Subgroup considerations Very poor and vulnerable families in low- and middleincome countries can be reached by parenting interventions and are likely to experience good outcomes in terms of improvement in parenting practices, as well as reduction in adolescent behaviour problems. By targeting families with adolescents most in need, parenting interventions have the potential to narrow disparities between groups, in maltreatment and related risks (4), Chapters 2, 4. The GDG cautioned that within families where serious maltreatment and parent-adolescent conflict is occurring, specialized parenting interventions coupled with child/adolescent protection service interventions should always be considered to prevent further harms from occurring and mitigate the consequences of previous abuse and neglect.

Context and system considerations When designing and delivering interventions for parents of adolescents it is critical to consider neighbourhoodand community-level risk factors which in some lowand middle-income countries may include easy access to drugs, alcohol and weapons, the presence of gangs and organized criminal groups, sexual exploitation (offline and online), and HIV-infection risks. Adolescents are particularly susceptible to such risks, and parents and caregivers participating in adolescent-focused interventions may find it helpful to be offered resources to help them talk with adolescent family members about alcohol and drug use, violence, the influence of peers, sexual exploitation, and HIV-infection. Facilitating parents’ ability to support their adolescents’ changing needs, while still helping them provide optimal caregiving, is pivotal in ensuring adolescents’ well-being. Including adolescents and increasing the participation of fathers in the intervention activities can, if managed by skilled staff, lead to improved communication and mutual respect. Systems for delivering parent and caregiver interventions must be accessible and acceptable to parents and adolescents, and have an adequate workforce and organizational capacity to support delivery. Prior to beginning implementation there is a need for careful assessment of organizational readiness, and for advocates or intervention champions at one or more levels in the system (e.g. at policy-maker and donor level, and at delivery level) to help ensure successful implementation and sustainability.

Implementation considerations Parent and caregiver interventions are likely to be effective when universally accessible by all parents and caregivers and when selectively delivered to parents and caregivers at high risk of maltreating their adolescents (4), Chapters 2, 4. There were too few maltreatment interventions delivered on an indicated basis in low- and middle-income countries to analyse their effects. However, evidence from high-income countries suggests that effects on positive parenting and adolescent behaviour outcomes are greater when interventions are delivered on an indicated basis to adolescents showing high levels of behaviour problems. Indicated interventions are similar in content to those delivered on a universal and selective basis, but often have additional components. For example, in maltreatment response interventions there may be trauma-care elements over and above routine parenting components, and they are likely to require a higher level of professional skill and training compared to delivery on a universal or selective basis. Evidence from qualitative studies with staff and managers suggests that staff must be given adequate time and support to prepare and deliver interventions as part of their core duties, and technical support to ensure that intervention fidelity is maintained (5), Chapter 2. Strong leadership and support systems can help ensure that these conditions are met. Implementation costs may be reduced if lay health or community workers are employed. Many group-based programmes for this stage of development involve parents and adolescents together in the same groups, meaning that staff may need additional training and support for managing these more challenging group dynamics (5), Chapter 2.