Parenting, Child Maltreatment, and Social Disadvantage: A Population-Based Implementation and Evaluation of the Triple P System of Evidence-Based Parenting Support.

Child Maltreatment (CM) is a widespread public health problem, with adverse outcomes for children, families, and communities. Evidence-based parenting support delivered via a public health approach may be an effective means to prevent CM. The Every Family 2 population trial applied a public health approach to delivering evidence-based parenting support to prevent CM in disadvantaged communities. Using a quasi-experimental design, 64 matched low socioeconomic communities in the Australian states of Queensland and New South Wales received either the full multi-level Triple P system (TPS) of parenting support, or Care as Usual (CAU). Two population indicators of CM, the number of substantiated cases of CM, and the number of notifications of CM to protective services were compared using Welch's t-test to evaluate intervention effectiveness. After two years of intervention, medium to large effect sizes favoring TPS communities were found for substantiations (d = 0.57, p < .05) and notifications (d = 1.86, p < .001). These findings show the value of the TPS, deployed using a public health approach, in efforts to prevent CM in socially disadvantaged communities. A number of uncontrolled contextual factors are described that may have contributed to some of the differences detected between TPS and CAU communities.

A comparison of perceived barriers to optimal child sleep among families with low and high income.

OBJECTIVE: Families with low-income experience suboptimal sleep compared to families with higher-income. Unique drivers likely contribute to these disparities, along with factors that universally impede sleep patterns, despite income level. To inform intervention tailoring, this mixed-methods study gathered parent's perceptions about child sleep challenges to identify similarities/differences in families with lower-income and higher-income. METHODS: Parents who experienced difficulties with their child (ages 2-4years) sleep were categorized as lower income (n = 15; $30,000 ± 17,845/year) or higher income (n = 15; $142,400 ± 61,373/year). Parents completed a survey and semistructured interview to explore barriers and facilitators for child sleep. Two coders independently evaluated transcripts for lower-income and higher-income groups using inductive analyses. Constant-comparison methods generated themes and characterized similarities/differences by income group. RESULTS: Groups were similar in themes related to diverse bedtime routines, nighttime struggles with child sleep, parent strategies to reduce night wakings, parent effort to provide a sleep-promoting environment, and presence of electronic rules. Groups differed in themes related to factors influencing routine setting (eg, lower income: external factors influencing routines; higher income: personal attributes for structure), parent appraisal of child sleep (eg, higher income: ambivalence; lower income: mostly negative appraisal), nap timing and duration (eg, lower income: longer naps), and strategy utilization and pursuit of resources (eg, higher income: more parents tried various strategies and accessed online/print resources). CONCLUSIONS: Parents experienced many similar barriers to child sleep, with a few distinct differences by income group. These findings can inform future intervention components for all families, as well as customized components to address the unique needs of families across income levels.

Prevention Science and Health Equity: A Comprehensive Framework for Preventing Health Inequities and Disparities Associated with Race, Ethnicity, and Social Class.

The ultimate goal of our public health system is to reduce the incidence of disability and premature death. Evidence suggests that, by this standard, the USA falls behind most other developed countries largely as a function of disparities in health outcomes among significant portions of the US population. We present a framework for addressing these disparities that attributes them, not simply to differences in the behavioral and physical risk factors, but to social, environmental, and structural inequities such as poverty, discrimination, toxic physical setting, and the marketing of harmful products. These inequities result from de facto and instituted public policies. An analysis of the NIH research portfolio indicates a relative lack of investment in experimental evaluations of preventive interventions-especially studies targeting disadvantaged populations. Moreover, experimental research on reducing social inequities is almost entirely lacking. A line of research focusing on the drivers of inequities and their dissolution must include experimental evaluation of strategies for getting policies adopted that will reduce inequities. In conclusion, a summary is provided of the types of research that are needed and the challenges involved in conducting the experimental research that is essential for reducing inequities and disparities and, in turn, prolonging life.

Barriers to Optimal Child Sleep among Families with Low Income: A Mixed-Methods Study to Inform Intervention Development.

This study gathered formative data on barriers to optimal child sleep to inform the development of a sleep intervention for parents of preschool-aged children in low-income households. Parents (n = 15, age: 34 ± 8 years, household income: $30,000 ± 17,845/year) reporting difficulties with their child's sleep participated in this study. Mixed methods included an online survey and semi-structured phone interview. Items assessed barriers/facilitators to optimal child sleep and intervention preferences. Interview transcripts were coded using inductive analyses and constant-comparison methods to generate themes. Derived themes were then mapped onto the Theoretical Domains Framework to contextualize barriers and inform future intervention strategies. Themes that emerged included: stimulating bedtime activities, child behavior challenges, variability in children's structure, parent work responsibilities, sleep-hindering environment, and parent's emotional capacity. Parent's intervention preferences included virtual delivery (preferred by 60% of parents) to reduce barriers and provide flexibility. Mixed preferences were observed for the group (47%) vs. individual (53%) intervention sessions. Parents felt motivated to try new intervention strategies given current frustrations, the potential for tangible results, and knowing others were in a similar situation. Future work will map perceived barriers to behavior change strategies using the Behavior Change Wheel framework to develop a parenting sleep intervention.

Family-Based Prevention of Child Traumatic Stress.

Most children experience potentially traumatic events, and some develop significant emotional and behavioral difficulties in response. Although the field has mainly focused on treatment, a prevention framework provides an alternate approach to reducing the public health burden of trauma. Because parents and families can affect children's trauma exposure and reactions, family-based preventive interventions represent a unique opportunity to address child traumatic stress. This article discusses family-based programs that address child traumatic stress across 3 categories: preventing children's exposure to traumatic events, preventing traumatic stress reactions following exposure, and preventing negative long-term sequelae of trauma.

Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis.

BACKGROUND: High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality. OBJECTIVE: This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers. METHODS: A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches. RESULTS: For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t168=23.2; P<.001), family costs (t185=9.2; P<.001), and total costs (t171=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars. CONCLUSIONS: The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal. TRIAL REGISTRATION: ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Introduction to the Special Issue: Interplay of Family Factors and Cognitive-Affective Processes in Youth.

Substantial research suggests that caregivers and families are powerful socialization agents when it comes to how youth process and regulate cognitive-affective information, which in turn can be a risk or resilience factor for various forms of developmental psychopathology. To this end, Clinical Child and Family Psychology Review features this special journal issue on the "Interplay of Family Factors & Cognitive-Affective Processes in Youth." Featured articles review a wide array of methodologies and highlight numerous forms of cognitive-affective processing and family contextual factors. Multiple themes emerged across the twelve articles, emphasizing the need to examine (1) complex pathways within families, (2) the quality of cognitive-affective processes across individuals, (3) neurodevelopmental pathways linking socialization and cognitive-affective processes, (4) nuanced methods to assess "in-the-moment" cognitive-affective processes, (5) the impact of cultural background on how family factors intersect with youth cognitive-affective processes, and (6) the socialization of positive emotion. These papers showcase the applicability of this significant area of research for future efforts in prevention and intervention with youth at risk for, or already experiencing, some form of psychopathology.

Online-delivered parenting intervention for young children with disruptive behavior problems: a noninferiority trial focused on child and parent outcomes.

BACKGROUND: This study evaluated whether an evidence-based parenting intervention, when delivered online, could effectively address disruptive behavior problems in young children and yield outcomes comparable to in-person delivery of the same intervention. METHODS: Families (n = 334) of children (3-7 years; 63% White, 22% African American, 15% other races; 63% male) with disruptive behavior problems were randomized to online-delivered intervention (ODI) or staff-delivered intervention (SDI), resulting in baseline and demographic equivalence. Primary outcome measures for child disruptive behavior (independent observation, parent report) and secondary outcome measures of parenting and family impact were assessed at baseline, postintervention, and follow-up. Conducted using intent-to-treat (ITT) as well as per-protocol (PP) methods, noninferiority analyses, which drew on an HLM framework with repeat measures across three timepoints and on REML to provide unbiased estimates of model parameters, tested whether the outcome-difference CI did not exceed the a priori noninferiority margin. RESULTS: For ITT and PP analyses, the ODI was found to be noninferior to the SDI on the primary outcome: independently observed child disruptive behavior and parent-reported child behavior problems. The pattern for secondary outcomes was more varied: (a) noninferiority for observed positive and aversive parenting; (b) noninferiority for observed quality of parent-child relationship at post but not follow-up assessment; (c) noninferiority for parent-reported inappropriate/inconsistent discipline for PP but not ITT analyses; and (d) noninferiority not confirmed for parenting daily hassles and adverse family quality of life, despite large effect sizes for the ODI (Cohen's d .75-1.07). Finally, ODI noninferiority was found for teacher-reported child disruptive behavior. CONCLUSIONS: The tested online-delivered parenting intervention demonstrated clear noninferiority with the corresponding staff-delivered parenting intervention on the primary outcome, child disruptive behavior problems, and reflected substantial though nonuniform noninferiority and meaningful effect sizes for secondary outcomes related to parenting and family. Future research will guide optimization of online interventions.

Development and Validation of Fidelity Monitoring and Enhancement in an Evidence-Based Parenting Program.

This article adds to current research by examining treatment fidelity of an evidence-based parenting program (namely Triple P) as part of a large clinical trial which included a range of procedures for promoting fidelity including both expert and peer supervision. Procedures for monitoring and promoting fidelity are described, and two major aspects of fidelity, namely content adherence and process fidelity, were evaluated. All treatment sessions for 166 families participating in the Standard Triple P-Positive Parenting Program were video-recorded and then sampled for evaluation without advanced knowledge by delivery practitioners. Independent coders at an external site assessed content adherence and rated delivery process. Fidelity promotion included high-quality training of practitioners on a standardized protocol, ongoing clinical supervision by peers and supervisors, and fidelity feedback sessions. Average content fidelity was consistently high (i.e., over 80%). Process fidelity scores were similarly high across sessions. A brief survey indicated practitioners found that the fidelity and implementation model was useful and contributed to increasing self-efficacy over the course of the initiative.

A Strategic Plan for Strengthening America's Families: A Brief from the Coalition of Behavioral Science Organizations.

Despite significant progress in research on the treatment and prevention of psychological, behavioral, and health problems, the translation of this knowledge into population-wide benefit remains limited. This paper reviews the state of America's children and families, highlighting the influence of stressful contextual and social conditions on child and family well-being and the concentration of disadvantage in numerous neighborhoods and communities throughout the nation. It then briefly reviews the progress that has been made in pinpointing policies that can reduce stressful contextual conditions such as poverty, discrimination, and the marketing of unhealthful foods and substances. It also describes numerous family and school interventions that have proven benefit in preventing psychological and behavioral problems as diverse as tobacco, alcohol, and other drug use; depression; antisocial behavior; academic failure; obesity prevention; and early childbearing. We argue that progress in translating existing knowledge into widespread benefit will require a nationwide effort to intervene comprehensively in neighborhoods and communities of concentrated disadvantage. We present a strategic plan for how such an effort could be organized. The first step in this organizing would be the creation of a broad and diverse coalition of organizations concerned with advancing public health and well-being. Such a coalition could increase public support both for the policies needed to focus on these disadvantaged areas and the research needed to incrementally improve our ability to help these areas.

Progress in Nurturing Human Well-Being.

Substantial evidence in the behavioral and social sciences has accrued in support of numerous intervention programs and policies bearing on improving the lives of children and families. To this end, Clinical Child and Family Psychology Review features a special journal issue on "Evolving Toward a More Nurturing Society." The field has achieved numerous advances regarding how to create and promote nurturing environments that foster successful development and prevent psychological and behavioral problems in children and youth. Such advances cut across multiple strategies (e.g., programs and interventions, practices, and public policies), settings (e.g., family, school including preschool and K-12, service sectors, community), domains (e.g., behavioral health, parenting, cognitive and academic functioning, nutrition, physical activity, obesity, safety, and many other domains), and developmental periods of childhood. The special journal issue showcases a sampling of strategies and domains relevant to producing optimal conditions of nurturance for children and families.

Achieving Population-Level Change Through a System-Contextual Approach to Supporting Competent Parenting.

The quality of parenting children receive affects a diverse range of child and youth outcomes. Addressing the quality of parenting on a broad scale is a critical part of producing a more nurturing society. To achieve a meaningful population-level reduction in the prevalence rates of child maltreatment and social and emotional problems that are directly or indirectly influenced by parenting practices requires the adoption of a broad ecological perspective in supporting families to raise children. We make the case for adopting a multilevel, whole of population approach to enhance competent parenting and describe the essential tasks that must be accomplished for the approach to be successful and its effects measurable. We describe how a theoretically integrated system of parenting support based on social learning and cognitive behavioral principles can be further strengthened when the broader community supports parental participation. Implications for policy and practice are discussed.

Assessing child maltreatment prevention via administrative data systems: A case example of reproducibility.

Critical issues about scientific reproducibility have been raised about biomedical research, including the reliability of data and analyses within a given study. The case example in this article examined a reproducibility issue pertaining to the use of administrative data systems for evaluation of child maltreatment (CM) prevention, making use of a prevention study conducted over a decade ago that provided a unique opportunity. The place-randomization study, which randomized counties to condition, found that community-wide implementation of a parenting and family support intervention produced positive impact on county-wide rates for substantiated CM cases and out-of-home placements, documented through a state information system. The key consideration is whether and to what extent the administrative record data re-examined retroactively a decade later for the original study's time period would yield comparable results to those based on data acquired at the time of the study. The results indicated that despite small changes over time, the same data patterns and statistical effects were reproducible for the two archival outcome variables. For substantiated CM, the reproduced analyses reflected higher effect sizes and a clear pattern of reduction as a function of intervention. For out-of-home placements, effect sizes were quite comparable to the original ones, reflecting preventive impact. Overall, this case study illustrated the verifiability of data reproducibility in the context of a population outcome evaluation, which underscores the importance of reliable population-prevalence measurement as an essential part of a comprehensive public health strategy aimed at the prevention of CM.

Potential Mediators in Parenting and Family Intervention: Quality of Mediation Analyses.

Parenting and family interventions have repeatedly shown effectiveness in preventing and treating a range of youth outcomes. Accordingly, investigators in this area have conducted a number of studies using statistical mediation to examine some of the potential mechanisms of action by which these interventions work. This review examined from a methodological perspective in what ways and how well the family-based intervention studies tested statistical mediation. A systematic search identified 73 published outcome studies that tested mediation for family-based interventions across a wide range of child and adolescent outcomes (i.e., externalizing, internalizing, and substance-abuse problems; high-risk sexual activity; and academic achievement), for putative mediators pertaining to positive and negative parenting, family functioning, youth beliefs and coping skills, and peer relationships. Taken as a whole, the studies used designs that adequately addressed temporal precedence. The majority of studies used the product of coefficients approach to mediation, which is preferred, and less limiting than the causal steps approach. Statistical significance testing did not always make use of the most recently developed approaches, which would better accommodate small sample sizes and more complex functions. Specific recommendations are offered for future mediation studies in this area with respect to full longitudinal design, mediation approach, significance testing method, documentation and reporting of statistics, testing of multiple mediators, and control for Type I error.

A Review of Technology-Based Youth and Family-Focused Interventions.

In the past 10 years, mental and behavioral health has seen a proliferation of technology-based interventions in the form of online and other computer-delivered programs. This paper focuses on technology-based treatment and preventive interventions aimed at benefitting children and adolescents via either involving the parents and families, or only the youth. The review considered only technology-based interventions that had at least one published study with a randomized controlled trial design. Questions being addressed included: (1) What are the technology-based interventions in the mental/behavioral health area that have been systematically evaluated in published studies? (2) What are the common and unique characteristics of these interventions and their application with respect to sample characteristics, target problems, and technology characteristics (platforms, structures, elements, and communication formats)? and (3) Which intervention approaches and strategies have accrued the greatest evidence? The review identified 30 technology-based psychosocial interventions for children and families, 19 of which were parent or family-focused (32 studies) and 11 of which were youth-focused (in 13 studies). For the parent/family-focused interventions, greatest promise was found in those that addressed either youth behavioral problems or depressive/anxious symptoms, as well as more general bolstering of parenting efficacy. The youth-focused interventions showed some promise in reducing depressive/anxious symptoms. Advantages and disadvantages of the technology-based approaches were considered, and areas for future research and development were discussed.