0.8) 6.2 (0.9) 6.1 (1.0) Uncaring 14.0 (0.8) 12.0 (0.9) 13.3 (0.9) Unemotional 4.2 (0.7) 4.6 (0.7) 5.1 (0.8) Child functioning level Everyday situations Child behavior - total 42.4 (2.7) 33.4 (3.0) 33.6 (3.0) Transition situations 13.9 (1.1) 10.5 (1.1) 11.1 (1.1) Dining situations 7.8 (0.7) 6.7 (0.7) 6.4 (0.7) Situations outside home 10.3 (0.8) 8.0 (0.8) 7.8 (0.8) Home situations 10.3 (0.8) 8.0 (0.9) 8.2 (0.9) Parental skills mean (SE) mean (SE) mean (SE) Parenting scale Total 3.5 (0.1) 3.1 (0.1) 3.2 (0.1) Laxness 2.8 (0.2) 2.4 (0.2) 2.5 (0.2) Overreactivity 4.4 (0.3) 3.6 (0.3) 3.8 (0.3) Hostility 2.2 (0.2) 1.9 (0.2) 2.2 (0.2) DASS-21 i Total 24.4 (3.8) 20.3 (3.9) 23.5 (4.0) Depression 8.2 (1.5) 6.7 (1.5) 7.7 (1.5) Anxiety 2.7 (1.0) 2.9 (1.1) 3.4 (1.2) Stress 13.5 (1.7) 10.6 (1.8) 12.5 (1.9) a Measurements before the program started, b Measurements at 12 months after starting the program, c Measurements at 24 months after starting the program, d Least-squares means, e SDQ = Strengths and Difficulties Questionnaire; f ARI = questionnaire for irritability; g CBCL/1.5-5 = Child behavior checklist for preschool children; h ICU= Inventory of Callous-Unemotional Traits; i DASS-21 = 21-item Depression, Anxiety, and Stress Scale. Table 4 Changes from baseline to 12 months and 24 months after, in child psychopathology, child function level and parental skills. Variable Baseline a to 12 months b Baseline to 24 months c 12 months to 24 months Mean (95% CI) P Value Cohen’s d Mean (95% CI) P Value Cohen’s d Mean (95% CI) P Value Child psychopathology SDQ d Total 5.4 (3.5–7.3) < .001 0.62 4.5 (2.4–6.5) < .001 0.47 -0.9 (-2.1–0.3) .34 Emotional 1.4 (0.7–2.1) < .001 0.43 0.8 (-0.0–1.7) .053 0.21 -0.6 (-1.1 – -0.1) .031 Conduct 2.2 (1.6–2.8) < .001 0.78 2.1 (1.4–2.8) < .001 0.65 -0.1 (-0.7–0.5) .68 Hyperactivity 1.2 (0.5–2.0) .002 0.34 1.0 (0.3–1.8) .008 0.29 -0.2 (-0.8–0.3) .44 Peer 0.6 (0.1–1.0) .018 0.25 0.6 (0.1–1.2) .025 0.24 0.1 (-0.4–0.6) .77 Prosocial e -0.8 (-1.4 – -0.2) .009 -0.27 -0.2 (-0.8–0.4) .45 -0.08 0.6 (0.1–1.1) .024 Impact 1.2 (0.6–1.8) < .001 0.45 0.5 (-0.2–1.1) .15 0.16 -0.7 (-1.3 – -0.2) .012 ARI f Irritability 3.1 (1.9–4.3) < .001 0.57 2.9 (1.7–4.1) < .001 0.52 -0.2 (-1.4–1.0) .71 CBCL/1.5-5 g Externalizing 7.5 (4.7–9.9) < .001 0.66 5.2 (2.4–8.1) .001 0.39 -2.3 (-4.1 – -0.4) .016 Total 17.4 (9.8–25.0) < .001 0.49 11.0 (3.5–18.5) .005 0.32 -6.4 (10.2 – -2.7) .001 ICU h Total 3.4 (0.9–5.9) .008 0.30 1.7 (-0.8–4.2) .17 0.15 -1.7 (-3.7–0.4) .11 Callousness 1.9 (0.6–3.2) .004 0.31 1.9 (0.5–3.4) .008 0.29 0.0 (-1.2–1.3) .94 Uncaring 2.0 (0.7–3.2) .003 0.33 0.8 (-0.3–1.8) .17 0.15 -1.2 (-2.3 – -0.2) .027 Unemotional -0.4 (-1.0–0.1) .14 -0.16 -0.9 (-1.8–0.0) .044 -0.22 -0.5 (-1.2–0.2) .14 Child’s ability to function Everyday situations (child behavior) Child behavior total 9.1 (5.3–12.9) < .001 0.52 8.9 (4.9–12.8) < .001 0.49 -0.2 (-3.3–3.0) .91 Transition situations 3.4 (2.0–4.9) < .001 0.52 2.8 (1.2–4.4) .001 0.38 -0.6 (-1.7–0.5) .27 Dining situations 1.0 (0.2–1.9) .013 0.28 1.4 (0.6–2.3) .001 0.37 0.4 (-0.4–1.2) .36 Situations outside home 2.3 (1.1–3.4) < .001 0.43 2.6 (1.4–3.7) < .001 0.49 0.3 (-0.7–1.2) .54 Home situations 2.2 (1.1–3.3) < .001 0.45 2.0 (0.9–3.2) .001 0.40 -0.2 (-1.2–0.9) .73 Parental skills Parenting scale Total 0.5 (0.3–0.6) < .001 0.68 0.4 (0.2–0.5) < .001 0.49 -0.1 (-0.2–0.0) .15 Laxness 0.4 (0.1–0.6) .002 0.35 0.3 (0.1–0.5) .021 0.26 -0.1 (-0.4–0.1) .39 Overreactivity 0.8 (0.5–1.1) < .001 0.59 0.6 (0.3–0.9) .001 0.41 -0.2 (-0.4–0.1) .091 Hostility 0.2 (0.0–0.3) .013 0.28 -0.0 (-0.3–0.2) .70 -0.04 -0.2 (-0.5 – -0.0) .031 DASS-21 i Total 4.0 (-0.8–8.9) .10 0.18 0.9 (-4.2–5.9) .73 0.04 -3.2 (-8.3–1.9) .22 Depression 1.5 (-0.7–3.8) .17 0.15 0.6 (-1.4–2.6) .57 0.06 -1.0 (-2.8–0.8) .29 Anxiety -0.2 (-1.7–1.2) .74 0.04 -0.7 (-2.7–1.2) .45 0.08 -0.5 (-2.0–1.0) .51 Stress 2.9 (0.7–5.0) .009 0.29 1.0 (-1.1–3.2) .34 0.10 -1.9 (-4.3–0.6) .14 a Measurement before the program started, b Measurement at 12 months after the program started, c Measurement at 24 months after the program started, d SDQ = Strengths and Difficulties Questionnaire; e Increase in prosocial SDQ subscore indicates improvement. f ARI = questionnaire for irritability; g CBCL/1.5-5 = Child behavior checklist for preschool children; h ICU= Inventory of Callous-Unemotional Traits; i DASS-21 = 21-item Depression, Anxiety, and Stress Scale. Interestingly, there were differences between parenting profiles regarding the long-term changes. Parental overreactivity and laxness improved between baseline and the 12-month follow-up and between baseline and the 24-month follow-up. Parental hostility showed improvement between baseline and the 12-month follow-up but not between baseline and the 24-month comparison. In fact, hostility showed significant deterioration between the 12-month and the 24-month follow-up. We observed no significant association in parental mental health problems, measured with DASS-21, between baseline and either of the follow-ups. Finally, to graphically illustrate the key findings, Figures A–D describe the changes of main outcome measures across time points including posttreatment and at the 6-month follow-up, which has previously been reported in detail [ 11 ]. Of note, the parenting scales and ICU were not measured posttreatment. The figures illustrate that SDQ conduct, and ARI irritability scores exhibited the largest improvement between baseline and posttreatment and further improvement between posttreatment and the 6-month follow-up; the findings at the 12- and 24-month follow-ups were rather stable. Among the ICU measures, callousness and uncaring showed improvement between baseline and the 6-month follow-up. After that, callousness stayed quite stable while uncaring and unemotional showed deterioration. As for the parenting measures, all parenting styles showed improvement between baseline and the 6-month follow-up. After that, overreactivity and laxness were quite stable, while hostility showed deterioration. Discussion Principal Findings To the best of our knowledge, this is the first study on long-term follow-up of digital guided parent training intervention among children referred to treatment from specialized care. The findings mostly complement the previously conducted 6-month follow-up study [ 11 ] by showing that the SFSW program was associated with significant improvements in children’s externalizing symptoms at 12 months and 24 months after baseline. Of note, most of the improvement took place between baseline and posttreatment assessment, and the level of externalizing problems showed stability from the 12- to the 24-month follow-up. The current study’s importance is in demonstrating that digital parent training with weekly remote phone coaching, seems to lead to enduring improvements in disruptive behavior problems in children with severe disruptive behavior problems. The findings align with a 24-month follow-up study of the SFSW program [ 10 , 24 – 26 ], which was utilized as a preventive and early intervention among 4-year-old children, identified through national medical check-ups [ 27 ]. However, since the target group was different, the level of disruptive behavior problems among the children in the present study were much more severe [ 11 ], which suggests the promise of such interventions in supporting populations with different levels of symptom severity. Most comorbidities such as hyperactivity, emotional and peer problems, and child functioning in everyday situations maintained their improvement from baseline to the 12-month and 24-month follow-ups as well. Interestingly, the program seemed to have very clear association with decreased irritability. This novel finding implies that some of the major effects of parent training may be associated with decreasing irritability in parent–child interactions; this requires further research. For some problems, such as callous-unemotional traits, improvement was reported at the 12-month follow-up but not at the 24-month follow-up. Callous-unemotional traits characterize a specific subgroup of children exhibiting early-starting, stable and severe conduct problems. It has been argued that conventional parenting interventions frequently prove ineffective within this subgroup [ 28 , 29 ]. Another important finding was that parenting profiles seemed to have different responses to the parent training program. Improvements in parent overreactivity and laxness were shown both in the comparison between baseline and the 12- and 24-month follow-ups, while parental hostility improved until the 12-month follow-up then deteriorated to the same level as at baseline. It could be interpreted that parental hostility is, in the long run, resistant to parent training programs. There is limited research on the effects of parenting interventions on reducing parental hostility. Parental hostility can have broad impacts within the family, potentially disrupting the ability of one parent to maintain a positive relationship with their child [ 30 ]. There is a significant positive correlation between parent hostility and child aggression, indicating that the more hostile parents are toward others, the more aggressive their children tend to be [ 31 ]. Similar findings regarding conduct problems, callous-unemotional traits and parenting were made in a previous study [ 32 ], where higher levels of parental harshness were related to higher levels of child conduct problems and callous-unemotional traits. Children subjected to abuse resulting from their parents’ aggressive behavior may suffer adverse effects on their self-control and exhibit challenges in impulse control by acting impulsively, speaking before thinking, and demonstrating a reduced capacity to tolerate frustration or cope with failure [ 33 ]. There are also findings showing that parental attitudes play a substantial role in the gradual enhancement of a child’s self-control, exerting a significant impact on the individual [ 31 ]. In cases where parent training proves to be ineffective in the long term in reducing parental hostility, the parent could benefit from receiving personal support or therapy to address this issue. It is likely that more tailor-made and targeted interventions and treatment plans would benefit this subgroup of families, which are at risk to fall into this kind of negative cycle. When the study started in May 2020, Helsinki was grappling with the peak of the COVID-19 pandemic, marked by a state of emergency declared nationwide in Finland. Stringent social distancing measures were enforced in the region to curb the virus’s transmission, significantly affecting families residing in the area. The COVID-19 pandemic has highlighted the importance of exploring remote, digital or digitally assisted solutions for ensuring that young children, and their families, are provided with prompt support for mental health problems. This study demonstrated that technology can provide effective alternatives to traditional face-to-face interventions and can overcome a number of barriers during crises. Technology can be used to provide the right treatment at the right time, with high levels of support and fidelity, providing greater access and convenience, and requiring fewer costs and less time. Limitations It is important to acknowledge certain limitations. The study design did not allow for direct conclusions regarding the program’s efficacy as it lacked an intervention-control group design. However, the COVID-19 pandemic meant that treatment and family counseling services could not be provided in the usual way, and conducting a randomized controlled study design would have been considered ethically inappropriate. The constraints of social distancing, which included school closures, also prevented us from conducting direct observations of parenting, clinical assessments and teacher ratings. Conclusions This study provides strong support for the utility of remotely delivered interventions, which can reach a broader customer base by reaching into people’s homes and schools, thereby enhancing accessibility of services. Incorporating remote interventions into child mental health services also serves as a safeguard during crises situations such as COVID-19. The study shows that remote digital child mental health services bring substantial benefits to families that can last for up to two years. Overall, the study emphasizes that guided digital parent training programs can be a crucial component in developing evidence-based treatment practices for children and families. The study also emphasizes the importance of conducting long-term follow-ups to understand long- term intervention gains. The study results indicate that different parenting profiles and child psychopathology may have varying effects on the long-term outcome of the program. This finding is important when developing personalized parenting interventions for increased impact. Declarations Acknowledgements: We extend our gratitude to the head of Helsinki Family Counselling Centers, Leena Lehikoinen, and all the other professionals from the Family Counseling Centers in Helsinki who contributed to making this study possible. Funding: This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program (grant agreement No. 101020767) and from the Research Council of Finland (decision number: 345546). Competing interest information: Andre Sourander is the founder and director of Digifamilies, a provider of evidence-based treatments to Finnish public health services. The remaining authors have no conflicts of interest to disclose. All authors read and approved the final manuscript. Author Contribution S.S. drafted the original manuscript text. S.S., A.S., T.R and M.K. designed and conducted data collection for the study. M.W. and A.B. contributed to revising and editing the manuscript. S.H-Y-S was the corresponding biostatistician. All authors contributed to editing the manuscript. All authors have read and contributed to editing the final manuscript. 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JAMA Psychiatry. 2016; 73(4): 378–387. https://doi.org/10.1001/jamapsychiatry.2015.3411 Ristkari T, Kurki M, Suominen A, Gilbert S, Sinokki A, Kinnunen M et al (2019) Web-Based Parent Training Intervention With Telephone Coaching for Disruptive Behavior in 4-Year-Old Children in Real-Word Practice: Implementation Study. J Med Internet Res 21(4):e11446. https://doi.org/10.2196/11446 Ristkari T, Mishina K, Lehtola M, Sourander A, Kurki M (2020) Public health nurses' experiences of assessing disruptive behaviour in children and supporting the use of an internet-based parent training programme. Scand J Caring Sci 34(2):420–427. https://doi.org/10.1111/scs.12744 Fleming GE, Neo B, Briggs NE, Kaouar S, Frick PJ, Kimonis ER (2022) Parent Training Adapted to the Needs of Children With Callous–Unemotional Traits: A Randomized Controlled Trial. Behav Ther 53(6):1265–1281. https://doi.org/10.1016/j.beth.2022.07.001 Frick PJ, Ray JV, Thornton LC, Kahn RE (2013) Can Callous-Unemotional Traits Enhance the Understanding, Diagnosis, and Treatment of Serious Conduct Problems in Children and Adolescents? A Comprehensive Review. Psychol Bull 140(1):1–57. https://doi.org/10.1037/a0033076 Newland RP, Ciciolla L, Crnic KA (2015) Crossover Effects Among Parental Hostility and Parent-Child Relationships During the Preschool Period. J Child Fam Stud 1;24(7):2107–2119. https://doi.org/10.1007/s10826-014-0012-7 Yoo SY, Ahn HY (2023) Correlation between Parental Hostility and Child Self-Control and Aggression. Healthc (Basel) 11(17):2433. https://doi.org/10.3390/healthcare11172433 Waller R, Powell T, Rodriguez Y et al (2021) The Impact of the COVID-19 Pandemic on Children’s Conduct Problems and Callous-Unemotional Traits. Child Psychiatry Hum Dev 52(6):1012–1023. https://doi.org/10.1007/s10578-020-01109-y Kim YH, Kim HK (2019) Developmental Pathways to Adjustment Problems in Adolescents: A Comparative Study between Korea and the United States. Korean J Youth Stud 26(6):73–103. https://doi.org/10.21509/KJYS.2019.06.26.6.73 Additional Declarations Competing interest reported. Andre Sourander is the founder and director of Digifamilies, a provider of evidence-based treatments to Finnish public health services. The remaining authors have no conflicts of interest to disclose. All authors read and approved the final manuscript. 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. 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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-4170561","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":287831242,"identity":"26a4ece3-5523-491e-9f57-7af49348cd0f","order_by":0,"name":"Saana Sourander","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Saana","middleName":"","lastName":"Sourander","suffix":""},{"id":287831243,"identity":"900fc20b-eea9-4f7d-b70f-cc2a21395e4d","order_by":1,"name":"Minja Westerlund","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Minja","middleName":"","lastName":"Westerlund","suffix":""},{"id":287831244,"identity":"715080fc-2a9c-468d-99fb-ec34ad7e839e","order_by":2,"name":"Amit Baumel","email":"","orcid":"","institution":"University of Haifa","correspondingAuthor":false,"prefix":"","firstName":"Amit","middleName":"","lastName":"Baumel","suffix":""},{"id":287831245,"identity":"1ace1247-515b-4f5c-8711-980671c8863a","order_by":3,"name":"Susanna Hinkka-Yli-Salomäki","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Susanna","middleName":"","lastName":"Hinkka-Yli-Salomäki","suffix":""},{"id":287831246,"identity":"8a274cd9-6e3f-4148-a811-57e5fab98c51","order_by":4,"name":"Terja Ristkari","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Terja","middleName":"","lastName":"Ristkari","suffix":""},{"id":287831247,"identity":"373c841f-6654-48c4-8d75-528ed716e967","order_by":5,"name":"Marjo Kurki","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Marjo","middleName":"","lastName":"Kurki","suffix":""},{"id":287831248,"identity":"d59be098-25a8-4640-bde7-6b39d2374a46","order_by":6,"name":"Andre Sourander","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnElEQVRIiWNgGAWjYHACAyC2AbM+JJCgJY2Bh4GBcQYpWg5DtBClnn928+YPH9vOJ+6XSGBseECMFok7x8okZ7bdTuwBaSHOYTdyzJh5IVrYHxClRf5GjvFn3rZzJNhicCPHQJq37QAJWgxvpJVJzjiXbNxz5mEjcVrkbiRv/vChzE62vT35YOMPYrQgAcYGEjWMglEwCkbBKMAJAFDANSREVPjuAAAAAElFTkSuQmCC","orcid":"","institution":"University of Turku","correspondingAuthor":true,"prefix":"","firstName":"Andre","middleName":"","lastName":"Sourander","suffix":""}],"badges":[],"createdAt":"2024-03-26 14:29:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4170561/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4170561/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54321069,"identity":"db716b66-4ff1-4851-99bb-8be0f9d48793","added_by":"auto","created_at":"2024-04-08 19:24:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51435,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA-D.\u003c/strong\u003e Mean curves of SDQ (Strengths and Difficulties Questionnaire) conduct scores, irritability score, ICU (Inventory of Callous-Unemotional Traits) score and Parenting Scale subscores. (A) SDQ conduct scores over time (model-based least-squares means (SE)). (B) Irritability score over time (model-based least-squares means (SE)). (C) ICU subscales over time (model-based least-squares means (SE)). (D) Parenting Scale subscores over time (model-based least-squares means (SE)).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4170561/v1/6ff2ddfc986551912ad893c7.png"},{"id":57480469,"identity":"ec1f8d3f-51cc-40e8-a460-95b87ce337e6","added_by":"auto","created_at":"2024-05-31 08:59:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1175431,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4170561/v1/47180525-eed7-44d6-993d-07e9a56bfedf.pdf"}],"financialInterests":"Competing interest reported. Andre Sourander is the founder and director of Digifamilies, a provider of evidence-based treatments to Finnish public health services. The remaining authors have no conflicts of interest to disclose. All authors read and approved the final manuscript.","formattedTitle":"Two-year Follow-up of Internet-based Parent Training with Telephone Coaching Aimed at Treating Child Disruptive Behaviors in a Clinical Setting during the COVID-19 Pandemic","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere is growing evidence from randomized controlled trials (RCTs) that parents can be trained to intervene and reduce child disruptive behaviors and improve their parenting skills [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Parent training has been found to be the most effective way to prevent and treat disruptive behaviors among children [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and is considered one of the most-validated therapeutic techniques in child mental health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In the face of the unmet need for accessible evidence-based treatment programs to tackle early-onset childhood disruptive behaviors, digitally administered remote treatments provide solutions that require fewer personnel, that may be less stigmatizing and that can reach geographically remote areas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExamining long-term outcomes of an intervention is an essential step in ensuring the sustainability of its effects. However, to our knowledge, there are no long-term follow-ups (i.e., more than 12 months) of digital parent training interventions in clinical settings. The Finnish Strongest Families Smart Website (SFSW) intervention is an 11-week program that includes parent training delivered through an interactive online platform and assisted by weekly telephone coaching. Previously, we conducted a randomized controlled trial (RCT), screening families at regular health check-ups for 4-year-old children, targeting children who had parent-reported high levels of disruptive behavior. The sample included 232 children in each study group, an intervention group and an educational control group. At a 24-month follow-up after randomization, the results maintained efficacy in reducing a wide range of child psychopathology (e.g., The Child Behavior Checklist externalizing score Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.22; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and improving parenting skills (e.g., parental laxness Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.33; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; parental overreactivity Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.26; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study extends the current knowledge on the long-term effects by evaluating the outcomes of families participating in the SFSW parent training program in a clinical setting at baseline and at 12- and 24-months after baseline. A unique aspect of this study is that the SFSW parent training program was administered to the study cohort during the worst phase of the COVID-19 pandemic, when the Helsinki capital region was partially isolated from other parts of Finland. Other services were severely limited, albeit the need of services was great. Due to the crisis, it was considered ethically inappropriate to conduct a randomized controlled study design in this study. The 6-month follow-up findings of this program were very promising and have been reported previously [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There were significant changes in most of the child psychopathology measures, including the CBCL externalizing score (95% CI 4.9\u0026ndash;9.0; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and when parenting skills were measured with the Parenting Scale (PS), the results showed significant changes in the total score (095% CI 0.4\u0026ndash;0.7; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur aim with this paper is to report long-term changes in children\u0026rsquo;s functioning, psychopathology levels, parenting skills and wellbeing from baseline until the 24-month follow-up. We hypothesized that the previously reported positive effects of the SFSW at the 6-month follow-up [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] would be at least partly maintained at the 24-month follow-up.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eThe study focused on families with children between the ages of 3 and 8 years who exhibited elevated levels of disruptive behavior when screened by professionals from eight different family counseling centers in Helsinki. Family counseling centers operate under social services and provide low-threshold services. The centers contribute to child development by reinforcing parenting skills and family relationships. They provide direct support, offer advice to assisting services, and facilitate referrals to specialized services. At family counseling centers, parent training that addresses child-rearing challenges is offered through individual or group sessions. During the pandemic lockdowns, face-to-face sessions were not possible, underscoring the importance of remote support methods. Professionals from the counseling centers selected families suitable for the remotely administered SFSW parent training program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eEthical approval for the study was received from the University of Turku, and the study also received a research permit from the city of Helsinki. This is a single-group study design with repeated measurements. Parents completed questionnaires at baseline, posttreatment and at 6, 12 and 24 months after starting the program. The study encompassed 50 families and took place from May 2020 to November 2022. Earlier findings comparing baseline, posttreatment and 6-month follow-up results have been reported previously [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment, eligibility and procedure\u003c/h2\u003e \u003cp\u003eThe professionals identified children with high levels of disruptive behavior problems. In addition, parents completed the Strengths and Difficulties Questionnaire (SDQ) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and were included if their child had a high level of conduct problems (\u0026ge;\u0026thinsp;5 points in the SDQ Conduct scale) and if the parents perceived their child to have difficulties concerning emotions, behavior or social interactions based on one item inquiring parents about these aspects. Additionally, inclusion in the study required at least one parent to be a native Finnish or Swedish speaker with access to both a telephone and a device with Internet connectivity. Exclusion criteria were if a child had been diagnosed with autism, Down syndrome, fetal alcohol syndrome, an intellectual disability or severe mental disorders. Eligible families were invited to participate. Commencing with the completion of baseline questionnaires, participants progressed through SFSW.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eThe SFSW parent training program utilized interactive online materials and telephone coaching. The program focused on enhancing skills to improve parent-child relationships, complemented by weekly telephone sessions conducted by trained family coaches\u0026mdash;licensed health care professionals, including nurses and public health nurses. All coaching calls were systematically recorded and subjected to random audits by the coach supervisor.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e includes an outline of the weekly themes covered in SFSW. The primary goal was for parents to recognize positive behaviors in their child and respond positively. The second aim was to apply learned skills in everyday situations, utilizing positive methods to reinforce the child\u0026rsquo;s positive behavior. The end of the program focused on solidifying the application of newfound positive parenting skills in daily life to support the child\u0026rsquo;s positive behavior. Parents practiced these skills with their child and discussed their progress during weekly telephone calls with their family coach, which were scheduled aiming to ensure sustainability beyond the program\u0026rsquo;s completion.\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\u003eThemes of the SFSW\u003csup\u003ea\u003c/sup\u003e Internet-based parent training program for children with behavioral problems.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGoals\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Notice the good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoost the child\u0026rsquo;s self-esteem, boost the parent\u0026rsquo;s self-esteem and change the parent\u0026rsquo;s view of their child\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Spread attention around\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthen the child\u0026rsquo;s empathy skills\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Ignore whining and complaining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeach parents self-regulation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Prepare for changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReinforce good daily routines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Plan ahead at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoost the self-esteem of the child and parent and involve the child in planning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Chart and stickers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvolve the child in planning and reinforce good daily routines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Plan ahead outside the home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoost the self-esteem of child and parent and involve the child in planning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Working with daycare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHelp the child to manage and succeed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Time out\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeach self-regulation and consistency\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. \u0026amp; 11. Problem solving revision and future application of skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeach parents skills to support child development and prepare for future challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBooster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemind parents of positive proactive parenting skills\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 \u003csup\u003ea\u003c/sup\u003e SFSW: Strongest Families Smart Website.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cp\u003eThe parents completed online questionnaires at baseline, after the program and at 6-, 12- and 24- months after they had started the program. In addition, demographic details of the family, children, and parents were collected during the screening phase. All of the measurements used in this study have demonstrated adequate reliability and criterion validity metrics and are described more extensively in our previous paper [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For brevity, we mention them briefly below while a comprehensive description is provided as a supplementary material (Appendix \u003cspan refid=\"Sec14\" class=\"InternalRef\"\u003eA\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eChild psychopathology and functioning\u003c/h2\u003e \u003cp\u003eChild psychopathology was assessed using the Finnish version of the 25-item SDQ [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which measures challenges the child experiences in emotions, behavior, or social interactions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Perceived difficulties were gauged through a single question regarding challenges in emotions, behavior or social interactions, with response options ranging from no difficulties to severe difficulties. Disruptive behavior was gauged by the externalizing subscale of the Child Behavior Checklist \u0026ndash; Parent Report Form (CBCL) for ages 1.5\u0026ndash;5 years (99 items) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], focusing on an externalizing subscale with 24 items related to attention issues and aggressive behavior along with the CBCL\u0026rsquo;s total score. Child irritability was measured by the Affective Reactivity Index (ARI), which includes six irritability symptom items and one impairment item [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A 17-item questionnaire, derived from Barkley\u0026rsquo;s Home Situations Questionnaire [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], measured the parents\u0026rsquo; experiences of their child\u0026rsquo;s functioning and behavior in daily situations. We used the 24-item Inventory of Callous-Unemotional Traits (ICU) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] to assess three precursors of child psychopathy: callousness, uncaring and unemotional traits [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eParenting, parental mental health and satisfaction\u003c/h2\u003e \u003cp\u003eThe Parenting Scale (PS), a 30-item tool, was used to evaluate three dysfunctional parenting discipline styles: laxness, overreactivity, and verbosity; reflecting rule enforcement, responses to mistakes, and lengthy verbal reactions, respectively [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We used the 21-item Depression, Anxiety, and Stress Scale (DASS-21) to assess parental stress, anxiety and depression symptoms in the past week [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics include numbers and percentages for categorical variables and means and standard deviations for continuous variables. We analyzed the outcome variables using linear mixed-effect models for repeated measurements with time as a within-factor. We used linear contrasts to estimate changes from baseline to 12 and 24 months as well as changes from 12 to 24 months. We included the sex, age and maternal education of the children as covariates in all models. McNemar\u0026rsquo;s test was applied to test the change in the number of children with a total SDQ score above the 90th percentile (i.e., abnormal range) at baseline and at the 24-month follow-up. The effect sizes of all outcome variables were calculated as T-test effect sizes using Cohen\u0026rsquo;s d. The statistical analyses were performed using SAS statistical software, version 9.4 (SAS Institute Inc.).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eThe study comprised 50 families, of which 44 (88%) completed the whole 11-week SFSW program. Twenty-four-month follow-up assessments were obtained from 37 (74%) subjects. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 37 (74%) of the 50 children were boys. Forty-eight (96%) children had definitive or severe behavioral problems at baseline, and only 2 (4%) had minor behavioral problems based on a single item in parent report, \u0026ldquo;Overall, do you think that your child has difficulties in one or more of the following areas: emotions, behavior or being able to get on with other people?\u0026rdquo;. In terms of program use, the mean duration of website access per theme was 48.0 minutes (SD 25.6), and the mean duration of the telephone coaching calls per theme was 35.3 minutes (SD 8.8). The total mean duration of the program per theme, including both online materials and telephone coaching, was 83.3 minutes (SD 28.0). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e also presents a comparison between the families who completed the 24-month follow-up and those who did not. The table shows the difference in maternal education\u0026mdash;in the non-completer group, mothers were less educated.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of enrolled families, and comparison between families completing and those not completing the 24-month follow-up measurements.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll families\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFamilies completing the 24-month follow-up \u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFamilies not completing 24-month follow-up\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eParent and Family Characteristics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily structure, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBiological parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne biological parent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years), mean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaternal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.9 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.9 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.6 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaternal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.8 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.3 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.5 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal educational level\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e, \u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege or university degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePaternal educational level\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e, \u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege or university degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother\u0026rsquo;s native language, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinnish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwedish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather\u0026rsquo;s native language\u003c/b\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e, \u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinnish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwedish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eChild Characteristics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years), n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBehavioral problems, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e refers to statistical test comparing families completing the 24-month follow-up to those who did not. \u003csup\u003eb\u003c/sup\u003e1 missing observation.\u003csup\u003ec\u003c/sup\u003e4 missing observations. \u003csup\u003ed\u003c/sup\u003e4 missing observations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLong-term Changes in Child and Parenting Measures\u003c/h2\u003e \u003cp\u003eDescriptive statistics of child psychopathology, child function level, parental skills and parental mental health at baseline and 12 months and 24 months after baseline are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. A statistical comparison of the different time-points is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In terms of child psychopathology, significant improvements between baseline and the 12-month follow-up as well as between baseline and the 24-month follow-up were found in CBCL total scores and externalizing scores; SDQ total scores and most sub-scales (emotional, conduct, hyperactivity and peer and problems); and irritability measured with the ARI scale. At the same time, there was a significant deterioration in CBCL total and externalizing scores and SDQ prosocial behavior scores between the 12-month and 24-month follow-ups.\u003c/p\u003e \u003cp\u003e We conducted an additional analysis of 37 (74%) of the 50 parents who completed the SDQ questionnaire both at baseline and at the 24-month follow-up as well as the parent training program. This analysis showed that 30 (81%) of the 37 children had a total SDQ score above the 90th percentile (i.e., abnormal range) at baseline, while only 14 (38%) remained in the abnormal range at the 24-month follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;.001, McNemar\u0026rsquo;s test), based on the population sample of 4\u0026ndash;16-year-old children [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. When using the 80th percentile cut-off point (i.e., abnormal or border range), 36 (97%) children were above the cut-off point at baseline, while the respective figure at the 24-month follow up was 23 (62%), indicating a highly significant change (P\u0026thinsp;\u0026lt;\u0026thinsp;.001, McNemar\u0026rsquo;s test).\u003c/p\u003e \u003cp\u003eWhen parents were asked about perceived difficulties regarding their child\u0026rsquo;s behavior problems with a single question\u0026mdash;\u0026ldquo;Overall, do you think that your child has difficulties in one or more of the following areas: emotions, behavior or being able to get on with other people?\u0026rdquo;\u0026mdash;at baseline, 2 (5%) out of 37 had no or minor problems, 20 (54%) had definite problems and 15 (41%) had severe problems. The respective figures at the 24-month follow-up were 14 (38%), 14 (38%) and 9 (24%) (P\u0026thinsp;=\u0026thinsp;.001, McNemar-Bowker test).\u003c/p\u003e \u003cp\u003eAmong the child psychometric measures, callousness and uncaring improved between baseline and the 12-month follow-up. However, uncaring deteriorated between the 12-month and the 24-month follow-up, and no significant improvement was found between baseline and 24 months. The SFSW parent training program did not have any significant positive association with unemotional traits at the 12-month or the 24-month follow-up.\u003c/p\u003e \u003cp\u003eChild functioning in everyday situations (e.g., transitions, dining, home and outside home activities) improved significantly between baseline and both follow-up points. No significant change was observed between the 12- and 24-month follow-up comparisons.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChild psychopathology, child functioning level, parental skills and parental mental health at baseline and 12 months and 24 months after the baseline (n\u0026thinsp;=\u0026thinsp;50).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline\u003csup\u003ea\u003c/sup\u003e \u003c/p\u003e \u003cp\u003eMean\u003csup\u003ed\u003c/sup\u003e (SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 months\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMean (SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 months\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMean (SE)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild psychopathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.8 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.3 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.1 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConduct problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyperactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.5 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.7 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeer problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProsocial behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.4 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.8 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARI\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.2 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBCL/1.5-5\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.8 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.8 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.2 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExternalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.5 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.0 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.2 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU\u003csup\u003eh\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.9 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.5 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCallousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.1 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.2 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUncaring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.0 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.6 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.1 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild functioning level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEveryday situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild behavior - total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.4 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.4 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.6 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransition situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.9 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDining situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.7 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSituations outside home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.8 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.2 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParental skills\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emean (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emean (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003emean (SE)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenting scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2 (0.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaxness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.4 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverreactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.8 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHostility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.9 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDASS-21\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.3 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.5 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.7 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.7 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.6 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5 (1.9)\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 \u003csup\u003ea\u003c/sup\u003e Measurements before the program started, \u003csup\u003eb\u003c/sup\u003e Measurements at 12 months after starting the program, \u003csup\u003ec\u003c/sup\u003e Measurements at 24 months after starting the program, \u003csup\u003ed\u003c/sup\u003eLeast-squares means, \u003csup\u003ee\u003c/sup\u003eSDQ = Strengths and Difficulties Questionnaire; \u003csup\u003ef\u003c/sup\u003eARI = questionnaire for irritability; \u003csup\u003eg\u003c/sup\u003eCBCL/1.5-5\u0026thinsp;=\u0026thinsp;Child behavior checklist for preschool children; \u003csup\u003eh\u003c/sup\u003eICU= Inventory of Callous-Unemotional Traits; \u003csup\u003ei\u003c/sup\u003eDASS-21\u0026thinsp;=\u0026thinsp;21-item Depression, Anxiety, and Stress Scale.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges from baseline to 12 months and 24 months after, in child psychopathology, child function level and parental skills.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eBaseline\u003csup\u003ea\u003c/sup\u003e to 12 months\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eBaseline to 24 months\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e12 months to 24 months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCohen\u0026rsquo;s d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCohen\u0026rsquo;s d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\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\u003eChild psychopathology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c9\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ\u003csup\u003ed\u003c/sup\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 \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4 (3.5\u0026ndash;7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.5 (2.4\u0026ndash;6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.9 (-2.1\u0026ndash;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4 (0.7\u0026ndash;2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (-0.0\u0026ndash;1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.6 (-1.1 \u0026ndash; -0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConduct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 (1.6\u0026ndash;2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1 (1.4\u0026ndash;2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.1 (-0.7\u0026ndash;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 (0.5\u0026ndash;2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 (0.3\u0026ndash;1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.2 (-0.8\u0026ndash;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 (0.1\u0026ndash;1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6 (0.1\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.1 (-0.4\u0026ndash;0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProsocial\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.8 (-1.4 \u0026ndash; -0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.2 (-0.8\u0026ndash;0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.6 (0.1\u0026ndash;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 (0.6\u0026ndash;1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5 (-0.2\u0026ndash;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.7 (-1.3 \u0026ndash; -0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARI\u003csup\u003ef\u003c/sup\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 \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1 (1.9\u0026ndash;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.9 (1.7\u0026ndash;4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.2 (-1.4\u0026ndash;1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBCL/1.5-5\u003csup\u003eg\u003c/sup\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 \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.5 (4.7\u0026ndash;9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.2 (2.4\u0026ndash;8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-2.3 (-4.1 \u0026ndash; -0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.4 (9.8\u0026ndash;25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.0 (3.5\u0026ndash;18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-6.4 (10.2 \u0026ndash; -2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU\u003csup\u003eh\u003c/sup\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 \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4 (0.9\u0026ndash;5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7 (-0.8\u0026ndash;4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.7 (-3.7\u0026ndash;0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCallousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9 (0.6\u0026ndash;3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9 (0.5\u0026ndash;3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0 (-1.2\u0026ndash;1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncaring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (0.7\u0026ndash;3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (-0.3\u0026ndash;1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.2 (-2.3 \u0026ndash; -0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.4 (-1.0\u0026ndash;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.9 (-1.8\u0026ndash;0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.5 (-1.2\u0026ndash;0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eChild\u0026rsquo;s ability to function\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEveryday situations (child behavior)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild behavior total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.1 (5.3\u0026ndash;12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.9 (4.9\u0026ndash;12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.2 (-3.3\u0026ndash;3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransition situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4 (2.0\u0026ndash;4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8 (1.2\u0026ndash;4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.6 (-1.7\u0026ndash;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDining situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0 (0.2\u0026ndash;1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.4 (0.6\u0026ndash;2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.4 (-0.4\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSituations outside home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3 (1.1\u0026ndash;3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.6 (1.4\u0026ndash;3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3 (-0.7\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 (1.1\u0026ndash;3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.0 (0.9\u0026ndash;3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.2 (-1.2\u0026ndash;0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eParental skills\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenting scale\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 \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5 (0.3\u0026ndash;0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4 (0.2\u0026ndash;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.1 (-0.2\u0026ndash;0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaxness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.4 (0.1\u0026ndash;0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3 (0.1\u0026ndash;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.1 (-0.4\u0026ndash;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverreactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8 (0.5\u0026ndash;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6 (0.3\u0026ndash;0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.2 (-0.4\u0026ndash;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHostility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2 (0.0\u0026ndash;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.0 (-0.3\u0026ndash;0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.2 (-0.5 \u0026ndash; -0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDASS-21\u003csup\u003ei\u003c/sup\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 \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0 (-0.8\u0026ndash;8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9 (-4.2\u0026ndash;5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3.2 (-8.3\u0026ndash;1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (-0.7\u0026ndash;3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6 (-1.4\u0026ndash;2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.0 (-2.8\u0026ndash;0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.2 (-1.7\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.7 (-2.7\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.5 (-2.0\u0026ndash;1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 (0.7\u0026ndash;5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 (-1.1\u0026ndash;3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.9 (-4.3\u0026ndash;0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.14\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 \u003csup\u003ea\u003c/sup\u003e Measurement before the program started, \u003csup\u003eb\u003c/sup\u003e Measurement at 12 months after the program started, \u003csup\u003ec\u003c/sup\u003e Measurement at 24 months after the program started, \u003csup\u003ed\u003c/sup\u003eSDQ = Strengths and Difficulties Questionnaire; \u003csup\u003ee\u003c/sup\u003eIncrease in prosocial SDQ subscore indicates improvement. \u003csup\u003ef\u003c/sup\u003eARI = questionnaire for irritability; \u003csup\u003eg\u003c/sup\u003eCBCL/1.5-5\u0026thinsp;=\u0026thinsp;Child behavior checklist for preschool children; \u003csup\u003eh\u003c/sup\u003eICU= Inventory of Callous-Unemotional Traits; \u003csup\u003ei\u003c/sup\u003eDASS-21\u0026thinsp;=\u0026thinsp;21-item Depression, Anxiety, and Stress Scale.\u003c/p\u003e \u003cp\u003eInterestingly, there were differences between parenting profiles regarding the long-term changes. Parental overreactivity and laxness improved between baseline and the 12-month follow-up and between baseline and the 24-month follow-up. Parental hostility showed improvement between baseline and the 12-month follow-up but not between baseline and the 24-month comparison. In fact, hostility showed significant deterioration between the 12-month and the 24-month follow-up. We observed no significant association in parental mental health problems, measured with DASS-21, between baseline and either of the follow-ups.\u003c/p\u003e \u003cp\u003eFinally, to graphically illustrate the key findings, Figures A\u0026ndash;D describe the changes of main outcome measures across time points including posttreatment and at the 6-month follow-up, which has previously been reported in detail [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Of note, the parenting scales and ICU were not measured posttreatment. The figures illustrate that SDQ conduct, and ARI irritability scores exhibited the largest improvement between baseline and posttreatment and further improvement between posttreatment and the 6-month follow-up; the findings at the 12- and 24-month follow-ups were rather stable. Among the ICU measures, callousness and uncaring showed improvement between baseline and the 6-month follow-up. After that, callousness stayed quite stable while uncaring and unemotional showed deterioration. As for the parenting measures, all parenting styles showed improvement between baseline and the 6-month follow-up. After that, overreactivity and laxness were quite stable, while hostility showed deterioration.\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal Findings\u003c/h2\u003e \u003cp\u003e To the best of our knowledge, this is the first study on long-term follow-up of digital guided parent training intervention among children referred to treatment from specialized care. The findings mostly complement the previously conducted 6-month follow-up study [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] by showing that the SFSW program was associated with significant improvements in children\u0026rsquo;s externalizing symptoms at 12 months and 24 months after baseline. Of note, most of the improvement took place between baseline and posttreatment assessment, and the level of externalizing problems showed stability from the 12- to the 24-month follow-up. The current study\u0026rsquo;s importance is in demonstrating that digital parent training with weekly remote phone coaching, seems to lead to enduring improvements in disruptive behavior problems in children with severe disruptive behavior problems. The findings align with a 24-month follow-up study of the SFSW program [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which was utilized as a preventive and early intervention among 4-year-old children, identified through national medical check-ups [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, since the target group was different, the level of disruptive behavior problems among the children in the present study were much more severe [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which suggests the promise of such interventions in supporting populations with different levels of symptom severity.\u003c/p\u003e \u003cp\u003eMost comorbidities such as hyperactivity, emotional and peer problems, and child functioning in everyday situations maintained their improvement from baseline to the 12-month and 24-month follow-ups as well. Interestingly, the program seemed to have very clear association with decreased irritability. This novel finding implies that some of the major effects of parent training may be associated with decreasing irritability in parent\u0026ndash;child interactions; this requires further research.\u003c/p\u003e \u003cp\u003eFor some problems, such as callous-unemotional traits, improvement was reported at the 12-month follow-up but not at the 24-month follow-up. Callous-unemotional traits characterize a specific subgroup of children exhibiting early-starting, stable and severe conduct problems. It has been argued that conventional parenting interventions frequently prove ineffective within this subgroup [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother important finding was that parenting profiles seemed to have different responses to the parent training program. Improvements in parent overreactivity and laxness were shown both in the comparison between baseline and the 12- and 24-month follow-ups, while parental hostility improved until the 12-month follow-up then deteriorated to the same level as at baseline. It could be interpreted that parental hostility is, in the long run, resistant to parent training programs.\u003c/p\u003e \u003cp\u003eThere is limited research on the effects of parenting interventions on reducing parental hostility. Parental hostility can have broad impacts within the family, potentially disrupting the ability of one parent to maintain a positive relationship with their child [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. There is a significant positive correlation between parent hostility and child aggression, indicating that the more hostile parents are toward others, the more aggressive their children tend to be [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Similar findings regarding conduct problems, callous-unemotional traits and parenting were made in a previous study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], where higher levels of parental harshness were related to higher levels of child conduct problems and callous-unemotional traits. Children subjected to abuse resulting from their parents\u0026rsquo; aggressive behavior may suffer adverse effects on their self-control and exhibit challenges in impulse control by acting impulsively, speaking before thinking, and demonstrating a reduced capacity to tolerate frustration or cope with failure [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. There are also findings showing that parental attitudes play a substantial role in the gradual enhancement of a child\u0026rsquo;s self-control, exerting a significant impact on the individual [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In cases where parent training proves to be ineffective in the long term in reducing parental hostility, the parent could benefit from receiving personal support or therapy to address this issue. It is likely that more tailor-made and targeted interventions and treatment plans would benefit this subgroup of families, which are at risk to fall into this kind of negative cycle.\u003c/p\u003e \u003cp\u003eWhen the study started in May 2020, Helsinki was grappling with the peak of the COVID-19 pandemic, marked by a state of emergency declared nationwide in Finland. Stringent social distancing measures were enforced in the region to curb the virus\u0026rsquo;s transmission, significantly affecting families residing in the area. The COVID-19 pandemic has highlighted the importance of exploring remote, digital or digitally assisted solutions for ensuring that young children, and their families, are provided with prompt support for mental health problems. This study demonstrated that technology can provide effective alternatives to traditional face-to-face interventions and can overcome a number of barriers during crises. Technology can be used to provide the right treatment at the right time, with high levels of support and fidelity, providing greater access and convenience, and requiring fewer costs and less time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eIt is important to acknowledge certain limitations. The study design did not allow for direct conclusions regarding the program\u0026rsquo;s efficacy as it lacked an intervention-control group design. However, the COVID-19 pandemic meant that treatment and family counseling services could not be provided in the usual way, and conducting a randomized controlled study design would have been considered ethically inappropriate. The constraints of social distancing, which included school closures, also prevented us from conducting direct observations of parenting, clinical assessments and teacher ratings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides strong support for the utility of remotely delivered interventions, which can reach a broader customer base by reaching into people\u0026rsquo;s homes and schools, thereby enhancing accessibility of services. Incorporating remote interventions into child mental health services also serves as a safeguard during crises situations such as COVID-19.\u003c/p\u003e \u003cp\u003eThe study shows that remote digital child mental health services bring substantial benefits to families that can last for up to two years. Overall, the study emphasizes that guided digital parent training programs can be a crucial component in developing evidence-based treatment practices for children and families.\u003c/p\u003e \u003cp\u003eThe study also emphasizes the importance of conducting long-term follow-ups to understand long- term intervention gains. The study results indicate that different parenting profiles and child psychopathology may have varying effects on the long-term outcome of the program. This finding is important when developing personalized parenting interventions for increased impact.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe extend our gratitude to the head of Helsinki Family Counselling Centers, Leena Lehikoinen, and all the other professionals from the Family Counseling Centers in Helsinki who contributed to making this study possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This project has received funding from the European Research Council (ERC) under the European Union\u0026rsquo;s Horizon 2020 research and innovation program (grant agreement No. 101020767) and from the Research Council of Finland (decision number: 345546).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest information:\u003c/strong\u003e Andre Sourander is the founder and director of Digifamilies, a provider of evidence-based treatments to Finnish public health services. The remaining authors have no conflicts of interest to disclose. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.S. drafted the original manuscript text. S.S., A.S., T.R and M.K. designed and conducted data collection for the study. M.W. and A.B. contributed to revising and editing the manuscript. S.H-Y-S was the corresponding biostatistician. All authors contributed to editing the manuscript. All authors have read and contributed to editing the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDretzke J, Davenport C, Frew E et al (2009) The clinical effectiveness of different parenting programmes for children with conduct problems: a systematic review of randomised controlled trials. 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Korean J Youth Stud 26(6):73\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21509/KJYS.2019.06.26.6.73\u003c/span\u003e\u003cspan address=\"10.21509/KJYS.2019.06.26.6.73\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\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":false,"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":"parent training, disruptive behavior, child psychopathology, child functioning, internet-based, family counseling","lastPublishedDoi":"10.21203/rs.3.rs-4170561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4170561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThere is a lack of studies examining the long-term outcomes of internet-based parent training programs implemented in clinical settings during the COVID-19 pandemic.\u003c/p\u003e\u003ch2\u003eObjective:\u003c/h2\u003e \u003cp\u003eTo study two-year outcomes of families with 3\u0026ndash;8-year-old children referred from family counseling centers to the Finnish Strongest Families Smart Website (SFSW), which provides digital parent training with telephone coaching aimed at treating child disruptive behaviors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCounseling centers in Helsinki identified 50 3\u0026ndash;8-year-old children with high levels of disruptive behavioral problems. Child psychopathology and functioning as well as parenting styles and parental mental health were reported by parents at baseline, posttreatment and at 6-, 12- and 24-month follow-ups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe SFSW program had positive long-term effects on child psychopathology and parenting skills. Improvements in child psychopathology, including Strengths and Difficulties Questionnaire (SDQ) total score (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.47, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), SDQ conduct scores (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.65; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and Affective Reactivity Index (ARI) irritability scores (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.52; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) were maintained until the 24-month follow-up. Similarly, treatment effects of parenting skills measured with the Parenting Scale, including overreactivity (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.41; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001) and laxness (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.26; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.021), were maintained until the 24-month follow-up. Parent training did not have a long-term effect on parental hostility (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.04; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.70).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThe study shows that the SFSW parent training program can yield significant long-term benefits. Findings indicate that the benefits of the treatment may vary between different parenting profiles, which is important to consider when developing more personalized parenting interventions.\u003c/p\u003e","manuscriptTitle":"Two-year Follow-up of Internet-based Parent Training with Telephone Coaching Aimed at Treating Child Disruptive Behaviors in a Clinical Setting during the COVID-19 Pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-08 19:24:30","doi":"10.21203/rs.3.rs-4170561/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":"973f9404-bda7-4602-8a1d-dbbd65fd0da0","owner":[],"postedDate":"April 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-31T08:51:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-08 19:24:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4170561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4170561","identity":"rs-4170561","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}