Gardner Frances, Leijten Patty, Harris Victoria, Mann Joanna, Hutchings Judy, Beecham Jennifer, Bonin Eva-Maria, Berry Vashti, McGilloway Sinead, Gaspar Maria, João Seabra-Santos Maria, Orobio de Castro Bram, Menting Ankie, Williams Margiad, Axberg Ulf, Morch Willy-Tore, Scott Stephen, Landau Sabine
Social Policy and Intervention, University of Oxford, Oxford, UK.
Social Policy and Intervention, University of Oxford, Oxford, UK; University of Amsterdam, Amsterdam, Netherlands.
Lancet Psychiatry. 2019 Jun;6(6):518-527. doi: 10.1016/S2215-0366(19)30162-2. Epub 2019 May 6.
Childhood conduct problems are a costly public health problem and are five times more common in socially disadvantaged groups than they are in advantaged groups. Untreated, conduct problems have a poor prognosis, with increasing gaps between socioeconomic groups, and high rates of subsequent criminality. Incredible Years is a high quality parenting programme for reducing conduct problems and is widely disseminated in Europe. Many trials have shown Incredible Years to be effective but the potential effects of parenting interventions on social inequality are unknown. Some behavioural interventions (eg, smoking cessation programmes), although beneficial overall, can widen inequality gaps. Because single trials and aggregate-level meta-analyses are ill equipped for examining differential intervention (moderator) effects, we pooled individual-level trial data to assess the effects of Incredible Years on social equity.
We did a systematic review and individual participant data meta-analysis by searching CINAHL, Embase, Global Health, Medline, and PsycINFO, for studies published from inception to March 15, 2019. We also searched the Incredible Years website library and consulted with experts, including the European Incredible Years mentors' network. We included data from all completed randomised trials of the Incredible Years parenting intervention in Europe that included children aged 1-12 years, including unpublished trials, without restriction on publication year or outcome measures. We included prevention (selective or universal) and treatment or indicated prevention trials (for children diagnosed or above the clinical cutoff for conduct problems). We excluded trials or conditions within trials that were not randomised, included additional non-parenting material (eg, child-focused interventions), or were abbreviated, non-standard versions of the usual Incredible Years intervention of 12-14 weekly sessions. We requested individual participant data from the study authors. The primary outcome was child conduct problems, assessed using the Eyberg Child Behavior Inventory Intensity (ECBI-I) scale. Moderators were analysed using multilevel modelling with multiple imputation.
Of 15 European trials of Incredible Years parenting programmes (n=1696 children), individual participant data were unavailable for one trial and one trial did not assess the primary outcome. Children were aged 2-10 years (median 5·1), 492 (30%) of 1651 children were from an ethnic minority and 931 (58%) of 1614 were from low-income families. Families who received the Incredible Years intervention reported an overall reduction in child conduct problems (13·5 points on the ECBI-I scale, 95% CI 10·9-16·1). There were no differential effects by family disadvantage (indicated by poverty, lone parenthood, teenage parenthood, household joblessness, or low education), or ethnic minority status.
We found no evidence for differential effects by social disadvantage, suggesting that Incredible Years is unlikely to widen socioeconomic inequalities in conduct problems. Furthermore, the programme might be an important tool for reducing social disparities and improving poor long-term outcomes in disadvantaged families because follow-up studies indicate that benefits persist. Clinicians and commissioners can be reassured that the programme is similarly effective for families from different backgrounds.
UK National Institute for Health Research.
儿童行为问题是一个代价高昂的公共卫生问题，在社会弱势群体中的发生率比优势群体高出五倍。若不加以治疗，行为问题的预后较差，社会经济群体之间的差距会不断扩大，随后犯罪率也会居高不下。“不可思议的岁月”是一项旨在减少行为问题的高质量育儿计划，在欧洲广泛传播。许多试验表明“不可思议的岁月”是有效的，但育儿干预对社会不平等的潜在影响尚不清楚。一些行为干预措施（如戒烟计划）虽然总体上有益，但可能会扩大不平等差距。由于单个试验和总体水平的荟萃分析难以检验差异干预（调节因素）的效果，我们汇总了个体水平的试验数据，以评估“不可思议的岁月”对社会公平的影响。
我们通过检索CINAHL、Embase、Global Health、Medline和PsycINFO数据库，查找从数据库建立至2019年3月15日发表的研究，进行了一项系统评价和个体参与者数据荟萃分析。我们还搜索了“不可思议的岁月”网站图书馆，并咨询了专家，包括欧洲“不可思议的岁月”导师网络。我们纳入了欧洲所有已完成的关于“不可思议的岁月”育儿干预的随机试验数据，这些试验纳入了1至12岁的儿童，包括未发表的试验，对发表年份或结局指标没有限制。我们纳入了预防（选择性或普遍性）试验以及治疗或针对性预防试验（针对已诊断或行为问题高于临床临界值的儿童）。我们排除了非随机的试验或试验中的条件、包含额外非育儿材料（如以儿童为重点的干预措施）的试验，或缩短的、非标准版本的通常为期12 - 14周的“不可思议的岁月”干预试验。我们向研究作者索取个体参与者数据。主要结局是儿童行为问题，使用艾伯格儿童行为量表强度（ECBI - I）进行评估。使用多重填补的多水平模型分析调节因素。
在15项欧洲“不可思议的岁月”育儿计划试验（n = 1696名儿童）中，一项试验无法获取个体参与者数据，一项试验未评估主要结局。儿童年龄为2至10岁（中位数5.1岁），1651名儿童中有492名（30%）来自少数民族，1614名儿童中有931名（58%）来自低收入家庭。接受“不可思议的岁月”干预的家庭报告称，儿童行为问题总体有所减少（ECBI - I量表上降低了13.5分，95%置信区间为10.9 - 16.1）。家庭劣势（以贫困、单亲家庭、青少年父母、家庭无业或低教育程度表示）或少数民族身份没有差异影响。
我们没有发现社会劣势存在差异影响的证据，这表明“不可思议的岁月”不太可能扩大行为问题方面的社会经济不平等。此外，该计划可能是减少社会差距和改善弱势家庭不良长期结局的重要工具，因为后续研究表明益处会持续存在。临床医生和决策者可以放心，该计划对不同背景的家庭同样有效。
英国国家卫生研究院。
