Effectiveness of the online video-feedback intervention to promote positive parenting and sensitive discipline (VIPP-Online): a randomized control trial in Chile

Abstract

Background

The first years of life are considered a crucial period for children’s developmental trajectories. Among the most important predictors of positive child developmental trajectories are parental sensitivity and child-parent attachment security. Both are seriously compromised by parental stress and burnout. The Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) has been developed to promote parental sensitivity and secure attachment. Considering the meta-analytic effectiveness of VIPP-SD, a more favorable cost-effectiveness of an online version of the intervention, and the need to provide parenting support to struggling parents, we aim to test the effectiveness of the online version of the VIPP-SD in a Chilean population.

Method

We will conduct an RCT that aims at implementing the VIPP-Online and to evaluate its effects on maternal sensitivity, limit setting, parental burnout, physiological stress levels, child behavioral problems, and infant attachment. Child temperament, mother’s mental health, and sociodemographic factors will be measured as possible moderators. We will involve 140 mothers with children of 14–15 months, selected for their high scores on a screening instrument for parental burnout. Families will be randomly assigned to either the experimental or the control group. The VIPP-Online intervention will include twelve weekly sessions implemented by trained psychologists.

Discussion

The study aims to provide evidence of the potential effectiveness of an online parenting intervention with cost-benefit advantages for the Chilean context, with a modality that allows for scalability without geographical obstacles.

Trial registration

NCT07365189, 23/01/2026.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-026-04126-z.

Background

One of the main tenets of attachment theory is that early caregiving experiences affect the quality of the infant-mother attachment relationship [1, 2]. When caregivers correctly interpret the needs of the child and respond promptly and accordingly (i.e. parental sensitivity), the infant has an increase chance of developing a secure attachment; meaning that the child is confident that the parent will be available and respond when in need. Conversely, when caregivers show either no response to the child’s needs or inconsistent responses, children are at risk for developing an insecure attachment relationship with the parent. The proposition of the relationship between sensitivity and attachment has been supported by meta-analytic studies [3, 4].

The benefits of forming a secure attachment have been widely reported in the literature over the past 40 years, with an influence that manifests in short- and long-term effects and involves aspects of a person’s psychological and physiological well-being [5]. In this regard, meta-analytic studies have shown that attachment security predicts higher social competence [6, 7], adaptive emotional regulation [8], and lower incidence of externalizing and internalizing problems [6]. Moreover, evidence shows that parental sensitivity has a broad impact on child development, including executive functions [9, 10], language skills [10, 11] and socioemotional outcomes such as emotional reactivity and regulation and social competence [12]. Parental sensitivity is also considered a buffer in case of early adversity, mitigating negative effects on physical health [13], emotion regulation [14] and executive functioning [15]. A second important caregiving dimension comprises discipline [16]. As children grow up, they are eager to assert their autonomy and to test boundaries, which frequently results in behaviors (e.g. disobedience, temper tantrums) that are challenging for parents.

Chilean children have a high risk of receiving less optimal types of parenting. A nationally representative sample, the Early Childhood Longitudinal Survey (ELPI) [17] indicates that 62.5% of caregivers report using some form of violent discipline methods, with 57% reporting the use of psychological aggression and 33% physical aggression with their children. Only 31% of parents use positive discipline methods exclusively. Moreover, Chilean parents have elevated rates of mental health problems. For example, the ELPI study found that 27% of primary caregivers show depressive symptoms and 14% of mothers are in the clinical range of parental stress [18]. One of our studies, using also the ELPI data, found that parental stress was among the stronger factors predicting internalizing and externalizing behaviors in children [19].

Parental burnout (PB) is a psychological problem resulting from long-term exposure to chronic stress in their role as caregivers, which can lead to intense exhaustion and emotional detachment from children, a loss of enjoyment in the parental role, and doubts about one’s own ability to perform such a role adequately [20]. A comparative study in Latin American countries found that Chile was among the countries with the highest rates of PB [21], and PB increased substantially after the pandemic [22]. Another Chilean study found that higher levels of PB after the pandemic predicted a higher risk of child maltreatment [23]. It is important to consider that studies in Chile have shown evidence that mothers, compared to fathers, are especially vulnerable to be affected by PB [22, 24]. This gender difference could be explained by the socioeconomic and cultural reality, in which mothers are much more involved in the upbringing of children than fathers, assuming most of the daily caregiving tasks and responsibilities [25].

Video-feedback to promote positive parenting and sensitive discipline (VIPP-SD)

Meta-analytical results [26] of 88 attachment-based parenting interventions showed that longer interventions were not more effective than shorter ones. It was also found that the most effective interventions focus on the behavior of the caregiver rather than parents’ representations or psychological difficulties. In addition, the use of video-feedback was identified in the meta-analysis as an effective approach to supporting positive parenting. Partly based on this evidence, Juffer, Bakermans-Kranenburg and Van IJzendoorn [27] developed the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD). The VIPP-SD is a protocolized and well-tested intervention in the domain of parental sensitivity, nurtured by a strong theoretical background and evidence-based components. The VIPP-SD is built upon attachment theory [1, 2] and social learning theory, particularly coercion theory [28]. Instead of rewarding negative child reactions, parents are taught to reinforce children’s positive behavior and discipline them in adequate ways, while being consistent in their limit-setting. VIPP-SD is a short-term (preventive) intervention for caregivers of children in the age of 1 to 6 years old. The program is carried out at the family’s home and consists of 6 visits (sessions) of about 2 h each. During the visits, video recordings are made of caregiver-child interactions in everyday situations. Thereafter, the video recordings of the previous visit are watched and discussed with the caregiver. While discussing the recordings, the caregiver and intervener work together on: increasing the observational skills of caregivers; increasing caregivers’ knowledge about the child development and parenting; increasing the capacity of caregivers to empathize with their children; making caregiving behavior more effective by using sensitive responsiveness and sensitive discipline. In all sessions, caregivers are explicitly acknowledged as the expert on their child, which is essential for building rapport and boosting the caregiver’s feelings of competence. Only then can caregivers explore new strategies and try out different parenting behavior. Recent research substantiates the efficacy of this parenting intervention in enhancing caregiver sensitivity and implementing consistent yet gentle limit-setting [29].

Online parenting interventions; VIPP-Online

Although there has been a growing interest in the use of technology to deliver interventions remotely for at least a decade [30] (“telepsychology”), the COVID crisis accelerated this transition, with different interventions developing an alternative online version or new interventions with an exclusive online format (e.g. Schein et al. [31]. Yet, questions have been raised about the effectiveness of this type of intervention. A recent study [32] synthesized available randomized controlled trials to compare the effectiveness of online versus in-person parenting interventions. The non-inferiority analysis showed that online parenting interventions were as effective as in-person interventions in improving parenting practices, child’s mental health and parental mental health. It was concluded that the online format is not inferior to the in-person intervention, however, considering the low number of studies examining this aspect it remains to be proven if online interventions have consistent positive effects. A different meta-analysis [33] also found no significant difference in the effectiveness related to delivery format, but they stressed the need to conduct studies with rigorous designs (i.e. Randomized Control Trials). During the pandemic, an online version of the VIPP-SD was developed [34] (VIPP-Online). The VIPP-Online maintains the core features of the intervention, with adaptations in the delivery format and the structure of the program. The intervention is delivered through a videoconference platform that allows (1) to record the parent-child tasks and (2) to simultaneously share the previously recorded parent-child interaction and provide feedback. The intervener provides directions in the recording sessions that ensure clearly capturing parent and child facial expressions during the task. Moreover, considering the delivery format, it is essential that both parents and interveners have access to good-quality internet and an electronic device (mobile phone, computer, tablet) with camera. To prevent fatigue arising from the delivery format, it was decided to shorten the sessions, with 30-minute sessions for recording the parent-child task and 40–60-minute sessions for video reviewing and feedback. Thus, the VIPP-Online has 12 sessions with alternating recording sessions and video feedback sessions. Currently, there are two RCTs being conducted (in Australia and the UK) to examine the effectiveness of the VIPP-Online, however, it is urgent to conduct such studies in non-WEIRD countries with geographically difficult-to-reach families.

Two potential benefits of online delivery compared to the traditional format stand out: its cost-effectiveness because interveners do not have to travel to the families’ homes for each session, and an opportunity to reach out to families living in remote areas but having internet access. Both benefits are especially important in a country with limited funding for implementing interventions and with between 25 and 35% of the population living in rural areas [35]. Moreover, the latest survey in Chile by the Undersecretary of Telecommunications [36] indicates that 96.5% of households in Chile have internet. In rural areas this percentage has reached 94.5% and is still growing, as a central aim to achieve connectivity all over the country. Thus, making progress in the area of remote interventions, especially in such a large territory and with many gaps in physical connectivity (roads, etc.), is both a great opportunity and meets a need. While telemedicine has already been advanced in the country, mainly in physical health, it is time to target other aspects of the wellbeing of families, and, above all, with evidence-based tools.

Objectives and hypothesis

The goal of this randomized controlled trial is to test whether the online Video-feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-Online) can reduce parental burnout and improve parenting practices, in mothers of young children in Chile.

The main questions the study aims to answer are:

Does the VIPP-Online increase maternal sensitivity and the use of consistent but gentle limit setting? Does it reduce parental burnout and stress? Does it improve child attachment security and reduce child conduct problems?

The main objective is to implement VIPP-Online and to evaluate its effects on maternal sensitivity, limit setting, parental burnout and Hair Cortisol Concentrations (HCC), child behavioral problems, and attachment security in a Chilean sample, and to explore the cost-effectiveness of the online intervention.

The specific Objectives are: O1. Implementing the VIPP-Online in a Chilean population. O2. Determining the effect of the VIPP-Online on parental sensitivity and discipline (limit setting). O3. Determining the effect of the VIPP-Online on parental burnout, cortisol-indicated stress levels. O4. Determining the effect of the VIPP-Online on child attachment security. O5. Determining the effect of the VIPP-Online on child behavior problems. O6. Exploring any moderating effect of infant temperament and maternal mental health on the effectiveness of the intervention on parent and child outcomes. O7. Examining the cost-effectiveness of the VIPP-Online.

Our hypotheses are: H.1: The VIPP-Online can be implemented with a high level of fidelity in the Chilean population. H.2: The VIPP-Online increases levels of maternal sensitivity and sensitive limit setting in a Chilean sample. H.3: The VIPP-Online decreases the levels of parental burnout and HCC. H.4: The VIPP-Online has a positive effect on children’s attachment security. H.5: The VIPP-Online decreases child behavioral problems.

Methods

Recruitment

Based on the official data from the National Institute of Statistics [37], in the Region of Los Ríos, there were 3,576 newborns in 2023. In the first three months of 2024, there were 254, 242, and 247 newborns respectively. Throughout the Municipality, we will reach out to mothers of children between 9 and 12 months old to measure parental burnout. We will select parents with the highest 30% scores on parental burnout for participation in the study. The sample will be composed of 140 mother-infant dyads, who will be randomly assigned to the experimental and control group respectively by an independent person, who is not familiar with the study (a colleague from another Department). The expected completion date for participant recruitment is August 30, 2027. To calculate the sample size, we used G*power 3.1. With a sample of N = 140 we have 0.91 power to detect a significant effect on change in parental burnout or sensitivity (time*group effect) based on a two-tailed test with Bonferroni-corrected alpha 0.025 and the meta-analytic effect size for VIPP-SD effects on parenting behaviour, and 0.81 power to detect a significant effect on child attachment (post-test only) with a two-tailed test with alpha 0.05 and the meta-analytic effect size for VIPP-SD effects on attachment security. These analyses point to adequate power of the proposed study. As an aside, the recent meta-analysis of the first 25 RCTs on the effectiveness of VIPP-SD²⁹, showed that only one study has been conducted in a South American sample (Colombia), and only three (two in the Netherlands and one in UK) of the 25 had samples bigger than our proposal. To keep expenses at the lowest but still responsible level possible, our sample size and power analysis are based on effect sizes of previous RCTs.

Inclusion criteria. To be eligible for participation, families have to meet inclusion criteria: (1) Mothers > 18 years, (2) Child age between 9 and 12 months old at first contact, (3) Mothers scoring in the top 30% of our sample on the Parental Burnout Scale (BPPS). (4) Written informed consent of mothers as participants and guardians, and (5) Internet connection at mothers’ home.

Exclusion criteria. Participants are not eligible to participate if any of the following criteria are met: (1) Child or parent with severe sensory impairment, learning disability, or language limitation, (2) Sibling already participating in the trial; (3) Family participating in active family court proceedings, (4) Parent participating in another closely related research trial and/or receiving an individual video-feedback intervention.

Intervention

The intervention is delivered through a videoconference platform that allows (1) to record the parent-child tasks and (2) to simultaneously share the previously recorded parent-child interaction and provide feedback. The intervener provides directions in the recording sessions that ensure clearly capturing parent and child facial expressions during the task. Moreover, considering the delivery format, it is essential that both parents and interveners have access to good-quality internet and an electronic device (mobile phone, computer, tablet) with camera. To prevent fatigue arising from the delivery format, we aim for 30-minute sessions for recording the parent-child task and 40– 60-minute sessions for video reviewing and feedback. Thus, the VIPP-Online has 12 sessions with alternating recording sessions and video feedback sessions (see Fig. 1).

Fig. 1.

The sessions of the VIPP-Online intervention. Overview of the twelve-session VIPP-Online program, indicating recorded sessions (REC) and feedback sessions with their corresponding main topics

Families in the control group will be contacted online individually by a psychologist (different from interveners) six times to discuss parenting strategies and child development, serving as an active control group. Later, as a waitlist group, they will receive the VIPP-Online intervention by the same group of interveners.

Instruments

Pretest. Before randomization, our study will include pretest home visits to the selected families. During these visits, the Brief Symptom Inventory (BSI), Infant Behavior Questionnaire - Revised - Very Short Form (IBQ-R-VSF), Child Behavior Checklist (CBCL), and the Parental Burnout Assessment (PBA) will be administered. A small sample of mother’s hair will be collected in this visit as well. To fill the forms during the home visit prevents missing data. Additionally, a 10-minute video recording of mother-child free play and clean-up task will be made to assess maternal sensitivity and limit setting. These measures together serve as pre-tests for our study. The answers of the questionnaires will be registered in a tablet (RedCap) to have the data automatically available in the dataset. Infant attachment will not be assessed in the pretest, because the Strange Situation Procedure ideally is conducted once, as it should not be familiar for the infant. Moreover, the randomization should result in groups with comparable attachment distributions at baseline. The pretest home visit will take around 90 min.

Posttest. At the end of the intervention, both groups (experimental and control) will be invited to the University laboratory to apply the questionnaires, take a hair sample, perform the Strange Situation Procedure to measure infant attachment, and a free play and task session for the measurement of sensitivity and limit setting. Two trained students will be in charge of these measures, unaware of the experimental or control condition of the families. Families will receive a participation compensation to offset their travel expenses.

Parental sensitivity, sensitive discipline and infant attachment will be coded from videotaped mother–child interactions by independent, trained observers who are blinded to intervention conditions.

Primary outcome measure

Maternal sensitivity: The Ainsworth et al. sensitivity scale [2] will be used to measure maternal sensitivity in 10-minute free play/task sessions. Trained observers code the caregiver’s behavior using two rating scales: Sensitivity vs. Insensitivity and Cooperation vs. Intrusiveness, on a scale ranging from 1 to 9, with high values indicating more sensitivity and cooperation. The procedure will be applied twice, first in the pre-test at home and again in the post-test in the laboratory.

Maternal Limit Setting: Parental limit-setting will be observed in a don’t touch task [38]. The task is video-taped and parental limit- setting is coded for positive discipline, using an adapted version of the revised Erickson 7-point rating scale for supportive presence, and physical interference and Laxness, both rated on a 5-point scale [39, 40].

Parental Burnout: The Parental Burnout Assessment [41] (PBA) is a 23-item questionnaire measuring the four dimensions of parental burnout: exhaustion - physical and emotional tiredness, contrast - the perceived discrepancy between the ideal caregiver they would like to be and the one they are currently, a comparison that produces guilt, feelings of being fed up - feeling tired of the parental role, and emotional distancing - putting an affective distance between themselves and their children). The Likert scale response options are: “never” (0), “a few times a year or less” (1), “once a month or less” (2), “a few times a month” (3), “once a week” (4), “a few times a week” (5), “every day” (6). High scores imply high levels of parental burnout.

Fidelity of the VIPP-Online: Based on written and audio-recorded feedback of sessions, fidelity will be coded in terms of the delivery of key components of the treatment, as well as global adherence to the manual. Note that fidelity is promoted by regular intervision and supervision sessions. We will randomly select 10% of audio recordings for two assessors trained in the intervention to rate the adherence to the VIPP-Online manual using a 5-point scale (1 = Did not follow the manual at all, 2 = Adapted most of the material, did not follow the manual closely, 3 = Sometimes adapted the material, followed manual somewhat, 4 = Adapted only minor elements, followed the manual quite closely, and 5 = Followed the manual very closely and delivered the session as specified). A score of 3 will be set as the acceptable fidelity threshold, as to receive this score most core components of the intervention are present in the feedback.

Secondary outcome measures

Hair Cortisol Concentrations: Hair samples will be collected by a trained research assistant. As hair grows approximately 1 cm per month (4 cm at least per sample), every 1 cm segment of hair represents the past month [42]. To collect hair samples, a strain of hair at the base of the vertex posterior of the scalp is selected and cut right at the scalp. Hair samples will be put into foil and stored at a dark location at room-temperature until sent to the lab for analysis.

Child Conduct Problems: Child conduct problems will be measured using the parent-reported Child Behavior Checklist [43] (CBCL) at the pre- and posttest. The CBCL is a 100-item questionnaire that asks parents to rate how true the behavior is of their child over the last two months on a three-point scale (0 = not true, 1 = somewhat true, or 2 = very true or often true). The measure gives a total score, and scores for externalizing and internalizing behavior problems. The externalizing score is made up of scores for attention problems and aggressive behaviors. We will use the aggressive behaviors subscale to evaluate child conduct problems. This measure will additionally be used for economic evaluation.

Infant attachment security: The Strange Situation Procedure [2] (SSP), considered the “gold standard measure” for the assessment of infant attachment pattern in a laboratory procedure, will be used at the post-test. The SSP consists of a series of eight episodes in which the child is exposed to stressful situations such as the entry of a stranger into the room and brief separation from the caregiver, alternating with meetings with the caregiver. The procedure is conducted in a one-way laboratory room set up as a living room with toys and requires recording for later coding. For the attachment outcome, the coding will be based on the continuous scale of security, secure v/s insecure dichotomic classifications, and the D-scale.

Health and social care service use: Health and social care service use in experimental and control groups will be measured using the Child and Adolescent Service Use Schedule (CA-SUS) [44]. Parents report their own and their child’s use of accommodation, hospital, community health and social services, and prescribed medication. This measure will be used for economic evaluation.

Parent’s quality of life: Quality of life will be measured with the 36-Item Short Form Health Survey questionnaire (SF-36) [45]. The SF-36 is a self-report questionnaire assessing health-related quality of life across eight physical and mental health domains. This measure will be used for economic evaluation.

Other pre-specified outcomes

Parental depression and anxiety symptoms: Two subscales of the Brief Symptom Inventory [46] (BSI) will be used to assess depression and anxiety symptoms of both parents. Each subscale has 6 items, which are answered on a 5-point Likert scale according to the frequency of symptomatology within the last seven days, where 0 = Not at all and 4 = Very much.

Temperament: The child’s temperament will be assessed through the Infant Behavior Questionnaire - Revised - Very Short Form (IBQ-R-VSF) [47] scale in the Spanish version, translated and validated in our country [48], reaching good reliability. The IBQ-R-VSF is a 34-item parent-report questionnaire, which asks about the frequency of occurrence of specific child behaviors during the last week, on a 7-point Likert scale. Scores are obtained on three dimensions: surgency, effortful control and negative affect, where higher scores indicate greater intensity of the dimension.

Parental sleep quality: The Pittsburgh Sleep Quality Index [49] (PSQI) will be used to assess parental sleep quality, an important covariate in the burnout literature. The PSQI is a 19-item self-report questionnaire that includes different dimensions of sleep such as sleep disturbances, use of sleep medication, sleep duration and subjective sleep quality. It provides cut-off scores that distinguish between good and poor sleepers.

Data analysis

A repeated measures ANOVA will be performed. The between-subjects factor will be experimental group vs. control group. The within-subjects factor will be pretest vs. posttest measurement. It is expected to find an interaction between both factors with positive development in the outcomes between pre- and posttest only (or stronger) in the experimental group. In the main analyses missing data will be imputed using conventional multiple imputation methods. In robustness tests we will conduct complete cases analyses. To account for possible non-compliance in the intervention a Complier Average Causal Effect (CACE) analysis will also be conducted, comparing compliers in the intervention group with matched control group participants who would have complied if they would have given the chance [44].

Discussion

VIPP-SD has been widely used and has been shown to be effective [29]. However, with the exception of one study conducted in Colombia [50], it has not been implemented in the South American context, and this will be an important possibility to estimate its local effectiveness for practitioners to promote positive parenting, sensitive discipline, decrease levels of parental burnout and cortisol, and promote positive child developmental outcomes such as attachment security and decreased behavioral problems. Additionally, the VIPP-SD has shown medium to large effect sizes for parenting and child attachment security and moderate costs in the original version (home visits), which according to Kraft [51] gives green light for scalability. For the online version this evidence might even be stronger when the intervention is effective because of the lower costs of the online implementation.

The online approach is a novel component of the study, with broad implications. As far as we know, this is the first study in Chile and South America that will assess the effectiveness of an online parenting intervention. Establishing the effectiveness of a parenting intervention that is culturally and ecologically valid is always challenging. Too often interventions with evidence based on samples from other cultural groups (i.e., USA and Europe) are simply translated and applied. However, in this project, the evidence will be built up from a pre-registered local RCT, which adds weight to its conclusions. Because the intervention is protocolized, it allows for scalability with a high level of fidelity. The use of the gold standard measure to evaluate the infant attachment relationship is also notable, in fact the majority of the outcomes will be measured in a robust way, using observational and endocrinological stress measures. Finally, taking into account that recent studies on parental burnout in Chile show high prevalences, and that the effects of parenting interventions on this syndrome are uncharted territory, testing and documenting any intervention effects on parental burnout and cortisol-indexed parental stress are crucial given the serious consequences of parental burnout for child well-being.

Authors’ contributions

RC, JV, MvIJ and MBK conceptualized the research and designed the study protocol; they also drafted the manuscript. RS reviewed and edited the manuscript draft, contributing significantly to the paper.

Funding

The study protocol was peer reviewed during the evaluation process of the funding application submitted to FONDECYT/ANID (Project No. 1252183).

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The project was submitted and approved by the Ethics Committee of the San Sebastián University (CEC N°69 − 25). During all stages of the project, the ethical norms established by the National Agency for Research and Development of Chile (ANID) and the American Psychological Association will be followed. Participants will be duly informed about the terms of their participation and that of their children in this study. Their authorization for the registration and use of the information will be requested by reading and signing a letter of informed consent. All data are treated pseudonymously. Based on experiences with 25 previous VIPP-SD trials suggesting absent adverse side-effects [51] participation in this study does not entail any risk for the families. Sampling hair for cortisol measurements is considered non-invasive, as the amount of hair needed is similar to what is usually lost for natural reasons. Participants will be able to withdraw from the study if they wish to do so, without any harm to themselves. In the event of detecting problematic interactions that may affect the well-being of individuals at any time during the study, clear and expeditious protocols for referral to psychological care centers available at the institution will be guaranteed. The data collected will be kept in a secure and confidential location. Only the research team and the assistants will have access to the data, which will be used for research purposes only. Once the data of the intervention have been collected, the same intervention will be offered to the control group.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.