Parent Training Interventions Research Articles

Parent-Child Interaction Therapy Adapted for Preschoolers with Callous-Unemotional Traits: An Open Trial Pilot Study

Children with co-occurring conduct problems and callous-unemotional (CU) traits show a distinct pattern of early starting, chronic, and aggressive antisocial behaviors that are resistant to traditional parent-training interventions. The aim of this study was to examine in an open trial the acceptability and initial outcomes of a novel adaptation of Parent–Child Interaction Therapy, called PCIT-CU, designed to target 3 distinct deficits of children with CU traits. Twenty-three Australian families with a 3- to 6-year-old (M age = 4.5 years, SD = .92) child with clinically significant conduct problems and CU traits participated in the 21-week intervention and 5 assessments measuring child conduct problems, CU traits, and empathy at a university-based research clinic. Treatment retention was high (74%), and parents reported a high level of satisfaction with the program. Results of linear mixed models indicated that the intervention produced decreases in child conduct problems and CU traits, and increases in empathy, with “medium” to “huge” effect sizes (ds = 0.7–2.0) that maintained at a 3-month follow-up. By 3 months posttreatment, 75% of treatment completers no longer showed clinically significant conduct problems relative to 25% of dropouts. Findings provide preliminary support for using the targeted PCIT-CU adaptation to treat young children with conduct problems and co-occurring CU traits.

Treatment of child externalizing behavior problems: a comprehensive review and meta–meta-analysis on effects of parent-based interventions on parental characteristics

This is the first meta-meta-analysis examining the effects of parent-based interventions for children with externalizing behavior problems on parental characteristics (parenting, parental perceptions, parental mental health, parental relationship quality). Parent training interventions are recognized as evidence-based interventions for the treatment of externalizing behavior problems, although meta-analytic effects are heterogeneous. The objective of the present study was to comprehensively combine meta-analytic results on parent training interventions to arrive at valid effect predictions. Electronic databases were searched (PsycINFO, Medline, PubMed). In total, 11 meta-analyses were included that mainly comprised parents of children under the age of 13years. Analyses were based on random effects models. Effect estimates were transformed to standardized mean differences (SMD) and corrected for primary study overlap. Results revealed a significant moderate overall effect for parenting (SMD 0.53) as well as for parents' report of parenting (SMD 0.60) and parental perceptions (SMD 0.52). Effects remained stable to follow-up. Results for observational data, parental mental health and parental relationship quality were small and only partially significant. Considerable heterogeneity within results was revealed. Overall, parent training interventions proved to be effective in improving parental characteristics for parents of children with externalizing behavior problems. Effectiveness was stronger regarding characteristics explicitly targeted by interventions. The findings should encourage health-care providers to apply evidence-based parent training interventions.

Are Callous-Unemotional Traits Associated with Differential Response to Reward Versus Punishment Components of Parent-Training? A Randomized Trial

ABSTRACTRelatively poor treatment outcomes have been reported for children with conduct problems (CPs) and high levels of callous-unemotional (CU) traits (e.g., a lack of guilt, a lack of empathy, shallow affect), yet the mechanisms underlying this effect are poorly understood. Recently, growing evidence of aberrant reward/punishment processing in children with CU traits has suggested that punishment-based parenting strategies may be less effective among children with high levels of CU traits. Using a randomized controlled trial design, we conducted an experimental test of whether CU traits are associated with differential response to reward versus punishment components of evidence-based parent-training interventions for CPs. Parents of children (n = 74) 3 to 8 years of age were randomized to either 5 weeks of reward-based or 5 weeks of punishment-based parenting strategies, after which time each received the alternative intervention. Contrary to predictions, neither type nor dosage of parent training strategies was found to moderate the relation between CU traits and treatment response. Implications for the treatment of CPs in children with high levels of CU traits, and research into mechanisms of behavior change, are discussed.

Service needs of adolescent parents in child welfare: Is an evidence-based, structured, in-home behavioral parent training protocol effective?

SafeCare is an evidence-based behavioral parent training intervention that has been successfully implemented in multiple state child welfare systems. A statewide implementation in Oklahoma established the effectiveness of SafeCare with a diverse group of parents, which included adolescent parents under 21 years of age, a particularly at-risk group. The current study examined whether SafeCare is also effective for this subsample of 294 adolescent parents with regard to child welfare recidivism, depression and child abuse potential, and attainment of service goals. Post-treatment adolescent parent ratings of program engagement and satisfaction were also examined. Among the subsample of adolescent parents, the SafeCare intervention did not result in significantly improved outcomes in terms of preventing recidivism or reduction in risk factors associated with child abuse and neglect as compared to child welfare services as usual. Further, no significant differences in program engagement and satisfaction between SafeCare and services as usual were detected. These findings shed light on the potential differences in program effectiveness between adolescent and adult parents, and the need for future research to rigorously evaluate the effectiveness of behavioral parenting programs with adolescent parents.

Systematic Review and Meta-analysis of Stepping Stones Triple P for Parents of Children with Disabilities.

The aim of this systematic review and meta-analysis was to examine the effectiveness of Stepping Stones Triple P (SSTP) parent training programs on child behavior problems and parenting outcomes in families of children with developmental disabilities. Sixteen suitable studies including data from over 900 families were identified in a search for English language published and unpublished controlled outcome studies. SSTP has five levels on a graded continuum of increasing intensity targeting families with differing degrees of treatment need from low intensity media-based parenting information campaigns at level 1, through brief interventions at levels 2 and 3, to more intensive parent training and family therapy interventions at levels 4 and 5. Analyses were conducted on the combination of all levels of SSTP and separately for each level. For combined levels, significant overall effect sizes were found for parent-reported child problems (d=0.46), researcher observed child behavior (d=0.51), parenting style (d=0.70), parenting satisfaction/self-efficacy (d=0.44), parental adjustment (d=0.27), and coparental relationship (d=0.26), but not researcher-observed parent behavior. Strong support was found for level 4 SSTP as an effective intervention for improving child and parent outcomes in families of children with disabilities who have clinically significant problems. Less intensive SSTP interventions for cases with circumscribed difficulties yielded fewer significant treatment effects, and there were relatively few studies of such interventions.

Does parental mental health moderate the effect of a telephone and internet-assisted remote parent training for disruptive 4-year-old children?

This study explores the moderators affecting the success of an Internet-based and telephone assisted remote parent training intervention and compares them to an educational control group. We prospectively identified 464 parents who reported at a health check that their 4-year-old children showed elevated levels of externalizing behavior. The moderators explored included parental attention deficit and hyperactivity disorder (ADHD) and parental distress. The dependent variables were child externalization scores and self-reported parenting skills. The measures were completed at baseline, six and 12-months follow-up. The 232 families randomized to active treatment received 11 Internet-based training sessions with weekly phone calls from a coach. The other 232 families had access to a website that provided general positive parenting advice and one 45-minute phone-call from a coach. Using hierarchical linear models, we explored if the parental ADHD or parental distress modified the treatment effects on child externalizing behavior or parenting skills. The results showed that none of the independent variables moderated intervention effects on child externalizing behavior or parenting skills. The lack of significant moderator effects could have been due to the treatment's personalization, the format's flexibility and adaptability to when and how the parents wanted to complete the sessions or the relatively low levels of ADHD and parental distress among the participants.

Approaches to the Management of Young Children’s Externalizing Behavior Problems in the Primary Care Setting

The current review summarizes the management of early-childhood externalizing behavior problems (ages 2–5) within the primary care setting. The review highlights factors pediatricians should consider when addressing externalizing behavior problems and summarizes general principles, opportunities for prevention and health promotion, parent-training interventions, integrated models, and therapies to consider when referring families to a specialty mental health provider. Pediatricians have an important role in addressing early-childhood externalizing behavior problems in the primary care setting, and practices can take a range of meaningful steps to address these issues both universally and for children with higher levels of impairment. In particular, integrated approaches offer the opportunity to increase access to behavioral health services while also providing the chance to build medical providers’ skills in managing early-childhood externalizing behavior problems in the primary care setting. Pediatricians have a range of options to consider and can use the literature regarding evidence-based programs to guide their decisions on the best interventions to implement in their settings. Further dissemination work is needed to better understand which programs are most effective when implemented in community settings.

Combining Parent and Teacher Training for Early ADHD: A Randomized Study of Effectiveness

Parent training (PT) has been documented as an effective intervention for early ADHD based on parental assessment, but documentation of transfer of its results outside the family context has been limited. Due to the cross-contextual impairments typically caused by ADHD, it has been proposed that PT in combination with an intervention in kindergarten or school based on systematic teacher training (TT) would be better suited. The objective of this study was to evaluate the effectiveness of a combination of PT and TT in a community sample of children with early ADHD problems. Families of 64 3-8-year old children were randomized to either PT alone with “The Incredible Years” PT or to a combined PT + TT intervention. Moderate to large pre-post effect sizes on mother-reported outcomes were revealed in both groups, in line with those generally reported in the literature on PT interventions for early ADHD. With an n of 64, the current study was powered to detect superiority of the PT + TT intervention if the difference was of a moderate effect size (Cohen’s d = 0.5). There were no statistically significant differences between the two groups on any of the outcome measures as rated by parents or teachers. In conclusion, the study did not provide support for the combined PT + TT intervention for early ADHD problems as a superior intervention in comparison with PT alone.

For Whom Do Parenting Interventions to Prevent Adolescent Substance Use Work?

Adolescent substance use continues to be a significant public health problem. Parent training interventions are effective preventive strategies to reduce youth substance use. However, little is known about differences in effectiveness for youth across demographic characteristics. This review assessed the effectiveness of parent training programs at reducing adolescent substance use by participant gender, age, and race/ethnicity. Pubmed/MEDLINE, ERIC, CINAHL, and PsycINFO were searched from database origin to October 31, 2016. We included randomized controlled trials that evaluated parent training interventions; reported youth initiation or use of tobacco, alcohol, or other illicit substances; and included adolescents aged 10 to 19. Two independent reviewers extracted data. Disagreements were resolved by consensus or a third researcher. Data were synthesized using harvest plots stratified by participant demographics. A total of 1806 publications were identified and reviewed; 38 unique studies were included. Risk of bias of included studies was high. No studies targeted male teens or youth in late adolescence. Few studies targeted Asian-American, Black/African-American, or Hispanic/Latino adolescents. Overall, interventions including male and female youth and youth in early adolescence (age 10 to 14 or in 5th to 8th grade) were more beneficial than interventions including female-only or both young and older adolescents. Programs tailored to specific racial/ethnic groups, as well as programs designed for youth from multiple races/ethnic groups, were effective. Current evidence supports the benefits of offering parenting guidance to all families with adolescent children, regardless of the gender, age, or race/ethnicity of the adolescent.

Concurrent child history and contextual predictors of children's internalizing and externalizing behavior problems in foster care

This study contributes to current research on the behavior problems of children in foster care by analyzing a more comprehensive set of concurrent child history and contextual predictors. Kinship home status and sibling status (i.e., whether the sibling is a biological sibling to the foster child) were evaluated as moderators of significant associations. Data were collected at the baseline of a foster parent training intervention program prior to any intervention services using parent phone interviews (N=310, 51.6% male, M age=7.57years). Two linear hierarchical regressions were used to evaluate each set of predictors' association with behavior problems as well as each individual predictor's contribution. Results indicated that as a set, the contextual variables predicted a significant and unique amount of variability in the child's internalizing and externalizing behavior scores, whereas the child history variables did not. Specifically, the child's placement in a non-kinship home, being in a non-ethnically matched child-parent pair, higher parent stress scores, a greater number of prior group home placements, and higher internalizing behavior scores for the child predicted higher child externalizing scores. Higher parent stress scores, higher focal sibling externalizing behavior scores, and higher externalizing behavior scores for the child predicted higher internalizing scores for the child. The association between focal sibling externalizing behavior scores and child internalizing scores was moderated by kinship home status, such that there was a stronger association between the focal sibling's externalizing score and the child's internalizing score if the child was in a kinship compared to a non-kinship home. Implications for intervention services are discussed, particularly the importance of assessing the child's foster home environment when addressing the child's behavior problems.

Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder.

Behavioural interventions are recommended for use with children and young people with attention deficit hyperactivity disorder (ADHD); however, specific guidance for their implementation based on the best available evidence is currently lacking. This review used an explicit question and answer format to address issues of clinical concern, based on expert interpretation of the evidence with precedence given to meta-analyses of randomised controlled trials. On the basis of current evidence that takes into account whether outcomes are blinded, behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. There is, however, evidence from measures that are probably blinded that these interventions benefit parenting practices and improve conduct problems which commonly co-occur with ADHD, and are often the main reason for referral. Initial positive results have also been found in relation to parental knowledge, children's emotional, social and academic functioning - although most studies have not used blinded outcomes. Generic and specialised ADHD parent training approaches - delivered either individually or in groups - have reported beneficial effects. High-quality training, supervision of therapists and practice with the child, may improve outcomes but further evidence is required. Evidence for who benefits the most from behavioural interventions is scant. There is no evidence to limit behavioural treatments to parents with parenting difficulties or children with conduct problems. There are positive effects of additive school-based intervention for the inattentive subtype. Targeting parental depression may enhance the effects of behavioural interventions. Parent training is an important part of the multimodal treatment of children with ADHD, which improves parenting, reduces levels of oppositional and noncompliant behaviours and may improve other aspects of functioning. However, blinded evidence does not support it as a specific treatment for core ADHD symptoms. More research is required to understand how to optimise treatment effectiveness either in general or for individual patients and explore potential barriers to treatment uptake and engagement. In terms of selecting which intervention formats to use, it seems important to acknowledge and respond to parental treatment preferences.

Clinical Implications From the Treatment of Severe Childhood Aggression (TOSCA) Study: A Re-Analysis and Integration of Findings

The Treatment of Severe Childhood Aggression (TOSCA) project examined augmentation of stimulant treatment and parent training (PT) with risperidone for severe physical aggression. This article summarizes the clinical implications; reanalyzes the data to examine the utility of 4 criteria for deciding to augment; and presents a treatment algorithm. The newly analyzed 4 criteria for augmenting after 3 weeks of stimulant and PT treatment consisted of not meeting a Clinical Global Impressions-Improvement (CGI-I) score of 1 and a normal score (≤15) on the Nisonger Child Behavior Rating Form Disruptive-Total (D-Total); a CGI-I score of 1 or 2 plus 25% improvement in D-Total score; a D-Total score no higher than 15; and a CGI-Severity score of 3 (mild) or better. Effect sizes were calculated. Prior TOSCA publications were reviewed for clinically relevant findings. All 4 criteria resulted in medium or better effect sizes (d= 0.59-0.72) when comparing risperidone with placebo. Providing risperidone to children who did not reach a CGI-I score of 1 plus a D-Total score no higher than 15 resulted in the greatest benefit. In addition, a review of clinically relevant data suggests that stimulant plus PT shows further improvement after 3 weeks even without augmentation. For those children who did not attain a CGI-I score of 1 and a D-total score no higher than 15, adding risperidone maximized the number of children benefitting from treatment and the average amount of benefit. Unless clinical circumstances dictate otherwise, practitioners should delay an antipsychotic drug for at least 1 month after the optimal stimulant dose is achieved and PT has commenced. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study); http://clinicaltrials.gov; NCT00796302.

The Comfort Ability Pain Management Workshop: A Preliminary, Nonrandomized Investigation of a Brief, Cognitive, Biobehavioral, and Parent Training Intervention for Pediatric Chronic Pain.

Psychological intervention is widely recognized as an integral part of the recovery process from pediatric chronic pain, but service acquisition is often limited by resource barriers. The aim of this study was to assess the feasibility, acceptability, and satisfaction of a brief, structured, skills-based, group intervention designed expressly to address gaps in service delivery. Exploratory outcomes were also assessed. Adolescents with chronic pain (n = 102; ages 10-17 years) and their mothers (n = 105) completed self-report questionnaires at baseline, 1-week, 1-month, and 3-month posttreatment. This study demonstrated feasibility, and overall high acceptability and satisfaction among adolescents and parents. Exploratory analyses within this nonrandomized design suggest that adolescents demonstrate improvement in functionality (p = .0012), depression symptoms (p < .0001), and pain catastrophizing (p < .0001) by 1-month posttreatment and continued making gains over time. Parents made significant changes in parenting practices (p-values < .01) and in their beliefs about their adolescent's ability to manage pain (p < .001) by 1-week posttreatment and continued making gains over time. This brief intervention is both feasible and acceptable. Although small effect sizes were found for all outcome measures, parents and adolescents made significant gains postintervention. In the absence of a direct comparison group, we cannot determine if these improvements are exclusively attributable to the intervention. Future research will be needed to understand the degree to which this brief intervention may effectively enhance the attainment of evidence-based psychoeducation and cognitive behavioral skills that are known to foster adaptive parent and adolescent responses to chronic pain.

Atypical antipsychotics for disruptive behaviour disorders in children and youths.

Atypical antipsychotics for disruptive behaviour disorders in children and youths.

Family Resources and Effects on Child Behavior Problem Interventions: A Cumulative Risk Approach

Family resources have been associated with health care inequality in general and with social gradients in treatment outcomes for children with behavior problems. However, there is limited evidence concerning cumulative risk—the accumulation of social and economic disadvantages in a family—and whether cumulative risk moderates the outcomes of evidence-based parent training interventions. We used data from two randomized controlled trials evaluating high-intensity (n = 137) and low-intensity (n = 216) versions of Parent Management Training—Oregon (PMTO) with a 50:50 allocation between participants receiving PMTO interventions or regular care. A nine-item family cumulative risk index tapping socioeconomic resources and parental health was constructed to assess the family’s exposure to risk. Autoregressive structured equation models (SEM) were run to investigate whether cumulative risk moderated child behaviors at post-treatment and follow-up (6 months). Our results showed opposite social gradients for the treatment conditions: the children exposed to cumulative risk in a pooled sample of both PMTO groups displayed lower levels of behavior problems, whereas children with identical risk exposures who received regular care experienced more problems. Furthermore, our results indicated that the social gradients differed between PMTO interventions: children exposed to cumulative risk in the low-intensity (five sessions) Brief Parent Training fared equally well as their high-resource counterparts, whereas children exposed to cumulative risk in the high-intensity PMTO (12 sessions) experienced vastly better treatment effects. Providing evidence-based parent training seem to be an effective way to counteract health care inequality, and the more intensive PMTO treatment seemed to be a particularly effective way to help families with cumulative risk.

A Reexamination of Child Problem Behaviors as Measured by ECBI: Factor Structure and Measurement Invariance Across Two Parent Training Interventions.

The Eyberg Child Behavior Inventory (ECBI) is a widely used instrument that assesses disruptive problem behaviors via parent report. The present study compares three different conceptualizations of problem behaviors using traditional confirmatory factor analysis (CFA), a bifactor-CFA, and a bifactor exploratory structural equation model, whereof the latter two represent novel conceptualizations of disruptive problem behaviors. Data were derived from 353 Norwegian parents assigned to parent management training-the Oregon model (PMTO; N = 137) or brief parent training (BPT; N = 216), who rated their child's problem behavior (age 3-12 years). The factor models were estimated within the PMTO and BPT samples, and in the total sample. Results showed that the bifactor-CFA, with a general problem behavior factor and three specific factors representing oppositional defiant, conduct problem, and inattentive behavior provided the best model fit. Furthermore, factorial invariance across control/intervention groups and across time (pre/post intervention) was estimated within the PMTO and BPT samples. Results revealed properties of metric and intercept invariance across intervention/control groups and over time, within both interventions. Implications of the results are discussed.

Behavioral Parent Training in Infancy: What About the Parent–Infant Relationship?

Behavioral parent training (BPT) and attachment interventions have demonstrated efficacy in improving outcomes for young children. Despite theoretical overlap in these approaches, the literature has evolved separately, particularly with respect to outcome measurement in BPT. We examined the impact of the Infant Behavior Program (IBP), a brief home-based adaptation of Parent–Child Interaction Therapy, on changes in attachment-based caregiving behaviors (sensitivity, warmth, and intrusiveness) at postintervention and 3- and 6-month follow-ups during a videotaped infant-led play. Sixty mother–infant dyads were randomly assigned to receive the IBP (n = 28) or standard care (n = 30). Infants were an average age of 13.52 months and predominately from ethnic or racial minority backgrounds (98%). We used bivariate correlations to examine the association between attachment-based caregiving behaviors and behaviorally based parenting do and don’t skills and structural equation modeling to examine the direct effect of the IBP on attachment-based caregiving behaviors and the indirect effect of behaviorally based parenting skills on the relation between intervention group and attachment-based caregiving behaviors. Behaviorally based parenting do and don’t skills were moderately correlated with attachment-based caregiving behaviors. Results demonstrated a direct effect of the IBP on warmth and sensitivity at postintervention and 3- and 6-month follow-ups. The direct effect of the IBP on warmth and sensitivity at the 3- and 6-month follow-ups was mediated by increases in parenting do skills at postintervention. Findings suggest that behaviorally based parenting skills targeted in BPT programs have a broader impact on important attachment-based caregiving behaviors during the critical developmental transition from infancy to toddlerhood.

Procedures and compliance of a video modeling applied behavior analysis intervention for Brazilian parents of children with autism spectrum disorders.

Video modeling using applied behavior analysis techniques is one of the most promising and cost-effective ways to improve social skills for parents with autism spectrum disorder children. The main objectives were: (1) To elaborate/describe videos to improve eye contact and joint attention, and to decrease disruptive behaviors of autism spectrum disorder children, (2) to describe a low-cost parental training intervention, and (3) to assess participant's compliance. This is a descriptive study of a clinical trial for autism spectrum disorder children. The parental training intervention was delivered over 22 weeks based on video modeling. Parents with at least 8 years of schooling with an autism spectrum disorder child between 3 and 6 years old with an IQ lower than 70 were invited to participate. A total of 67 parents fulfilled the study criteria and were randomized into two groups: 34 as the intervention and 33 as controls. In all, 14 videos were recorded covering management of disruptive behaviors, prompting hierarchy, preference assessment, and acquisition of better eye contact and joint attention. Compliance varied as follows: good 32.4%, reasonable 38.2%, low 5.9%, and 23.5% with no compliance. Video modeling parental training seems a promising, feasible, and low-cost way to deliver care for children with autism spectrum disorder, particularly for populations with scarce treatment resources.

Developing and implementing digital-assisted parent training intervention for disruptive behavior in primary health care

BackgroundAccording to many epidemiological studies early prevention of mental health problems is essential in childhood. The objectives are:– to determine whether a digital-assisted intervention using whole-population screening that targets the most symptomatic 4-year-old children is effective at 12 months after the start of treatment;– to describe the Finnish Strongest Families intervention model in primary health care.MethodsThe target population was children with high level of DBD symptoms screened from the population of 4-year olds attending annual child health clinic check-ups. The RCT study was conducted in southwest-Finland between 2011 and 2013. In the control group, participants (n = 232) were given access to a parent training website and a telephone call from a coach. Participants (n = 232) in the intervention group received internet and telephone delivered the Finnish Strongest Families program.ResultsDuring the 12-months follow-up results of the intervention showed the behavioural problems of the four-year-old children reduced significantly in the families who participated in the 11-week program compared to the control group. So far, this evidence-based intervention has been implemented in 13 municipalities in Finland and the nationwide implementing process is in progress.ConclusionsTraining parents online and over the telephone significantly decreases preschool children's disruptive behavior. Therefore, it is important to provide low threshold, digitally delivered, family oriented promotion, prevention and early intervention programs in the primary care. More studies are needed to evaluate the long-term effects and cost-effectiveness of digital interventions in preventive mental health care.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Adapting an attention-deficit hyperactivity disorder parent training intervention to different cultural contexts: The experience of implementing the New Forest Parenting Programme in China, Denmark, Hong Kong, Japan, and the United Kingdom.

The New Forest Parenting Programme (NFPP) is a parenting program developed for parents who have a child with attention-deficit hyperactivity disorder (ADHD). It is a manualized program that is delivered in a parent's home over 8 weeks, or in a group format, or through a self-help manual. Three randomized controlled trials have been carried out in the United Kingdom. The NFPP group has adapted the program according to feedback from parents and therapists, and for use with different populations, both within the United Kingdom and internationally. The first international trial took place in New York, United States. Trials in Denmark, Hong Kong, and Japan followed. More recently, a trial of the self-help manual has been carried out in mainland China. This paper will outline the adaptions that were needed in order to be able to deliver the program in different countries with their own expectations of parenting, culture, and language. Training had to be differently focused; manuals and handouts had to be revised, translated and back-translated; and supervision had to be delivered at a distance to maintain the fidelity of the program. The international group will outline their experience of running trials in their own countries with the NFPP in a face-to-face format (Denmark), a group format (Hong Kong and Japan), and a self-help format (mainland China).