Video-feedback intervention to promote positive parenting and sensitive discipline

A number of parenting programs aim to promote parental sensitivity and/or efficient disciplinary strategies, as low parental sensitivity and inefficient disciplinary behavior have been found to predict negative socio-emotional development in the child [23–26]. One such intervention is VIPP-SD, where the original version focused on promoting parental sensitivity and secure attachment, and an additional focus on sensitive discipline (SD) was added later [19,27]. The VIPP-SD intervention aims to provide parents with strategies for managing difficult child behaviors in addition to promoting sensitive parenting, thereby addressing an overarching goal of reducing child behavior problems and preventing further development of antisocial behavior [19]. Informed by Ainsworth’s concept of parental sensitivity, VIPP-SD focuses on promoting parents’ observational skills and awareness of the child’s signals, the parental ability to correctly interpret these signals and to respond to them adequately and promptly [28]. Sensitive parenting is addressed through four themes that constitute the structure and progression of the intervention (see Table 1). The sensitive discipline component is addressed in parallel through four discipline themes (see Table 1) and is based on an integration of attachment theory and Patterson’s [29] coercion theory, supplemented with Hoffman’s [30] constructs on inductive discipline and empathy [19,27]. Coercion theory originates from social learning theory, where reinforcement processes are considered an important factor for overall personality development [19]. Effective disciplining is, among other, suggested to be supported by parents reinforcing positive child behavior and ignoring negative behavior. In VIPP-SD, this approach is supplemented by additional non-coercive strategies, such as distraction and induction. Coercion theory and attachment theory derive from different theoretical traditions, but both emphasize the significance of contingent and non-aversive parent-child interactions [19,27].

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Table 1. Structure and themes of the VIPP-SD intervention for each session.

https://doi.org/10.1371/journal.pone.0312607.t001

VIPP-SD is a brief home-based intervention targeting 1–6-year-old children and their parents. It includes seven sessions of 1½-2 hours each with a 2-4-week interval. The use of video-feedback is central and is hypothesized to be an active intervention component [20]. The targeted parent and child are videotaped during daily interactions, such as playing together, clean-up situations and mealtimes. The VIPP-SD intervener analyzes the video and prepares feedback for the parent according to the VIPP-SD manual [18]. In the feedback, the intervener reinforces positive parent-child interactions and appropriate disciplinary strategies. The intervention is both standardized, following a specific thematic progression through the use of a manual (see Table 1) and personalized through the use of individualized video material, analysis and feedback, hereby allowing for implementation in various contexts [20].

Previous qualitative research on VIPP-SD

To the best of our knowledge, parents’ and other caregivers’ experience of VIPP-SD has only been examined qualitatively in relation to adapted versions of VIPP-SD. Specifically, six feasibility/pilot studies have qualitatively explored parents’ and other caregivers’ experiences. Using interviews, Barnicot and colleagues [32] reported on 23 mothers’ experiences of VIPP-PMH (VIPP-SD adapted for a perinatal mental health context with focus on perinatal ‘personality disorder’) and Williams [33] analyzed interviews on 14 fathers’ experience, where two received VIPP-SD individually and 12 received an adapted version of VIPP-SD with their partner. Using a mixed method design, Dugmore and colleagues [34] explored eight adoptive parents’ experience with VIPP-Family Placement, Oliveira and colleagues [35] explored 11 foster carers’ experiences of VIPP-Foster Care, and Iles and colleagues [36] explored five families’ experience with receiving VIPP-Co, designed for parents together. Further, Starreveld and colleagues [37] explored three primary school teachers’ experience with VIPP-School. Across all six studies, participants reported gaining a better understanding of their child and their child’s signals [32–37]. This included a more nuanced and positive interpretation of the child’s behavior and emotions. Additionally, the studies reported that parents/caregivers experienced positive change in their interactions, specifically in how they responded and adapted to their child’s signals and needs [32–37]. Several of the studies furthermore reported experiences of improvements in the parent/caregiver-child relationship [33–35]. Another recurring finding was that participants felt reassured and more confident about their parenting/caregiving following the intervention [32–36]. Some studies found that participants reported acquiring helpful strategies to manage difficult child behaviors [32,33,35], or developing a different and more positive perspective on challenging child behaviors [32,37]. However, in the study by Williams [33], some fathers experienced dissatisfaction with the level of feedback received regarding their management of specific challenges and reported no increase in confidence in managing difficult behaviors following the intervention. In the study by Iles and colleagues [36] a theme reflects the parents’ difficulties in generalizing learnings from the VIPP-Co intervention to daily situations, specifically regarding challenging child behaviors. Overall, the studies find predominantly positive experiences from participating in various adaptations of VIPP-SD. However, they also indicate challenges in meeting the needs of families with children exhibiting externalizing behaviors, warranting further exploration of this specific group. Furthermore, to date, no qualitative study has targeted parents of preschool children (aged 3–5 years) exhibiting externalizing behaviors and explored their experiences of outcomes of VIPP-SD.

The current study

The present study is, to the best of our knowledge, the first to focus exclusively on the experience of change among parents of preschool children with externalizing behaviors following the VIPP-SD-intervention. We focused on exploring changes that the parents report regarding themselves, their child, and experienced changes in parenting and the parent-child relationship. The study thus has the potential to provide new insights on perceived outcomes of the intervention for this group, contributing to the existing knowledge on VIPP-SD as a facilitator of change in families struggling with externalizing problems.

Study setting

The current study is a part of a feasibility study of VIPP-SD conducted in two Danish municipalities, where VIPP-SD-trained childcare providers (pedagogues and specialized pedagogical professionals) delivered VIPP-SD to parents of children with externalizing behavior.

Recruitment

Families could participate in the study if their child was at risk for developing externalizing behavior problems by showing extended amounts of aggressive, non-compliant and/or hyperactive behavior in the childcare center and/or at home. A list with descriptions of externalizing behaviors and examples of how these may be expressed by the child were provided for parents and professionals to identify relevant families. The list entailed 12 examples of externalizing behaviors with inspiration from the SDQ-questionnaire and items used to screen for behavioral- and attention problems, such as “often fights with other children or bullies them”, “often loses temper” and “restless, overactive, cannot stay still for long”. Inclusion criteria for the study were that the child’s behavior should match at least two of the 12 descriptions, and parents and/or professionals were concerned for the child’s socio-emotional development. Childcare providers, childcare managers and public health visitors could refer families to the study. Information was also posted on the childcare centers’ online communication platform, so that parents who recognized their child’s behavior in the description, could sign up for the study themselves. Families were excluded if the child had other problems than externalizing behavior, e.g., internalizing behavior problems, known developmental disorders (e.g. diagnosis of autism), or if there was known parental substance abuse, domestic violence or child maltreatment. Recruitment period for this study: April 1.st 2021 –July 1.st 2022.

Participants

15 families were included and received the VIPP-SD intervention. For the current study, interview data from 11 families were included. Three families were excluded as they had a VIPP-SD intervener who was a familiar childcare provider from their child’s childcare center, which made the parental experience different from the rest, and one family was excluded due to substantial deviations from the standard VIPP-SD procedure by the intervener. Of the 11 families, eight were invited to participate by staff in their child’s childcare center, two were invited by their public health visitor, and one mother signed up for the study herself. The participants were nine mothers, and two fathers aged 27–47 years (M = 36.7), with eight boys and three girls aged 3–5 years (M = 3.9). Overall, the families were well-resourced: all parents were married and living together with the other parent, most had completed either a bachelor- or a master’s degree, and none of the participants were unemployed.

Intervention

When families were included in the study, the target parent would be matched with the first available VIPP-SD intervener. The parents were advised that the target parent should be the one experiencing most challenges with the child and/or the parent who spent most time with the child. The 11 families all received a full VIPP-SD intervention in their homes, delivered by a VIPP-SD-trained childcare provider from one of the two municipalities. The childcare providers either worked in a different childcare center, than the one the family were affiliated with, or were linked to the childcare center as pedagogical consultants. All childcare providers attended a four-day accredited training in VIPP-SD and conducted a complete practice intervention under supervision before starting project trajectories. To ensure the quality of the intervention and adherence to the VIPP-SD manual, each childcare provider further received 3 hours of online supervision per family, which was provided by a certified VIPP-SD supervisor.

We made one adaptation of the original manual to the Danish cultural context: We renamed the concept of “sensitive time-out” to “sensitive pause”. The sensitive pause was described to the parents as not just being a pause for the child, but also as a tool and a pause for parents to manage their own difficult emotions. The change was approved by the VIPP-center at Leiden University and by the original developers of the intervention.

Data collection

The interviews were conducted by two trained psychology students, within a month after the parents had completed the VIPP-SD intervention. The interviewers were not familiar with VIPP-SD, allowing for authentic curiosity and non-directive questioning. The interviews followed an adapted version of Elliott’s Client Change Interview Schedule [38,39]. The CCI explores three main areas in relation to change; the perceived changes by the participants during and after the intervention period, how the participants understand the sources of these changes, including helpful aspects of the intervention, and possible difficult, hindering or missing aspects of the intervention for change [22,39]. The length of the interviews ranged from 57 minutes to 1 hour and 23 minutes. All interviews were audio recorded and transcribed by the two interviewers and a team of research assistants. Transcription were conducted following Clarke and Braun’s [40] notation system, inspired by Jefferson [41]. All transcripts were anonymized and QSR International Nvivo 14 software was used as transcription tool.

Data analysis and reflexivity

Interviews were analyzed using the reflexive thematic analysis (TA) developed by Braun and Clarke [42,43]. TA is a method for developing, analyzing and interpreting patterns of meaning across a qualitative dataset. Reflexive TA acknowledges and values the subjective and situated researcher and requires a reflexive approach regarding the researcher’s role, research practice and process [44]. TA is best described as an iterative process consisting of six recursive phases: (1) familiarization, (2) coding, (3) generating initial themes, (4) developing and reviewing themes, (5) refining, defining and naming themes, and (6) writing the rapport. Thus, the analysis process moves continuously between data, coding and theme generation. The flexibility of TA made this method suitable for our analysis, both for its capacity to facilitate a combined inductive and deductive theme generation, and in terms of how the method’s theoretical flexibility permitted the analysis in later stages to be informed by the theories inherent in VIPP-SD. The coding and main analysis were conducted by (NML) and (TS), both female psychologists and trained VIPP-SD interveners and supervisors. The analysis was further discussed with (BC), (AF) and (MSV), all of whom had no experience with delivering the VIPP-SD. QSR International Nvivo 14 software was used to conduct the coding and initial steps of clustering and analysis. In the familiarization and coding phase, both coders read all transcripts and independently coded three identical interviews to discuss overall impressions of data and to reflect upon similarities and differences in perspectives. This part of the process assisted us in refining our initial understandings of the material and increased our reflexivity by raising our awareness of possible preconceptions and subjective assumptions, such as being particularly attuned to specific areas of change at the expense of others. This was followed by a process of individual coding of respectively five (TS) and six (NML) interviews, before going on to the phases of clustering codes into themes, discussing interconnections and generating thematic maps and final themes in collaboration. The different elements in the analysis (i.e., codes, themes, etc.) were discussed with the research team during each phase, to enhance the plausibility of the interpretation and to serve as a means to reflect on subjectivity. The latter was also supported by the first author keeping a self-reflective journal. In our analysis of the data, we applied a combined inductive and deductive approach. As both coders were researchers with specific interest in early intervention and attachment, as well as being trained VIPP-SD interveners and supervisors, this knowledge by default served as a lens for us to read and code the data, as well as development of themes [44]. However, the codes and themes were developed through an inductive data-driven approach and were not pre-determined. During the coding process, we continuously reflected on how our positions, values and experience affected our reading of the data and sought to allow room for both the unanticipated, and for possible contradictions, to promote a nuanced interpretation. We coded primarily on the semantic, manifest level. Some code labels however also reflected a more latent, analytical level, when it made sense to explore meanings at a more implicit level, e.g., code labels reflecting expressions of implicitly expressed change/absence of change [44]. Since we wanted to investigate the parents’ own understandings, perspectives, and subjective experiences, the epistemological position adopted in this study most closely corresponds to an experiential and critical realist approach. This approach acknowledges the participants’ statements as an important source of knowledge, while also acknowledging that perceptions of reality and truth are situated in and shaped by both context and knowledge generation processes [44].

Theme 1: “All of her behavior is actually just a result of how she feels, right?”—Enhanced parental understanding

Theme 1 reflects a salient pattern centering on the parents’ experiences of having acquired an enhanced understanding of their children. This change was articulated by parents as a significant benefit from receiving VIPP-SD. Furthermore, it was embedded within their narratives about new ways of interpreting their children’s behavior, where they tried to “look behind the behavior” (P1). The parents’ descriptions of an improved understanding implied reflections on the child’s internal states, intentions, and needs in diverse situations, and how this influenced the child’s behavior. For example, in play situations, parents reported that they were now able to interpret child behaviors, such as uneasiness or unfocused behavior, in a more positive and understanding manner. They also experienced this to be the case in everyday life situations, where parents reported an enhanced understanding of the child’s reactions to demands, such as the challenges children face in transitioning between activities: “Because naturally, when you take children out of a game or whatever they’re interested in, something they’re engaged with, well, then—then it’s not great, is it, to be taken out of it, right?”(P2)

Some parents described the improved understanding as being helpful in relation to their concerns about more pervasive difficult behavior. One parent, struggling with the challenges of her child’s externalizing behavior after becoming an older sister, expressed how she had gained new insights into the reasons behind her child’s behavior:

“She has never, like, done bad things just to be bad, you know. And I’ve always known that. But I feel like I’ve had that confirmed and nuanced in my conversations with [the intervener], you know. So, all of her behavior is just a result of how she feels, right? So, when she struggled with a new one coming into the family, you know, um, we’ve really been focused on her a lot [before the new baby], you know. Um, and we haven’t been able to do that the same way, so I think that’s why it’s been so hard for her.” (P3)

Some of the statements revealed how parents now reflected on the contradictions between their own wishes and needs and the needs of the child, giving way to a more flexible attitude. One parent described how his enhanced understanding of his child’s emotional states helped him to change his once-negative interpretations of the child’s behavior during conflicts, which also reduced his negative thoughts regarding the quality of their relationship. He described how he previously tended to think that the child’s anger during conflicts reflected a dislike of him, whereas he was now able to understand the child’s behavior as specific to the situation. Other parents described similar insights, such as “of course the child gets angry, but the child is not angry with me, the child is angry with the situation” (P2). Parents also described how the VIPP-SD intervention had increased their knowledge of typical child development and behavior. This supported their improved understanding and acceptance of their own child’s behaviors and signals and was often accompanied by feelings of relief following the acknowledgment of the child’s behavior as typical or age appropriate. Some parents’ descriptions further reflected how some experienced greater acceptance of their child’s distinct qualities and individuality through their improved understanding.

Theme 2: Meeting the child’s needs in comfort and in play

Theme 2 centers on the parents’ experiences of change in interactions, particularly how they responded to their children’s needs differently following the VIPP-SD intervention. The parents’ statements indicate that the improved understanding of child behavior and development also led the parents to do something differently: “So yeah, I think there are many things where we’ve luckily become wiser, and now can see what her needs are in a different way, and then also fulfill them in a different way.” (P1)

Changes in the parents’ behavior were exemplified by their descriptions of concrete situations. For example, instances of outbursts and frustration around bedtime were now handled with increased patience, psychical proximity, and affection. One parent’s narrative illustrates how the new interpretations of child behavior led to changed parental responses characterized by warmth, comfort, and understanding:

“We also talked a lot about, uh, how sometimes she wants to be carried. And she wants to be carried, where it’s like, "you’re five, so you can walk by yourself," right? But, where we also agreed, well, she might also uh, she might be lacking that close contact in some way, because she’s rejected it for so long. So maybe it’s okay to pick her up and give her that, because being carried is not just a "I don’t feel like walking by myself," there’s so much more to it. There’s presence, there’s caressing, there’s love, there’s […], it’s so much more than just dragging your child because they don’t want to walk. […] So, we are much more receptive when she wants that affection and care, because she hasn’t sought it in the same way before. Uh, so that has been really nice.” (P1)

Parents, in general, reported having gained a new awareness of how frequently their children seek contact and emotional support, as well as an increased awareness of the significance of providing opportunities for physical proximity. For instance, prioritizing a quiet time on the sofa after returning home from childcare, engaging in conversation and reading, rather than immediately attending to practical tasks such as preparing dinner.

Parents shared experiences of change, both regarding their own behavior and that of their child, especially in the context of playing together. They repeatedly described how their own participation in play had changed, with the parents trying to follow the child’s initiatives and letting the child explore based on his/her own needs. Some emphasized how a parent’s role in play can be characterized by being present and supportive. The parents’ efforts to take a step back and allow the child to lead during playtime were explicitly described as a particularly significant change in parental behavior:

"[…] I could see from the first films we made, that I might have been a bit too quick to, not intervene, but to step in and control the play. Because I could see that now my child might get a bit stuck, but there I have learned that he needs a bit more time to figure it out. Where we as adults we’re a bit like ’we don’t want to sit and watch, let’s just move on, let’s find something else to do,’ now I have become more aware that my child, or both my children, fundamentally need to be allowed to explore more […]. It might take them two minutes to figure out what that car can do, or what that thing can do, but that’s part of their learning process. Um, so I have definitely learned that about myself. That I need to step back, so it’s not me who’s leading the way.” (P5)

As evident in this statement, the emphasis on allowing the child to explore at their own pace during play also highlights the parents’ abilities and willingness to prioritize the needs of the children over their own agendas.

The shift in how the parents engaged with and followed their child’s signals seemed to allow for a more playful attitude. Some parents’ narratives included descriptions of how they increasingly supported pretend play and allowed themselves to be drawn into the world of imagination. Additionally, some reported being more aware of how important joyful playing with their parent is for the child, as well as how children initiate sharing joyful emotions with the parent:

“That made me aware of how much my child actually seeks my recognition through his eye contact with me when he is happy about something. Because the first thing he does is to look up at me and be acknowledged with a glance, a smile, or something else. So, I think about that much more now than I did before.” (P8)

Apart from a shift in the way the parents engage in play, the parents also expressed new insights into the importance and positive outcomes of playing together, leading to a renewed focus on prioritizing playing and having fun together. Finally, some parents reported a noticeable increase in their children’s initiatives regarding interactive activities following the intervention, and some described how their child now prefers playing together instead of alone.

Theme 3: Learning to prevent and manage conflicts is essential–diverse experiences of gains and progress

Theme 3 centers on the parents’ experiences of change in relation to the prevention and management of conflict, which they expressed as a particularly important area for change. Most parents experienced improvements in their ability to set limits and deal with difficult situations in successful ways, but many also noted how they would have liked to receive even more guidance within the area of conflict management and how they wished more time had been spent focusing on conflicts. As such, Theme 3 captures the parents’ diverse experiences within this area.

Most parents described how they still had conflicts with their child, but through VIPP-SD, they had learned new ways to handle them. This changed both the way they acted in difficult situations with their child and their subsequent thoughts and feelings. Prior to the intervention, some parents described feeling powerless during conflicts with their child, being anxious and uncertain about what to do:

"I’m also sitting here thinking that before, uh conflicts were something that could, well, […] make a chill run down my spine, because ’oh, ohhh what now,’ right. Whereas now, I think we’ve gained a newfound calmness, or at least I have, to resolve conflicts and trust that it’s just a feeling and it will pass. So, um, what can one say, more energy to resolve conflicts maybe.” (P1)

Parents described how conflicts could trigger them in ways where their own emotions would spiral, similar to the child’s reaction, making conflicts even more heated. After the VIPP-SD intervention, parents described how they were now able “stay calm” (P6) while handling challenging situations with their child. This ability to better regulate their own emotions during conflicts, was reported by several parents and perceived as a significant game changer. Staying calm and not raising their voice at their child was experienced as preventing conflicts from escalating and resulted in shorter durations of conflicts with lower intensity. The increased ability to regulate their own emotions thereby also reflected a decrease in parenting behavior that could be characterized as more negative:

"Um, I’ve also been prone to raising my voice, because […] when you’re busy, sometimes you raise your voice because as a parent, you think they’ll listen more. And it just doesn’t happen. So, it’s also sometimes trying to keep your volume down, mean and say things the same way, but without raising your voice. Sometimes that in itself has made him actually shift down a gear or listen better." (P6)

Parents further reported gaining new skills through the VIPP-SD intervention to prevent and manage conflicts, so they now had a “box of tools” to guide their behavior (e.g., preparing the child for upcoming changes, only making one request at a time, distraction and positive reinforcement of appropriate behavior, using “the sensitive pause” when conflicts become particularly heated etc.).

In general, parents reported a more flexible approach to limit-setting and demands after receiving VIPP-SD. For example, some parents described how they increasingly took the child’s mental state into account before asking the child to complete tasks or adhere to demands. Parents described becoming more patient with the child and that this eased conflicts and sometimes even prevented them from occurring. They explained how they now made a greater effort to understand what triggers the child’s frustration, with some parents describing how they were now better able to empathize with their child during conflicts. The acknowledging stance was described by some as a significant change compared to how they used to handle conflicts prior to receiving VIPP-SD:

" […] then I actually use that thing of trying to sit down in there completely calm, and simply say to him ’I can really see that you’re upset,’ ’I can see you got mad at me when I said no to the orange, but it’s so you can eat your dinner, then you can have it afterwards.’ Then he might be angry and upset, but I stay there and embrace it. And there can be days where I can be in there and embrace it, and some days where I can feel that I need to take a break, and then I come back again and talk with him about the feelings he has. Um, and that’s something I haven’t done much in that way before." (P6)

The major changes, according to the parents, were to be found within themselves, in their interactions with their child and their behavioral pattern, whereas the child, to some extent, behaved and responded as usual in relation to conflicts. However, some also described notable positive changes in the child’s behavior. For example, some parents shared examples wherein the child’s behavior during conflicts exhibited fewer externalizing tendencies than before; for instance, the child did not hit, bite or throw things around anymore, and some children were more compliant.

Although many parents reported that VIPP-SD supported conflict management, experiences varied regarding the extent of outcomes within this domain. Several expressed a need for more support in this area. Some parents felt that sessions with little or no focus on conflicts were a wasted opportunity, as their primary concern was learning how to deal with the child’s externalizing behavior. They considered conflicts the key issue, making subjects, such as play, seem irrelevant. When asked about unfulfilled expectations, some parents’ accounts suggested that they still felt a need for tangible, practical knowledge after VIPP-SD, particularly concerning understanding and knowing how to handle “the real conflicts” and typical challenging situations: "Um, or if the intervener had been with us in the supermarket, she could have given advice on, well, how […] to handle it, and how not to handle it. What would one say to the child.” (P8) One parent further described changing his parenting approach in some situations, though he did not feel the intervention had improved his conflict-management skills specifically.

Theme 4: “I’m actually not a bad parent”–new positive perspectives

A common pattern centers on how the parents experienced a boost in their parental confidence through participating in VIPP-SD. While some parents entered the project with self-blame and a focus on the challenges in everyday life, they described how they became aware of the things they did well and their successes in parenting. Realizing all the things that worked made a significant impression on many parents and left them feeling more competent and capable as parents:

"Because I feel like before, I was a bit worried and very much in that negative spiral. You only saw the challenges and the issues […]. And I feel like VIPP has shed light on the good things and what you actually do without even thinking about it. So that […] has made me think ’okay, I’m actually not as bad a parent as I felt I was,’ because I actually do some things already that I just hadn’t thought about myself. And that was actually really nice, because I’ve had such a […] guilty conscience. […], so it’s been really nice to have it illuminated from the outside in a different way." (P6)

Several parents described how the intervention led them to recognize their importance to their child, fostering an understanding that their child liked them and wanted to spend time with them, a realization they had not been certain of prior to VIPP-SD. Through the intervention, parents came to recognize that even though the catalyst for their participation in the intervention project was embedded in the conflicts and everyday struggles with their child, the interaction between the parent and child was full of positive moments. For many parents this realization came as a surprise, and they described how it made them reconnect with feelings of love and warmth towards their child:

“We’ve become a bit more in symbiosis in some way. And I also said to the intervener, every time she was out here, when we were going to watch what she had filmed, I could feel in some way, that I just loved my child a bit more and wanted to bring her home, because […] you don’t often see yourself from the outside, but it was just […] so clear, how much love there was between us when I watched these video clips. So, it was really nice.” (P1)

Implications for research

Even though a recent comprehensive study of the efficacy of VIPP-SD on externalizing behaviors show positive and promising results [21], participants in our and similar studies express a wish for more help in relation to managing conflicts and challenging behavior. This, combined with the absence of meta-analytical evidence for the effect of VIPP-SD on children’s externalizing behaviors, underscores the need for future research to investigate whether the intervention could be even more efficient in addressing management of situations characterized by a high level of conflict and negative affect. This is important not only in terms of promoting efficacy but also in terms of making sure the intervention is experienced as meaningful to the participants, thereby preventing low engagement and attrition. Future studies should investigate which intervention components are not only most effective but also perceived as vital for desired change by parents of children with externalizing behavior, as well as potential inhibiting factors. This is important due to the flexibility of the method, which, on one hand, allows the intervention to be individualized, but on the other hand risks some learning messages being underrepresented in some VIPP-SD trajectories. This highlights the importance of future explorations of the key facilitators of change in VIPP-SD, to be able to ensure they are sufficiently delivered in the individual trajectories. Future studies could, moreover, include measures of reflective functioning/parental mentalization, parental emotion regulation capacities and parental self-efficacy as potential mediators or pathways for change.

Strengths and limitations

The primary objective of the present study was to elicit a detailed analysis of participants’ experiences of change following VIPP-SD. Qualitative research does not aim for generalizability but strives for depth and nuanced insight, combined with taking measures to allow readers to be able to assess the degree of transferability to other contexts. We promoted credibility and transferability by employing strategies to enhance reflexivity, and by continuously seeking feedback from the research team to critically evaluate the research process and analysis, in addition to providing descriptions of the process of analysis, of the research setting, the context and participants, as well as the data collection methods.

The primary limitation of the study might be the homogenous sample. Firstly, our sample consisted of volunteer participants who completed the entire intervention. Though they did point to areas for improvements, they might have been more prone to elaborate on positive experiences than participants who dropped out. As the study focused on experienced change from participation, a prerequisite was completion of the intervention. Since the embedding feasibility study had a high proportion on non-completers, it would have been interesting to investigate more divergent experiences. Furthermore, our sample was resourceful in terms of education, marital status, and employment status. Additionally, our study included both mothers and fathers, but nine out of 11 participants were mothers. Research points to a need to explore the experience of fathers specifically, who are underrepresented in studies of parenting interventions [70,71].

While most participants reported predominantly positive experiences with the intervention, variations in experiences were observed in both the degree and domains of change. Our investigation did not explore factors such as individual differences among participants, which could be a pivotal area for future research exploring ’what works for whom’. Furthermore, we were unable to investigate the potential long-term effects of the intervention. For instance, some parents might observe additional positive changes in their children’s behavior over an extended period if the changes in parental behavior are maintained. Conversely, we cannot ascertain whether the reported changes endure over time.

Our focus on the most prominent patterns of change relating specifically to the parent and child involved in the intervention, resulted in some reported changes not being covered in the present analysis, such as improved parental teamwork and broader family dynamics.

Finally, the study was conducted during 2020–2023 while COVID-19 still affected the Danish society. It is unknown if and how this affected the experiences with participation. None of the participants in the sample mentioned the pandemic when asked about important factors affecting outcomes, but the length of many intervention trajectories did exceed the recommended timeframe because of repeated cancellations and re-bookings that might have been related to the effects of the pandemic.