Digital Behavioral Parenting Programs With and Without Added Emotion Regulation Strategies to Manage Anger in Parenting

BACKGROUND Hard-to-manage anger can impact parenting and increase the risk for interpersonal difficulties, including violence between partners and physical and emotional violence by parents towards children. Several central risk factors for harsh parenting are tied to the caregiver, including hard-to-manage child-directed anger and parenting skills, which are modifiable intervention targets.

Targeting anger in parenting through emotion regulation (ER) strategies that have proven effective for anger problems in adults more broadly represents an under-researched approach. Behavioral parent training (BPT) programs have the strongest research support for reducing harsh and abusive parenting, yet meta-analyses generally show only modest between-group effects. At the same time, cognitive-behavioral interventions incorporating ER strategies have demonstrated efficacy for reducing anger in adults in randomized controlled trials. Integrating such strategies into BPT may offer a promising avenue for enhancing intervention effects, particularly for parents who struggle with anger and emotional escalation.

Delivering interventions digitally can also provide a more efficient and accessible way to reach families, as many families never initiate parenting interventions or discontinue them prematurely due to barriers such as transportation, time constraints, stigma, or shame. Importantly, robust evidence indicates that internet-delivered parenting programs can achieve effects comparable to those of face-to-face interventions.

AIM The overall aim of this project is to evaluate the feasibility, acceptability, and preliminary effects on intervention outcomes and target mechanisms of two newly developed digital parenting interventions, when delivered to parents who experience difficulties with anger in parenthood, compared both to each other and to a waitlist control.

The interventions are internet-delivered adaptations of evidence-based parenting programs, collectively called the Supporting Healthier Interactions in Families by Online Tools (SHIFT) parenting programs. The first intervention is a BPT program (henceforth referred to as SHIFT) that includes parenting strategies to manage child disruptive behavior problems. The parenting strategies are drawn from established BPT programs. The second intervention (henceforth referred to as SHIFT+) integrates the same parenting strategies with emotion regulation (ER) techniques drawn from anger-management treatments. Findings from this study will inform a future large-scale RCT to evaluate the comparative effectiveness of these interventions compared with each other and with a waitlist control.

RESEARCH QUESTIONS

1. Are the study procedures and design feasible for a full-scale RCT, operationalized as (1) recruiting the target number of participants within a 6 month period, (2) completion of assessments, defined as the proportion of enrolled participants completing intervention outcomes at 8 weeks, and (3) that participants are referred through the tested recruitment pathways?
2. Are the SHIFT parenting programs feasible and acceptable, operationalized as (1) compliance with the programs, defined as completing at least three of six online modules, (2) parent ratings of satisfaction, credibility and expectancy of the programs, and (3) that social service' family support workers (referred to as 'therapists') provide therapist support consistent with the intervention setup?
3. How do therapists and parents experience that the digital parenting interventions have influenced parents, as well as therapists' work in supporting families, and how can the interventions be improved?
4. Is participation in one of the SHIFT parenting programs, relative to participation in the other and relative to waitlist control, associated with improvements in parent-reported intervention outcomes, operationalized as (1) anger in parenthood, (2) parenting practices, (3) parent mental health and distress, and (4) children's mental health and behavior problems, and (5) parent ER, and how large are preliminary effect estimates?
5. Is participation in the SHIFT-programs, relative to each other and waitlist control, associated with improvement in weekly measures of target mechanisms, operationalized as (1) ER (reappraisal), (2) parenting practices, and (3) children's child disruptive behavior problems, and how large are preliminary effect estimates?

METHODS Recruitment and intervention delivery take place in collaboration with family support services within social services in municipalities across Sweden. The study setting is family support services that parents can access on their own initiative, without requirements on a child welfare report being filed.

The trial will be advertised to parents via municipal webpages and information distributed via local arenas into contact with parents, such as child health care, primary care, schools, preschools, family centers, and local newspapers. Social services/therapists also inform parents during routine contacts.

Parents who are interested in participating will access a study website. On the website, they first read more information about the study. Thereafter, they click on a link to read the detailed study information and provide digital informed consent. In the consent form, the parent indicates whether one or two parents in the family will participate.

When parents have consented to participate, they complete a digital screening. Parents who indicate that they 1) find the digital format suitable, 2) understand Swedish, and 3) score above a cut-off on the Parent Anger Scale (PAS) will be contacted for a telephone screening by the research team. During the telephone screening, the researcher will ensure that the participant has understood the study information, provide opportunity to ask questions, and assess eligibility according to the study's inclusion and exclusion criteria. If two parents take part in the study, the second parent must also complete consent and the baseline assessment before randomization. The second parent do not have to score above the PAS cut-off. Participants who are excluded will be informed of this decision and, where appropriate, referred to other municipal services or local healthcare.

Eligible participants will, after the telephone screening, complete baseline assessments and be randomized to: (1) SHIFT, (2) SHIFT+, or (3) waitlist. These three arms allow both to evaluate effects versus no intervention, and if ER improves the effects of BPT, which will be the focus of the coming full-scale RCT. Parents and a therapist/local study coordinator at each social service unit are informed about the allocation. The therapist/local coordinator assigns a therapist within their team who support parents during the intervention, which is delivered via a secure digital platform.

The researchers collect data by sending parents digital assessments via the platform. Parents complete assessments at baseline (before randomization), weekly during interventions or waitlist period, 8 weeks from baseline (post-assessment), and 6 months from baseline. Parents on the waitlist must complete the post-assessment before starting the intervention. When parents have completed the intervention, therapists also report their satisfaction with the intervention and the support provided during its delivery. Interviews with parents and therapists are conducted after completion of the interventions, following semi-structured interview guides. These will be conducted over telephone, recorded, and transcribed verbatim. All data is collected via the same secure platform as the internet delivered programs are delivered via.

RANDOMIZATION Block randomization with randomly varying block sizes will be used to allocate participants in a 1:1:1 ratio to SHIFT, SHIFT+, or the waitlist condition. The allocation sequence will be generated using a computer-based random number generator with the upcoming allocation concealed.

Randomization will take place after eligibility has been confirmed and the participant has completed the baseline assessment. At that point, the next allocation in the concealed sequence will be retrieved through a secure computerized procedure. Participants allocated to the waitlist will be re-randomized in a 1:1 ratio to receive SHIFT or SHIFT+ following the waiting period and completion of the 8-week assessment. A separate computer-generated allocation sequence with randomly varying block sizes will be used for this second randomization.

ANALYSES Analyses for research question 1: Feasibility of study procedures and design The number of participants recruited, and the recruitment time, is presented descriptively. If we include 80-90 families within 6 months, the trial procedures are considered feasible for a full-scale RCT. The proportion of parents completing intervention outcomes at 8 weeks follow-up will be presented.

Analyses for research question 2: Acceptability and feasibility of the SHIFT programs The proportion of participants who complete at least three of six online modules will be calculated and compared descriptively between the two active programs or with chi2-tests or similar. Group differences in quantitative feasibility ratings (e.g., satisfaction and credibility) will be examined using independent samples t-test or, depending on the number of families with two parents responding, appropriate inferential tests accounting for dependence among observations (e.g., multilevel modelling).

Analyses for research question 3: Experiences of digital interventions Qualitative data from interviews will be transcribed verbatim and analyzed using thematic analysis, content analysis or computationally intensive theory construction to identify patterns in the data, such as themes or categories, that are relevant to the research questions. Illustrative quotes will be presented.

Analyses for research question 4 and 5: Preliminary effects on intervention outcomes and target mechanisms The analyses will follow the intention-to-treat principle, i.e., including all participants as randomized. Effects only for intervention completers will be examined exploratory as a secondary analysis. Preliminary effects of the interventions on parent-rated outcomes assessed at repeated time points will be examined using linear mixed-effects models/generalized linear mixed-effects models or similar appropriate statistical models. Where two parents from the same family participate, nesting will be modelled to account for dependency in the data. At the post-assessment, the two active intervention conditions will be compared both with each other and with the waitlist control condition. At the 6-month follow-up, we will compare the two active interventions and explore whether gains observed in the intervention arms are maintained. At 6 months, participants who are randomized to SHIFT or SHIFT+ after the waitlist period will be included in an analysis comparing the two active interventions. Appropriate effect sizes, such as Cohen's d or odds ratios depending on the type of outcome variable, will be calculated.