Problem-Solving Skills Training for Parents of Children with Chronic Health Conditions

QuestionWhat is the association between problem-solving skills training (PSST) for parents of children with chronic health conditions and psychosocial outcomes of the parents, their children, and their families?

FindingsIn this systematic review and meta-analysis of 23 randomized clinical trials including 3141 parents, PSST was associated with improvements in parental problem-solving skills; decreased parental depression, distress, posttraumatic stress, and parenting stress; better quality of life for both parents and children; fewer pediatric mental problems; and less parent-child conflict.

MeaningThese findings suggest that PSST should be an active component of and serve as an emerging perspective for psychosocial interventions for parents of children with chronic health conditions.

ImportanceProblem-solving skills training (PSST) has a demonstrated potential to improve psychosocial well-being for parents of children with chronic health conditions (CHCs), but such evidence has not been fully systematically synthesized.

ObjectiveTo evaluate the associations of PSST with parental, pediatric, and family psychosocial outcomes.

Data SourcesSix English-language databases (PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library), 3 Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang), gray literature, and references were searched from inception to April 30, 2023.

Study SelectionRandomized clinical trials (RCTs) that performed PSST for parents of children with CHCs and reported at least 1 parental, pediatric, or family psychosocial outcome were included.

Data Extraction and SynthesisStudy selection, data extraction, and quality assessment were conducted independently by 2 reviewers. Data were pooled for meta-analysis using the standardized mean difference (SMD) by the inverse variance method or a random-effects model. Subgroup analyses of children- and intervention-level characteristics were conducted.

Main Outcomes and MeasuresThe psychosocial outcomes of the parents, their children, and their families, such as problem-solving skills, negative affectivity, quality of life (QOL), and family adaptation.

ResultsThe systematic review included 23 RCTs involving 3141 parents, and 21 of these trials were eligible for meta-analysis. There was a significant association between PSST and improvements in parental outcomes, including problem-solving skills (SMD, 0.43; 95% CI, 0.27-0.58), depression (SMD, −0.45; 95% CI, −0.66 to −0.23), distress (SMD, −0.61; 95% CI, −0.81 to −0.40), posttraumatic stress (SMD −0.39; 95% CI, −0.48 to −0.31), parenting stress (SMD, −0.62; 95% CI, −1.05 to −0.19), and QOL (SMD, 0.45; 95% CI, 0.15-0.74). For children, PSST was associated with better QOL (SMD, 0.76; 95% CI, 0.04-1.47) and fewer mental problems (SMD, −0.51; 95% CI, −0.68 to −0.34), as well as with less parent-child conflict (SMD, −0.38; 95% CI, −0.60 to −0.16). Subgroup analysis showed that PSST was more efficient for parents of children aged 10 years or younger or who were newly diagnosed with a CHC. Significant improvements in most outcomes were associated with PSST delivered online.

Conclusions and RelevanceThese findings suggest that PSST for parents of children with CHCs may improve the psychosocial well-being of the parents, their children, and their families. Further high-quality RCTs with longer follow-up times and that explore physical and clinical outcomes are encouraged to generate adequate evidence.

Childhood chronic health conditions (CHCs) include physical, developmental, behavioral, or emotional conditions with an expected duration of more than 3 months or the impossibility of cure.¹ Approximately 37% of children have at least 1 current or lifelong health condition.² The diagnosis of a childhood CHC and its prolonged treatments are profoundly unsettling experiences for children and their families, especially their parents.^3-5 Compared with parents of healthy children, parents of children with CHCs have reported worse mental health (more depression, anxiety, and posttraumatic stress),^6-8 significant stress and burden,^9,10 and a poorer quality of life (QOL).^6,11 Considering that parental psychosocial outcomes are strongly associated with children’s health and family adaptation,^12-14 interventions to improve parents’ well-being may have synergistic benefits for the whole family. Parental problem-solving skills, which are associated with parents’ well-being, are general coping skills applicable to a variety of difficult situations commonly encountered during the treatment of childhood CHCs.¹⁵ With better problem-solving skills, parents could become more self-assured to address children’s health concerns, fully use resources to cope with stress, and collaborate to address challenges presented by daily care, thereby improving family adaptation and children’s health outcomes.¹⁶ However, nearly one-half of parents lack problem-solving skills, especially the ability to solve daily problems related to their children’s complex treatment processes,³ which may eventually perpetuate negative outcomes for parental and child well-being.^17,18

Problem-solving skills training (PSST) is an effective intervention to improve problem-solving skills and decrease negative affectivity.^19,20 Based on the problem-solving therapy approaches of D’Zurilla and colleagues,^20,21 PSST includes 2 essential components: establishing a positive problem orientation and mastering the systematic steps to solve problems. The training has long been established as being effective in adults with chronic illness and their caregivers,^22,23 which theoretically could have broad outcomes for parents of children with CHCs due to the long-term nature and equally multiple, intensive, and ongoing stressors across childhood CHCs. Problem-solving skills training is a cognitive-behavioral process by which parents can identify and create problem-focused strategies to buffer the outcomes of stressful events and improve coping, thus preventing episodes of negative affectivity by effectively solving various children’s disease-related problems.^15,21 These problem-solving strategies, while possibly differing in specifics, are beneficial in helping parents to cope with significant stressors inherent to each CHC. Preliminary studies have shown the efficacy of PSST in enhancing problem-solving skills and alleviating depression symptoms for parents, although the majority of such studies have had small sample sizes. Moreover, these studies only considered improved parental well-being, and most did not show significant changes in pediatric or family adaptation outcomes.^15,24 In addition, although previous reviews of PSST have explored the effectiveness of psychosocial interventions for parents of children with CHCs, they had limited specificity.^19,25-28 To address these gaps, we evaluated the associations between PSST for parents of children with CHCs and parental, pediatric, and family psychosocial outcomes.

The study protocol for this systematic review and meta-analysis has been registered with PROSPERO (CRD42023424077). The revised Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline²⁹ was followed to report the findings.

A systematic search was performed across 6 English-language databases (PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library) and 3 Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang) from inception to April 30, 2023. The search strategies applied a combination of Medical Subject Heading terms and keywords, and the following constructs were used: child AND chronic health conditions AND parents AND PSST. The full search string for each database is provided in eTable 1 in Supplement 1. Gray literature was searched using OpenGrey, Mednar, and the World Health Organization’s search portal. We also screened reference lists of included studies to identify potentially eligible articles.

The population, intervention, comparator, outcomes, and study design framework was used to define the inclusion and exclusion criteria (Table 1). Eligible studies were RCTs that performed PSST for parents of children with CHCs and reported at least 1 psychosocial outcome of parents, children, or their families.

All identified articles were imported into EndNote, version 20.0 (Clarivate Analytics) to eliminate duplications. Title and abstract screening and full-text review were performed independently using the web-based software Rayyan³⁰ by 2 reviewers (T.Z. and W.X.). Data extraction was conducted in duplicate by the 2 reviewers and checked by another reviewer (Y.L.). Information was extracted using a predesigned worksheet, including publication details, population demographics (pediatric [age, medical condition, and illness duration] and parental [age, sex, race and ethnicity]), intervention and control group details (approach, mode, number of sessions, and duration), and psychosocial outcomes and measures.

We included only the postintervention data in the meta-analysis, as follow-up data were not reported consistently enough to achieve proper homogeneity. When both parents and children reported a psychosocial outcome of children, we prioritized extracting the parent-reported data, as they were more reliable. If multiple records were available for the same trial, we collected all relevant data and analyzed them as a single study. Corresponding authors were contacted via email to retrieve missing data.

The risk of bias for the included studies was assessed independently by 2 reviewers (T.Z. and W.X.) according to the revised Cochrane risk-of-bias tool, version 2.0,³¹ which includes 5 domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. We judged the studies to be low risk, of some concern, or high risk. Additionally, the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE)³² framework was applied to assess the certainty of the evidence for all outcomes. The certainty was categorized as high, moderate, low, or very low based on the risk of bias, inconsistency, imprecision, indirectness, and publication bias.^33,34 Any disagreements in the study selection, data extraction, and quality assessment processes were resolved through discussion to reach a consensus, and if conflicts persisted, they were arbitrated by a third reviewer (Y.L.).

Statistical analyses were performed using Stata, version 16 software (StataCorp LLC). We conducted a meta-analysis only when 2 or more intervention studies were available with similar participants and outcomes. The psychosocial outcomes included in this review were measured by different scales; therefore, the effect size is presented as the standardized mean difference (SMD) with 95% CI.³⁵ Statistical heterogeneity was assessed using both the χ² test and I² statistic.³⁶ The inverse variance method (P ≥ .10 and I²<50%) or a random-effects model (P < .10 or I²≥50%) was applied based on the P and I² values. Subgroup analyses were performed for children’s and intervention characteristics. In addition, we conducted leave-one-out sensitivity analyses to examine the consistent associations between PSST and all identified outcomes. We also used funnel plots and Egger test to evaluate the publication bias for analyses with at least 10 studies.³⁷ The threshold for statistical significance was set at a 2-sided P < .05. The most recent analysis update was performed between October 10 and 20, 2023.

The initial comprehensive search yielded 2665 publications: 2641 from 9 databases and an additional 24 from gray literature and reference list review. After removing 1195 duplicates and screening 1470 titles and abstracts, 227 full-text articles were assessed for eligibility. Ultimately, 23 eligible RCTs^38-60 were included in the review, and 21 studies^{38-42,44-48,50-60} were included in the meta-analysis (Figure 1). Almost perfect agreement on the study selection was achieved (97%; κ = 0.89).⁶¹

Table 2 summarizes the characteristics of the included 23 RCTs published between 2002 and 2021. Most were conducted in the US (21 studies^{38,40-44,46-60}), with 1 study each in Australia⁴⁵ and Jamaica.³⁹ Twenty-one studies^38-48,50-59 used a 2-arm RCT design. In addition, most studies (12 [52%])^{39,42,45-48,50,53-57} reported that a control group received usual care.

A total of 3141 parents were included in this review. Twenty-one studies^{38-47,49-58,60} reported on parent sex, which totaled 2799 mothers (94%) and 185 fathers (6%), and 6 studies^{38,39,42,53-55} only recruited mothers. The age of the parents ranged from 20 to 67 years, with an estimated mean (SD) age of 38.3 (9.0) years. Of 2914 parents who reported race and ethnicity,^{38,41-44,46-60} 569 (19%) were Hispanic, 316 (11%) were non-Hispanic Black, 1708 (59%) were non-Hispanic White, and 321 (11%) were of other race or ethnicity. The CHC diagnoses were traumatic brain injury (6 studies),^49,51,57-60 cancer (5 studies),^38,52-55 sickle cell disease (2 studies),^39,40 autism spectrum disorder (2 studies),^41,42 epilepsy (2 studies),^46,47 mental health problems (1 study),⁴³ inflammatory bowel disease (1 study),⁴⁴ first-episode psychosis (1 study),⁴⁵ diabetes (1 study),⁴⁸ chronic pain (1 study),⁵⁰ and asthma (1 study).⁵⁶ The mean (SD) age of the children was 10.0 (5.5) years, with the illness duration ranging from 2 weeks to 8 years.

Problem-solving skills training was confirmed as the primary focus of the intervention across the 23 RCTs, all of which were developed based on problem-solving therapy that emphasized positive problem orientation and covered the 5 core problem-solving steps (eTable 2 in Supplement 1). The number of PSST sessions included ranged from 2 to 21, with the duration of PSST varying from 5 weeks to 12 months. Most studies (18 [78%])^{38-43,45-48,50,52-57,60} involved interventions that required parents to attend face-to-face sessions, 6 of which integrated telephone-based online support.^40,43,45-48 In the remaining studies,^{38,44,49,51,52,58-60} PSST was delivered entirely online, including via telephone sessions, web-based didactic modules, and videoconferences. Three interventions^39-41 were group-based, 9 interventions^{38,42,43,45,50,52-55} were delivered to individuals 1 on 1, and 11 interventions^{44,46-49,51,56-60} included both parents and children.

The methodological quality assessment resulted in 96% mutual agreement (κ = 0.93).⁶¹ Seven studies (30%)^{39,42,45,47,50,51,56} were classified as low risk, 8 studies (35%)^{40,44,46,52,55,57,58,60} raised some concerns, and 8 studies (35%)^{38,41,43,48,49,53,54,59} were identified as having a high risk (Figure 2). Two studies^41,48 reported neither random sequence generation nor allocation concealment and hence were considered high risk for the randomization process. For 5 trials (22%),^{38,49,53,54,59} there was a high risk of reporting bias, as the prespecified outcomes were not fully reported (eTable 3 in Supplement 1).

Figure 3 illustrates the meta-analysis summary for all outcomes. Forest plots and GRADE ratings are presented in eFigure 1 and eTable 4 in Supplement 1, respectively.

Overall, PSST had a significant positive effect on problem-solving skills (12 studies including 1887 parents^{38-42,46,50,52-55,58}; SMD, 0.43; 95% CI, 0.27-0.58; I² = 64.28%), depression (12 studies including 2036 parents^{38,39,41,42,50-52,54,55,57,58,60}; SMD, −0.45; 95% CI, −0.66 to −0.23; I² = 85.29%), and distress (12 studies including 2038 parents^{38,45,50-55,57-60}; SMD, −0.61; 95% CI, −0.81 to −0.40; I² = 83.88%), all of which indicated a medium effect size and moderate certainty evidence. The studies also showed that PSST significantly alleviated posttraumatic stress (5 studies including 1469 parents^{38,50,52,54,55}; SMD, −0.39; 95% CI, −0.48 to −0.31; I² = 44.93%) and parenting stress (5 studies including 391 parents^{39,41,42,45,50}; SMD, −0.62; 95% CI, −1.05 to −0.19; I² = 76.24%). The levels of evidence for the associations of PSST with lower posttraumatic stress and parenting stress were moderate and low, respectively. The meta-analysis of parental anxiety showed a positive but nonsignificant effect. In addition, 2 studies^45,50 including 175 parents indicated a significant improvement in QOL among parents in the PSST group (SMD, 0.45; 95% CI, 0.15-0.74; I² = 0.00%), with low-certainty evidence and no heterogeneity (Figure 3).

There was an association between PSST and better pediatric QOL compared with control groups (6 studies including 590 parents^{40,44,47,48,56,60}; SMD, 0.76; 95% CI, 0.04-1.47; I² = 94.90%). Data for 436 parents showed a significant association between PSST and fewer children’s mental problems (6 studies^50,51,57-60; SMD −0.51; 95% CI, −0.68 to −0.34; I² = 34.54%) (Figure 3). We found that PSST had both medium effect sizes for improving pediatric QOL and mental health, with low- and moderate-certainty evidence, respectively, whereas no association was found for social functioning. Four RCTs^41,48,51,57 including 314 parents provided low-certainty evidence that PSST may reduce parent-child conflict (SMD, −0.38; 95% CI, −0.60 to −0.16), with moderate heterogeneity (I² = 36.98%).

Subgroup analyses were conducted according to child- and intervention-level characteristics (eFigure 2 in Supplement 1). Subgroup analysis by child age indicated that PSST was associated with significant changes in parental depression (SMD, −0.39; 95% CI, −0.52 to −0.26), problem-solving skills (SMD, 0.36; 95% CI, 0.24-0.48), posttraumatic stress (SMD, −0.40; 95% CI, −0.49 to −0.31), and parenting stress (SMD, −0.43; 95% CI, −0.72 to −0.13) for the parents of children who were 10 years or younger compared with the parents of older children (>10 years). Regarding changes in parental depression and posttraumatic stress, PSST had no association for parents of children who had not been newly diagnosed with a CHC but was associated with significant changes (reductions) for parents of children with newly diagnosed CHCs (depression: SMD, −0.40 [95% CI, −0.52 to −0.28]; posttraumatic stress: SMD, −0.40 [95% CI, −0.49 to −0.31]). Furthermore, compared with other medical conditions, PSST was associated with significant improvement in all psychosocial outcomes in parents of children diagnosed with cancer.

Overall, PSST delivered online yielded larger effects on all outcomes except for parent-child conflict than only face-to-face PSST. There was a significant improvement in depression (SMD, −0.39; 95% CI, −0.52 to −0.27) and problem-solving skills (SMD, 0.37; 95% CI, 0.24-0.50) among parents who received individual-based PSST. However, the parent-child interventions showed significant changes in pediatric and family psychosocial outcomes. As for intervention duration, PSST for 5 to 8 weeks had stronger effects on reducing parental depression and parenting stress and improving problem-solving skills than PSST with durations exceeding 8 weeks. The number of sessions followed a similar pattern, with significant improvements in depression (SMD, −0.48; 95% CI, −0.67 to −0.28) and problem-solving skills (SMD, 0.50; 95% CI, 0.29-0.70) among parents who underwent 8 to 12 sessions.

We assessed the publication bias for outcomes that included more than 10 trials (problem-solving skills, parental depression, and distress). Overall, the funnel plots were mostly symmetrical (eFigure 3 in Supplement 1); Egger tests were not significant for problem-solving skills (z = 1.64, P = .10), depression (z = −1.21, P = .23), and distress (z = −0.46, P = .65), thus indicating no publication bias. The leave-one-out sensitivity analyses yielded similar results to those of the primary analyses, indicating the robustness of key outcomes (eFigure 4 in Supplement 1).

This systematic review and meta-analysis of 23 RCTs is the first to our knowledge to adequately examine the positive association of PSST with improved parental, pediatric, and family psychosocial outcomes. The findings show that PSST was associated with improved problem-solving skills, less negative affectivity, and better QOL for parents. Positivity and problem-solving throughout PSST is achieved by refining problems and effectively troubleshooting obstacles commonly encountered during the treatment of childhood CHCs, thus contributing to parental well-being.^15,41 Additionally, PSST was associated with improvements in pediatric QOL, mental health, and parent-child conflict, in accordance with previous review results that psychological interventions for parents may facilitate their ability to scaffold behavioral and emotional changes in their children and thus reduce conflicts between parents and children.^19,27,62 Our findings extend this evidence by suggesting that PSST is also associated with better psychosocial outcomes for children and families, showing promise for the use of PSST to increase the well-being of all family members and promote family adaptation.

Problem-solving skills training is an emerging and promising area of research, with 17 (74%) included studies published in 2010 or later.^{39-47,49-52,55,56,59,60} A total of 3141 patients were included in this review, and there were sufficient sample sizes for most outcomes. Although the included RCTs were conducted in only 3 countries, which may decrease the representativeness of the results in terms of dissemination capability, the ethnic and linguistic diversity of parents across included studies showed equally positive responses to PSST when presented in various contexts. Across all psychosocial outcomes, the certainty of the evidence varied from moderate to very low. Despite the suggested effectiveness of PSST in this review, some heterogeneity remains. On one hand, the included studies used diverse definitions and instruments to measure psychosocial outcomes; on the other hand, the studies included parents of children with 11 different CHCs, all of which may have introduced clinical heterogeneity. However, the diversity may also suggest a better clinical fitness of the evidence in this review. Additionally, the current evidence on the long-term effects of PSST is limited by the small number of follow-up studies. Overall, although our review provides relatively high certainty of evidence, further research on higher-level evidence with sustained follow-up is warranted. Furthermore, it is necessary to expand the range of outcomes (eg, physical and clinical) to fully reflect the effectiveness of PSST, as most relevant studies have only reported psychosocial outcomes.

Our subgroup analysis revealed a significant decrease in negative affectivity among the parents of children aged 10 years or younger and who had been newly diagnosed with CHCs, as younger children are more reliant on their parents for daily life and disease management.⁶³ These findings are compatible with broader evidence supporting early PSST’s improvement of parental well-being when children are newly diagnosed.⁶⁴ A significant decrease in negative emotions was also found among parents of children with cancer compared with the parents of children with other medical conditions, possibly because cancer is a leading cause of death in children⁶⁵ and their parents may experience a substantial care burden.^8,66 The subgroup analysis according to intervention characteristics indicated that online intervention yielded larger effects on most outcomes than the in-person approach, which may be due to the flexibility and wider dissemination of an online approach.^52,67 With the rapid development of internet and mobile technologies in pediatric nursing,⁶⁸ future research could combine in-person PSST with enhanced online materials. Additionally, individual-based PSST was preferable for parental well-being, whereas the parent-child intervention favored pediatric and family psychosocial outcomes. The participants had more opportunities to receive personalized feedback in the individual-based interventions that included 1-on-1 activities⁶⁹ and to enhance family communication and cohesion in the parent-child intervention.²⁶ Hence, it may be worthwhile to integrate parent-child interaction when tailoring PSST according to families’ needs. Finally, PSST delivered for 5 to 8 weeks and consisting of 8 to 12 sessions had stronger associations in terms of parental psychosocial outcomes. This finding highlights the importance of shorter periods and less complexity to higher engagement in PSST, as parents’ busy schedules may interfere with long-term interventions.⁷⁰

This review had several limitations. First, we limited our search to articles in English and Chinese, which might have led to selection bias and affected the reliability of the results. Second, some of the findings must be interpreted with caution, as they were based on only 2 or 3 studies. Third, the assessment could differ across people due to the methodological subjectivity of the risk-of-bias tool and GRADE. Fourth, the psychosocial outcomes identified in this review were measured using multiple scales, and despite using SMD as recommended, the heterogeneity of most outcomes was high. Hence, the interpretability and application of the results were diminished. Finally, only the postintervention data were analyzed, as follow-up data were not reported consistently and sufficiently, and the long-term outcomes remain unclear.

The findings of this systematic review and meta-analysis suggest that PSST is associated with improvements in parental psychosocial outcomes (problem-solving skills, depression, distress, posttraumatic stress, parenting stress, and QOL) as well as pediatric (QOL and mental problems) and family psychosocial outcomes (parent-child conflict). Moreover, our findings on children- and intervention-level characteristics may guide the design and delivery of future PSST by presenting information on factors associated with effectiveness. Further high-quality RCTs with longer follow-up times and that explore physical and clinical outcomes are encouraged to generate adequate evidence for PSST. In conclusion, PSST should be an active component of psychosocial interventions for parents of children with CHCs.

Accepted for Publication: October 25, 2023.

Published Online: January 2, 2024. doi:10.1001/jamapediatrics.2023.5753

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Zhou T et al. JAMA Pediatrics.

Corresponding Author: Yuanhui Luo, PhD, Xiangya School of Nursing, Central South University, No. 172, Tongzipo Rd, Changsha City 410013, Hunan Province, China (yuanhui3@csu.edu.cn).

Author Contributions: Drs Zhou and Luo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zhou, Luo, J. Zhang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Zhou, Luo, H. Zhang.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Zhou, Xiong, Meng, H. Zhang.

Obtained funding: Luo.

Administrative, technical, or material support: Luo, J. Zhang.

Supervision: Luo, J. Zhang.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grant CMB-OC-22-462 from the China Medical Board (Dr Luo).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.