Transcript Parenting, Mental Health and the Future of Young Children

Engaging Families of Young Children in Parenting
Skills Interventions:
Lessons Learned from the Chicago Parent
Program
Deborah Gross, DNSc, RN, FAAN
Leonard & Helen Stulman Professor in
Mental Health and Psychiatric Nursing
Johns Hopkins University School of Nursing & School of
Medicine (Dept of Psychiatry & Behavioral Sciences)
Acknowledgements
• Co-authors of the Chicago Parent Program: Christine Garvey,
Wrenetha Julion, and Susan Breitenstein (Rush University)
• Louis Fogg, PhD, Statistician (Rush University)
• Alison Ridge, RN, DNP (Rush University)
• Joyce Harrison, Medical Director, Children’s Mental Health Center,
Johns Hopkins Hospital
• Harolyn Belcher, MD (The Family Center at Kennedy Krieger)
• Emily Hoppe and Laura Mitchell (JHU School of Nursing)
• The National Institute for Nursing Research (NIH)
• The Leonard & Helen R. Stulman Foundation
• The Zanvyl and Isabelle Krieger Fund
• The Morton and Jane Blaustein Foundation
• The Robert Wood Johnson Foundation
Objectives of Presentation
To describe:
1. The use of a parent advisory board to inform the
creation of a parenting skills intervention called the
Chicago Parent Program
2. Research supporting the efficacy of the Chicago
Parent Program for prevention in low-income
communities
3. The use of the Chicago Parent Program for clinic
populations
4. Lessons learned (and still learning) on strategies for
increasing parent participation rates in parenting
programs
There are many evidence-based parenting
programs…
Some examples:
• The Incredible Years (Webster-Stratton)
• Parent-Child Interaction Therapy (Eyberg)
• Triple P (Sanders)
• Helping the Non-Compliant Child
(Forehand)
However, all of these programs were
originally developed and evaluated on
White, non-Latino families
Chicago Parent Program
• To improve parenting skills & reduce child
behavior problems
• Developed with an advisory board of African
American and Latino parents of young children
• Designed to be culturally relevant for African
American and Latino parents of young children
(2-5 years)
• Designed to be contextually relevant for
parents from low-income, urban communities
Chicago Parent Program Features
• Social learning theory/Coercive
Process Model
• Uses video vignettes + parent
group discussion
• 12 2-hour parent group sessions
• Led by 2 trained group leaders
•
Detailed group leader manual
•
Program’s effectiveness supported
in randomized trials
12-Session Program Overview
Unit 1: The Value of Your
Attention (4 weeks)
Unit 2: Using Your Authority
Wisely (4 weeks)
• Child-centered Time
• Importance of Routines &
Traditions
• Praise & Encouragement
• Using Reward Programs
• Say What You Mean,
Mean What You Say
• Threats & Consequences
• Ignore & Distract
• Using Time-Outs
Program Overview (cont’d)
Unit 3: Managing your
Stress (2 weeks)
Unit 4: Sticking with the
Program (2 weeks)
• Reducing your Stress
• Problem-solving
• Putting it All Together
• Booster Session (1 month
later)
What Makes This Program Different?
• ~160 vignettes, 75% are families of color
• Managing misbehavior in public and at home
• Parenting strategies reframed to enhance
relevance:
• “Child-Directed Play” vs “Child-Centered Time”
• Reframing Praise: “10 years from now, how do you
want your children to feel deep down inside about
themselves?”
• Reframing Spanking: The 8 Keys to Effective
Discipline
8 Keys to Effective Discipline
1.
2.
3.
4.
5.
6.
7.
8.
Tied to a specific behavior
Punishment should fit the crime
Discipline is predictable
Discipline is controlled
Discipline without rage
Discipline without humiliation
Discipline with a positive ending
Children always know they’re loved
Sample Vignettes
Chicago Prevention Research: Sample
Descriptions from two RCTs
• 90% mothers
• All families of color
• 58% African American
• 42% Latino
• All receiving childcare subsidies based on low income
• 60% report annual incomes < $20,000
•
•
•
•
72% unmarried
Median education: High School/GED
M child age = 3 yr (range 2-4 yrs)
54% boys
RCT Design (n=504)
• 8 childcare centers
• Centers matched, randomized
– Control n = 237
– CPP n = 267
• Intent to treat design
• RM-MANOVA with planned contrasts
Chicago Parent Program Effects (n=504)
T2= post-intervention; T3=6-month f/up; T4=1yr f/up; * p< .05; **p<.01
Variable
Overall Effect
Baseline-T2
T2-T3-T4
T3-T4
Corporal
punishment
4.24**
0.48
1.15
0.50
Following
through
2.74*
3.78*
0.00
3.07
Parenting selfefficacy
3.88**
6.79**
0.02
0.43
Child behavior
problems
(Parent)
2.63*
4.44*
0.18
0.07
Externalizing
(Teacher)
3.94**
3.32
0.27
9.28**
Internalizing
(Teacher)
2.62*
1.73
0.00
6.23**
Chicago Parent Program Effects
Observed Behavior (n=504)
T2= post-intervention; T3=6-month f/up; T4=1yr f/up; * p< .05; **p<.01
Variable
Overall Effect
Baseline-T2
T2-T3-T4
T3-T4
Parent Praise
2.30
6.56*
1.27
0.01
Commands
0.33
0.00
0.46
0.34
Child Aversive
Behavior
2.48
6.78**
1.23
0.00
Summary (2002-2011)
Compared to controls, CPP parents:
• used less corporal punishment
• used more consistent discipline
• reported higher parenting self-efficacy
• had children with greater reductions in
behavior problems
However….
Parent participation rates were low (2002-2006)
– M enrollment = 35% of eligible families
– M attendance = 36% of group sessions
– 37.5% of enrolled parents never attended
Low participation rates affect validity and
sustainability:
–
–
–
–
↓ treatment effects
↓ generalizability
↓ the number of families receiving help
↑ the cost of program delivery
2006-2011: Effect of Childcare Discounts
on Parent Participation Rates
Purpose: Test the cost-effectiveness of giving
low-income parents childcare discounts
contingent on attendance in CPP
8 Chicago childcare centers randomized:
– Standard centers: ↓ barriers to participation but
no discount
– Discount centers: ↓ barriers to participation +
discount ($5 + 20%)
Barrier Reduction Strategies
•
•
•
•
•
•
On-site parent groups at childcare center
Free childcare during parent groups
Siblings included in free childcare
Dinner for parents and children
Held on week-day evenings
Research evaluations conducted at convenient
locations
• Personable recruiters
• Toll free number if any problems
Results (n=323)
• M discount = $8.92/wk
(range = 0-$35)
• 24% of eligible families
enrolled
• 15% more parents enrolled
in discount (p = NS)
• M attendance in both
conditions = 50% of
sessions
• Parent engagement high in
both conditions
Results: Post-Interviews
Parents interviewed after CPP ended (n=61)
– 56% reported getting discounts while still
attending CPP
– 23% reported getting discount after CPP ended
– 21% had no recollection of getting discount
Administrators interviewed (n=4 centers)
– cost of administering discounts: $2.78/parent
– For some centers, discounts were an added
burden
The High Cost of Low Enrollment
Assuming Parents Attend All 12 CPP Sessions
2009 dollars
Enrollment Per Group
Costs per Parent
Session
Group Size = 3
Group Size = 6
Group Size = 15
Group Cost
$129.91 (83%)
$95.46 (78%)
$60.80 (69%)
Parent Opportunity
Cost
$27.28 (17%)
$27.28 (22%)
$27.28 (31%)
$157.10 (100%)
$122.74 (100%)
$88.08 (100%)
Total Cost (per
parent session)
The High Cost of Low Attendance
Cost per session: 15 parents enrolled, different attendance rates
2009 dollars
Number of parents in attendance per group session
Costs per Parent
Session
N = 1 parent
N = 10 parents
N = 15 parents
Group Cost
$911.93 (97%)
$91.19 (77%)
$60.80 (69%)
Parent Opportunity
Cost
$27.28 (17%)
$27.28 (22%)
$27.28 (31%)
$939.21 (100%)
$118.47 (100%)
$88.08 (100%)
Total Cost (per
parent session)
Conclusions, so far:
• CPP is effective for improving parent and child behavior
as a preventive intervention
• Like most preventive interventions, participation rates
are low
• Childcare discounts are not effective if they are too
small and too delayed
• Administering discounts is a burden for agencies
• But, the cost of low participation rates is substantial
• We need to continue to think of innovative ways to
improve parent participation rates
Chicago Parent Program in Baltimore:
The Preschool Therapeutic Learning Center*
The Children
–
–
–
–
–
–
–
–
2-5 years olds
43% African American
51% male
40% exposed to drugs in
utero
53% protective services
involvement
36% out of home
placements
38% domestic violence
exposure
83% developmental delays
The Parents
• 42% incarcerated
• 66% current or past history
of substance abuse
• 71% of mothers have a
psychiatric illness
• 50% of fathers have a
psychiatric illness
* 2009-2010
Preschool Therapeutic Learning Center Program
• Parents required to attend with their child
• 3 - 5 days/week, 9am to 12 noon
• Services currently include:
– child groups (life skills, socialization, movement,
OT)
– parent groups
– individual therapy
– family therapy
– medication management
• August 2009: Chicago Parent Program added to
treatment program
Child behavior problem score* changes
(from pre- to post-treatment)
with/without Chicago Parent Program
Before CPP** included
After CPP** included
• 19% decrease in
aggression and
hyperactivity
• 15% decrease in anxiety,
depression, social
withdrawal
• 32% decrease in aggression
and hyperactivity
• 40% decrease in anxiety,
depression, social
withdrawal
*Child Behavior Checklist
**Chicago Parent Program
2010-Present:
Extending the Chicago Parent Program into
Outpatient Treatment
• March 2010-Dec 2010 (Bayview)
• Jan 2011-present (CMHC at JHH)
– High parent satisfaction
– Improvements in child behavior problems
– improvements in parenting stress
Parent Interviews
EPIC Study
Collaboration with the Family Center at Kennedy Krieger Institute
• Funded by the NINR (2011-2016)
• Comparative effectiveness trial of two PT delivery
models for treating behavior disorders
• CPP vs Parent-Child Interaction Therapy
• Parents of 2-5 year olds referred for treatment
• Primary variables of interest:
–
–
–
–
–
Child behavior problems (parent report + observed)
Parenting self-efficacy
Parent Discipline
Parent and Clinician Satisfaction with treatments
Cost
Lessons Learned:
The Challenge of Teaching Parenting Skills to
At-Risk Families
• Parents want to be good
parents but many have no
history of good parenting to
draw from
• Groups are very beneficial for
parents but difficult to do well
• Parents must practice the new
skills, but don’t
• Parents need to see change in
their children’s behavior
• Parents learn there’s no “quick
fix,” which is demoralizing
• Family stress and
psychopathology make it
difficult to learn, practice,
persevere
Future Directions for
Practice & Research
• Develop short-term incentives
to sustain parent engagement
in treatment
• Better understand how to
match parent needs with
evidence-base treatments
• Create strong methods for
replicating evidence-based
treatments in under-resourced
communities
• Need to invest in intensive
treatments for parents and
preschool children with
serious mental health
problems
• Parenting skills training should
be a standard part of early
childhood mental health
services
Selected References
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•
•
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•
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Gross, D. et al. (in press) Cost effectiveness of childcare discounts on parent
participation in preventive parent training in low-income communities. Journal of
Primary Prevention
Gross, D. & Crowley, AA (2011). Health promotion and prevention in early
childhood: The role of nursing research in shaping policy and practice. In AS
Hinshaw and P. Grady (eds), Health policy through nursing research. NY: Springer
Breitenstein, S. et al. (2010) Measuring implementation fidelity in a communitybased parenting intervention. Nursing Research, 59, 158-165.
Gross, D. et al. (2009). Efficacy of the Chicago Parent Program with low-income
African American and Latino parents of young children. Prevention Science, 10, 5465.
Gross, D., et al. (2007). Preventive parent training with low-income ethnic minority
parents of preschoolers. In JM Briesmeister & CE Schaefer (Eds). Handbook of
parent training (3rd ed.). NY: Wiley.
Garvey, C. et al. (2006). Measuring participation in a prevention trial with parents
of young children. Research in Nursing & Health, 29, 212-222.
Thank you!
For more information from the presenter, email: [email protected]
For more information about the program:
www.chicagoparentprogram.org