Parent Training Targeting Externalizing Behaviors in Children in Primary Care: A Randomized Non-inferiority Study of the Comet-program Delivered Via the Internet or in Group Format.

Background:

The Comet-program is a Swedish parent training program developed to target externalizing behaviors in children between 3-11 years. The program content is behaviorally oriented and the emphasis lies on increasing parenting behaviors that reinforces pro-social behaviors in children, as well as limiting the reinforcement of anti-social behaviors. The program is manualized and normally delivered in group format with parents to 6-8 children in each group. The group sessions (11 sessions á 2.5 hours) are led by two practitioners and include information, role-playing, and home-work exercises. The group format has been evaluated in two large randomized controlled studies. The effect sizes on child externalizing behaviors have been medium to large (Cohen´s d). Because of the evidence supporting Comet and other research supporting the effectiveness of similar behavioral parenting programs, Comet has been implemented in primary and specialized care in Sweden. A challenge in primary care is however the implementation costs related to the program (e.g., training of group leaders and the time each group leader need to invest in each patient). Therefore, Comet (or similar programs) are in practice used to a small extent in primary care, despite clear recommendations to offer such treatments for externalizing behaviors. A possible solution would be to offer an internet-based version of the program, which in two large randomized controlled trials have shown medium effect sizes on externalizing behaviors in children. In the internet-based version, the patients (parents) work online with seven modules over a period of nine weeks. Every module contains information, video-clips, quizzes and homework exercises. Every week the patient communicates with a therapist, that gives brief guidance and feedback online.

The internet-based format of the program has however been implemented at a very small scale in regular care. One reason is probably reluctance on part of practitioners as well as patients in replacing face-to-face contact with online-contact. The management system used in health-care in Sweden is another obstacle, since only face-to-face contacts are included. Hence, the clinics are not financially compensated for any patient contacts online. To overcome these obstacles, the present study will compare the regular Comet program in group format to a modified version of the internet-based version. In the modified version, the online contact between the patient and the therapist will be replaced with three individual face-to-face sessions (45 min each). This will reduce the total amount of time invested per patient to 135 mins, compared to 410-550 mins per patient in the group format.

Research questions:

The primary research question in the study is: (1) Will the internet-based version of Comet be at least as effective as the group format in reducing externalizing behaviors in children?