Feasibility, acceptability, and effects of a web-delivered behavioral parent training intervention for rural parents of children with autism spectrum disorder: A protocol.

Caregivers of children with autism spectrum disorder (ASD) often report higher levels of stress and mental health issues. Support services and parent training programs may help buffer the effects of caring for a child with ASD. However, due to the national lack of trained ASD providers and disparity of ASD support resources available in rural areas, caregivers often go without support. A possible solution to reach caregivers in rural areas is web-based interventions. This paper describes an ongoing pilot study examining the feasibility, acceptability, and preliminary effects on caregiver well-being and disruptive child behaviors for a web-based parent training program (Attend Behavior) for caregivers of young children (ages 2-11 years old) with autism spectrum disorder (ASD) living in rural areas (trial registration NCT05554198). The intervention is available on the internet as well as a downloadable app for mobile phones. Participants will be invited to use the intervention program for 12-weeks. Prior to using the program, participants will be asked to take a baseline survey assessing depressive symptoms (PROMIS Depression Short Form-6a), caregiver stress (Parenting Stress Index-Short Form), child disruptive behaviors (Home Situations Questionnaire-ASD and Aberrant Behavior Checklist). After 12-weeks, participants will be asked to complete a post-intervention survey with the same measurement scales plus questions regarding intervention acceptability, appropriateness, and feasibility (Acceptability of Intervention, Intervention Appropriateness Measure, and the Feasibility of Intervention Measure). Participants are also invited to partake in a brief 1:1 interview with a study team member to give further feedback regarding the intervention. Study retention and participant app usage data will be examined. Information generated from this pilot study will be used to inform a future larger scale randomized control trial of Attend Behavior.

Implementation of a Parent Training Program During Community-Based Dissemination (From In-Person to Hybrid): Mixed Methods Evaluation.

BACKGROUND: Parent training interventions support and strengthen parenting practices and parent-child relationships and improve child behavior. Between March 2018 and February 2020, a community-based parenting program conducted 38 in-person Chicago Parent Program (CPP) groups. In response to the COVID-19 pandemic, we modified the delivery of the in-person CPP to hybrid delivery using the self-administered, web-based version of the CPP (ezParent) paired with web-based, videoconferenced group sessions. OBJECTIVE: This study aims to describe the delivery transition and implementation outcomes of the hybrid delivery of the CPP (ezParent+group) during community-based dissemination. METHODS: This single-group, mixed methods retrospective evaluation examined the implementation outcomes using the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) framework. We report on data from hybrid ezParent delivery between September 2020 and August 2022. Parents completed pre- and postprogram surveys that included motivation to participate and perceived changes in parent-child behavior. Digital analytics captured ezParent completion. Facilitators completed fidelity assessments and participated in postintervention interviews. RESULTS: In total, 24 hybrid ezParent groups (n=240 parents) were delivered by 13 CPP-trained facilitators. Parents reported high levels of satisfaction with the program and improvements in their feelings of parenting self-efficacy and their child's behavior following their participation in hybrid ezParent. On average, parents completed 4.58 (SD 2.43) 6 ezParent modules. The average group attendance across the 4 sessions was 71.2%. Facilitators found the hybrid delivery easy to implement and reported high parent engagement and understanding of CPP strategies. CONCLUSIONS: Using the hybrid ezParent intervention is a feasible and effective way to engage parents. Lessons learned included the importance of academic and community-based organization partnerships for delivering and evaluating robust programs. Implementation facilitators and barriers and future research recommendations are discussed.

Families in transition (FIT) study protocol: feasibility, acceptability and preliminary effects of a group-based parent training in parents of youth in psychiatric residential treatment.

INTRODUCTION: Although adolescents make treatment gains in psychiatric residential treatment (RT), they experience significant difficulty adapting to the community and often do not sustain treatment gains long term. Their parents are often not provided with the necessary support or behaviour management skillset to bridge the gap between RT and home. Parent training, a gold standard behaviour management strategy, may be beneficial for parents of these youth and web-based parent training programmes may engage this difficult-to-reach population. This study focuses on a hybrid parent training programme that combines Parenting Wisely (PW), a web-based parent training with facilitated discussion groups (Parenting Wisely for Residential Treatment (PWRT)). This study aims to: (1) establish the feasibility and acceptability of PWRT, (2) evaluate whether PWRT engages target mechanisms (parental self-efficacy, parenting behaviours, social support, family function) and (3) determine the effects of PWRT on adolescent outcomes (internalising and externalising behaviours, placement restrictiveness). METHODS AND ANALYSIS: In this randomised control trial, parents (n=60) will be randomly assigned to PWRT or treatment as usual. Each week for 6 weeks, parents in the PWRT condition will complete two PW modules (20 min each) and attend one discussion group via Zoom (90 min). Adolescents (n=60) will not receive intervention; however, we will evaluate the feasibility of adolescent data collection for future studies. Data from parents and adolescents will be collected at baseline, post intervention (6 weeks post baseline) and 6 months post baseline to allow for a robust understanding of the longer-term effects of PWRT on treatment gain maintenance. ETHICS AND DISSEMINATION: The study has been approved by The Ohio State University Institutional Review Board (protocol number 2022B0315). The outcomes of the study will be shared through presentations at both local and national conferences, publications in peer-reviewed journals and disseminated to the families and organisations that helped to facilitate the project. TRIAL REGISTRATION NUMBER: NCT05764369 (V.1, December 2022).

The Case for Assessing and Reporting on Facilitator Fidelity: Introducing the Fidelity of Implementation in Parenting Programs Guideline.

The sizeable body of evidence indicating that parenting programs have a positive impact on children and families highlights the potential public health benefits of their implementation on a large scale. Despite evidence and global attention, beyond the highly controlled delivery of parenting programs via randomized trials, little is known about program effectiveness or how to explain the poorer results commonly observed when implemented in community settings. Researchers, practitioners, and policymakers must work together to identify what is needed to spur adoption and sustainment of evidence-based parenting programs in real-world service systems and how to enhance program effectiveness when delivered via these systems. Collecting, analyzing, and using facilitator fidelity data is an important frontier through which researchers and practitioners can contribute. In this commentary, we outline the value of assessing facilitator fidelity and utilizing the data generated from these assessments; describe gaps in research, knowledge, and practice; and recommend directions for research and practice. In making recommendations, we describe a collaborative process to develop a preliminary guideline-the Fidelity of Implementation in Parenting Programs Guideline or FIPP-to use when reporting on facilitator fidelity. Readers are invited to complete an online survey to provide comments and feedback on the first draft of the guideline. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-023-00092-5.

A secondary analysis examining the influence of emotional support on the mental health of caregivers of children with autism spectrum disorder.

PURPOSE: The study purpose was to examine the effect of emotional support on the overall mental health and stress for caregivers of children with autism spectrum disorder (ASD). METHODS: A cross-sectional retrospective study using secondary data from the 2016-2019 National Survey of Children's Health was conducted using single variable and multivariable linear regression analyses. RESULTS: More informal emotional support sources were associated with better overall mental health (ß = 0.124, SE = 0.015, p < .001) and reduced stress (ß = -0.261, SE = 0.039, p < .001) for caregivers of children with ASD, controlling for covariates. The number of formal emotional support sources was not significantly associated with caregiver overall mental health or stress when controlling for covariates. Increased amounts of total emotional support sources were significantly associated with increased overall mental health (ß = 0.042, SE = 0.010, p < .001) and reduced stress (ß = -0.093, SE = 0.024, p < .001) for caregivers. Other factors significantly associated with caregiver outcomes included caregiver sex, caregiver marital status, caregiver education level, economic hardship, child sex, child race/ethnicity, ASD severity, and child receipt of ASD treatment. CONCLUSION: More emotional support sources, in particular informal support sources, may be a protective factor for well-being for caregivers of children with ASD. PRACTICE IMPLICATIONS: Health care providers should evaluate the impact of their formal support services on caregivers of children with ASD and advocate for increased informal and formal support resources for these caregivers.

Administrative Dashboard for Monitoring Use of a Web-Based Parent Training Intervention: Usability Study.

BACKGROUND: Web-based parent training (PT) programs can strengthen parent-child relationships by equipping caregivers with knowledge and evidence-based strategies to manage behavior. Hybrid facilitation of PT includes facilitator interaction paired with self-administered and web-based PT. Web-based administrative dashboards provide users (eg, administrators, facilitators, and researchers) with an integrated platform to monitor parent progress and activities within a PT program or website. Despite the utility and prevalence of administrative dashboards for web-based behavioral interventions, to our knowledge, no research studies have explored the perspectives and insights of dashboard users to enhance user experience and program delivery. OBJECTIVE: The purpose of this study is to evaluate the usability of the administrative dashboard (ezDashboard) for the ezParent program, a 6-module web-based PT program for parents of children aged 2-5 years. METHODS: This study used a descriptive, single-group design with administrators who were overseeing the implementation of the ezParent program and trained facilitators for hybrid ezParent delivery. Participants spent at least 30 minutes reviewing and evaluating the ezDashboard and then completed a survey of their experience with the dashboard. The survey included the validated 10-item System Usability Scale and open-ended questions focusing on user performance, navigation ease, and overall usefulness of the ezDashboard. RESULTS: Participants (N=15) indicated high usability of the ezDashboard with System Usability Scale scoring a total mean score of 83.5 (SD 16.3). Most participants (n=13, 87%) rated the overall user-friendliness of the ezDashboard as good (n=3, 20%), excellent (n=9, 60%), or best imaginable (n=1, 7%). Open-ended questions revealed the ezDashboard is or would be useful to monitor parent progress and trends in engagement (n=8, 53%) and for reviewing topics for discussion and communicating with parents (n=5, 33%). ezParent administrators (n=4) identified that real-time data for ezParent use helps overall management of program uptake. Suggestions for features to add to the ezDashboard included the ability to track partial progress of program modules (4/14, 29%), total time spent per module (2/14, 14%), and exportable reports (4/14, 29%). Other ideas for improvement included direct messaging capabilities, videoconferencing platform integration, and being able to modify participant account and contact information. CONCLUSIONS: Results indicate that the ezDashboard is easy to use and provides functional information to facilitators and administrators in delivering ezParent. Qualitative results indicate that integrating suggested features into the ezDashboard may help provide a smoother experience for facilitators, administrators, and ultimately the parents using the program. Providing resources for facilitators and administrators in real time to monitor intervention participants' progress in a program can be helpful in tracking progress and providing facilitated support in tailoring program content and program completion.

Web-Based Parent Training in Parents with Adolescents Admitted to Psychiatric Residential Treatment: A Mixed-Methods Study.

Despite intensive treatment, adolescents discharged from residential treatment (RT) often do not maintain treatment gains in the community. Providing support and education to caregivers through parent training may ameliorate the loss of treatment gains. Successful parent training programs have been delivered to this population; however, these interventions were delivered in-person, posing significant barriers affecting reach, access, and engagement. A convergent mixed methods design was used to assess the acceptability, appropriateness, and feasibility of a web-based parent training in a sample of parents (N = 20) with adolescents admitted to RT. Parents completed two interviews and an end-of-program survey. Parents completed at least 80% of the assigned modules and felt that PW was easy to use and that the features facilitated learning. Parents reported practicing the skills in their daily lives and found it beneficial to have a partner to practice with. Consistent with previous studies, parents perceived the delivery method as a strength because the web-based delivery circumvented multiple known barriers to in-person interventions. A large subset of parents related to the scenarios, while a small subset of parents felt the modules were challenging to relate to because of the severity of their adolescent's mental health challenges. Overall, findings indicate that web-based parent training programs may be an acceptable, appropriate, and feasible adjuvant evidence-based support. However, tailoring the intervention content is necessary to create a more relatable intervention that captures the breadth and severity of mental health challenges adolescents in RT face.

Variation in Evidence-Based Practices Among Youth-Serving Residential Treatment Facilities.

BACKGROUND: Residential treatment is among the most intensive and expensive settings for children with behavioral health challenges; yet, the extent to which evidence-based practices are used in these settings is unknown. AIM: The purpose of this study was to describe the extent which family therapy, case management, telehealth, peer support, and family psychoeducation are provided in residential treatment using data from the National Mental Health Services Survey (N-MHSS). Organizational factors-region, ownership, payment, licensing/accreditation, and facility size-were examined in relation to evidence-based practices to understand disparities in care. METHODS: This was a secondary analysis of publicly available data from the 2018 N-MHSS. A subpopulation was created consisting of residential facilities that served children (N = 576). Descriptive statistics were used to describe the sample, and Cohen's h was calculated to determine patterns of evidence-based practice utilization. RESULTS: Evidence-based practices from most to least prevalent were family therapy (76%), family psychoeducation (74%), case management (71.1%), telehealth (17.2%), and peer support (8.7%). The provision of evidence-based practices was not evenly distributed. There were primarily small to moderate differences by organizational factors, including region (i.e., Northeast, Midwest), ownership status (i.e., for-profit), payment type (i.e., self-pay, private insurance), licensing/accreditation (Department of Family and Children Services), and facility capacity (>251 clients served per year). CONCLUSION: Findings demonstrate a need for research-practice partnerships to determine the barriers that prevent effective evidence-based practices from being implemented in the residential treatment setting.

ezPreemie study protocol: a randomised controlled factorial trial testing web-based parent training and coaching with parents of children born very preterm.

INTRODUCTION: Children born very preterm (VPT; gestational age <32 weeks) are twice as likely to demonstrate behaviour problems such as aggression, non-compliance, temper tantrums and irritability compared with their term-born peers. While behavioural parent training (BPT), also referred to as behaviour therapy is a gold standard for prevention and treatment of childhood problem behaviours, there are limited accessible and effective BPT interventions for families with children born VPT. The purpose of this paper is to describe a multicentre, randomised controlled protocol for a factorial design trial evaluating the independent and combined effects of the ezParent BPT intervention plus brief, weekly coaching calls on parent and child outcomes for families with toddlers born VPT. METHODS AND ANALYSIS: The study employs a 2×2 factorial randomised design. Parents (n=220) of children aged 20-30 months corrected age who were born VPT (<32 weeks) will be recruited from two large metropolitan Neonatal Intensive Care Units follow-up clinics and randomised to one of four conditions: (1) ezParent (2) ezParent +coach, (3) Active control or (4) Active Control +coach. Data on parenting and child behaviour outcomes will be obtained from all participants at baseline and 3, 6 and 12 months postbaseline. All analyses will use an intention-to-treat approach, independent of their actual dose of each intervention. ETHICS AND DISSEMINATION: The study protocol has been approved by The Ohio State University Institutional Review Board (IRB) using a single IRB. Study results will be disseminated through presentations at regional and national conferences, publications in peer-reviewed journals, and sharing research reports with participating families and recruiting sites. TRIAL REGISTRATION NUMBER: NCT05217615.

Recruitment, Retention, and Intervention Outcomes from the Dedicated African American Dad (DAAD) Study.

A significant proportion of African American (AA) fathers live in households apart from their young children. This living arrangement can have detrimental effects for children, families, and fathers. One hundred seventy-eight (n = 178) AA fathers, not residing with their 2-6-year-old children, were enrolled in a randomized trial to test the Building Bridges to Fatherhood (BBTF) program against a financial literacy comparison condition. BBTF is an intervention that was developed collaboratively with a fathers' advisory council of AA fathers who oversaw all aspects of program development. Based upon advisory council feedback, short video scenes captured fathers interacting with their children, their children's mothers, and other fathers. These video scenes were used to jump start the discussion around fatherhood, parenting, communication, and problem solving during the intervention group meetings. The actors in the video scenes were recruited from the community. Two trained group leaders, using a standardized group leader manual, delivered the intervention. The Money Smart Financial Literacy Program (MSFLP), which served as the comparator, was also delivered by AA men. Program satisfaction was high in both conditions. Even so recruitment and retention challenges influenced the ability to detect father and child outcomes. This study informs the participation of vulnerable urban AA fathers in community-based fatherhood intervention research and provides insight into bolstering engagement in studies focused on this population.

Caregivers of Children with Autism Spectrum Disorder in Rural Areas: A Literature Review of Mental Health and Social Support.

PROBLEM: Caregivers of children with Autism Spectrum Disorder (ASD) report high levels of stress, social isolation, and poor mental health. Social and emotional support may buffer negative effects of stress for caregivers of children with ASD, however, those living in rural areas may be disadvantaged due to social isolation and increased distance from resources. This scoping review examined the literature regarding the mental health and impact of support for rural caregivers of children with ASD. ELIGIBILITY CRITERIA: Articles were limited to those available in the English language and conducted in a high income country. Articles had to include a population of rural caregivers of children with ASD and focus on caregiver mental health and/or the impact of support on caregiver mental health. SAMPLE: Searches were conducted with Embase, PubMed, CINAHL, ERIC, and PsycINFO and 22 articles were included. RESULTS: Study findings indicate overall poor mental health for rural caregivers of children with ASD. Formal and informal support appear to be beneficial in decreasing stress for rural caregivers of children with ASD. However, a few studies indicated that formal support may add stress to rural caregivers. CONCLUSION: There is limited information regarding support needs and the impact of support services on the mental health of rural caregivers of children with ASD. IMPLICATIONS: There is a need to increase access to support resources in rural areas for caregivers of children with ASD. Healthcare professionals, including nurses, can play a fundamental role in supporting, educating, and connecting caregivers to other support services.

Parenting a Child in Residential Treatment: Mother's Perceptions of Programming Needs.

The purpose of this study was to describe the experiences and perspectives of mothers with children in residential treatment (RT) regarding parenting, discharge planning, and home-based safety. One-hour interviews were conducted over the phone with 15 mothers. Transcripts were analyzed using a content analysis approach. Three themes were generated including parenting a child in RT, unprepared for discharge, and crisis intervention in the home. This study contributes insight into the lives of an underserved population with implications to inform future research interventions and clinical guidelines to address the needs of families with children in RT.

Low-Income Parents' Perceptions of and Engagement With a Digital Behavioral Parent Training Program: A Mixed-Methods Study.

BACKGROUND: Parent training is a method for strengthening parenting skills, reducing child behavior problems, and promoting positive parent-child relationships. However, few parents have access to these evidence-based programs. The ezParent program, a tablet-based delivery adaptation of the group-based Chicago Parent Program, is a parent training program designed to address the needs of families raising young children in urban poverty. AIMS: This study aimed to explore (a) parents' perceptions of the benefits and barriers associated with their use of the ezParent program and (b) the ways in which the ezParent components and perceived usability varied by program use (module completion). METHOD: An explanatory mixed-methods design was used with the overall intent to use the qualitative data to help explain in greater detail the quantitative results. RESULTS: Fifty-nine parents of 2- to 5-year-old children from two pediatric primary care clinics serving predominantly low-income and racial/ethnic minority families in Chicago (Cohort 1) and Baltimore (Cohort 2) participated in follow-up interviews. Among those interviewed, 23 (38.9.5%) parents completed all six modules and 12 parents (20.3%) completed none of the modules. However, of those 12, 8 (67%) logged in to the program and completed portions of Module 1. Parents who completed more modules reported more program benefits, and those who completed fewer modules reported more barriers. CONCLUSIONS: Exploring users' experience with current digital applications, researchers and application developers can better design future tablet-based interventions to be both effective and acceptable by consumers.

A Randomized Trial of Digitally Delivered, Self-Administered Parent Training in Primary Care: Effects on Parenting and Child Behavior.

OBJECTIVE: To evaluate the effects of a self-administered, digital behavioral parent training program on parent and child behavior for parents of young children. STUDY DESIGN: A randomized controlled trial compared ezParent (digital delivery of the evidence-based Chicago Parent Program) with an enhanced usual-care control. Introduction to the study occurred during well-child visits at 4 primary care clinics. In total, 287 parents of children age 2-5 years were randomized to ezParent or the control. Parents responded to surveys evaluating parent behavior, self-efficacy, and stress, and child behavior at baseline, and 3-, 6-, and 12-months postbaseline. Multilevel growth models examined parent and child outcomes for intervention efficacy in intent-to-treat analyses. Secondary moderation analysis explored intervention effects by program use and baseline parenting stress and child behavior problems. RESULTS: The intervention main effect was not significant for parent and child behaviors. In exploratory moderation analysis, parents in the ezParent condition with greater baseline parenting stress reported less corporal punishment (P = .044); and greater improvement in parental warmth (P = .008), setting limits (P = .026), and proactive parenting (P = .019). Parents reporting greater baseline child behavior problems reported greater improvements in parental warmth (P = .007), setting limits (P = .003), and proactive parenting (P = .010). There were no differences in outcomes based on program usage. CONCLUSIONS: Results suggest that ezParent as a self-administered behavioral parent training program may not be intense enough for child and parent behavioral change as a universal prevention model. Parents may require different levels of support for completion based on their level of service seeking, family characteristics, risk profile, and motivation for change. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02723916.

Community Health Workers: Connecting Communities and Supporting School Nurses.

For over a century, community health workers (CHWs) have acted as agents of social justice, health care promotion, and change for the underresourced communities they serve and come from. Over 50,000 CHWs are employed in the United States, and this number is growing with the need for CHWs to help fight both the COVID-19 pandemic and social injustice plaguing our nation. Even with many students learning from home, it is crucial that healthcare be integrated into the school system since a child's health greatly affects their ability to learn. CHWs in schools can help overcome community and cultural barriers to connect families to various community resources and provide important health screenings and education. On return to the traditional classroom, the myriad of tasks such as infection prevention, contact tracing, and temperature screening are not feasible for a school nurse to do alone. CHWs may be just the leaders we need to help schools address the challenges faced in 2020.

Family resilience and flourishment: Well-being among children with mental, emotional, and behavioral disorders.

Approximately 20% of children and adolescents in the United States are affected by mental, emotional, and behavioral (MEB) disorders. Child flourishment and family resilience contribute to healthy family development, including the promotion of child MEB wellbeing. Identifying factors that promote child flourishment and family resilience are critical. This study aimed to determine the prevalence and parenting factors associated with family resilience and child flourishment among children aged 6-17 years with MEB disorders. This was a secondary analysis of the 2016-2017 National Survey of Children's Health. The sample consisted of parents and their children (n = 1,900, weighted n = 5,375,670). Data were weighted to be representative of the US population and analyzed using descriptive statistics and linear regression. We found that only 6.3% of children aged 6-17 with an MEB were optimally flourishing. Parental aggravation was negatively associated with child flourishment, and parental coping was positively associated with child flourishment. In total, 66.5% of families with children exhibited resilience. Parental coping and availability of parental emotional support were positively associated with family resilience. Potential interventions that leverage study findings include parent training to increase parental emotional regulation (e.g., increase frustration tolerance, coping skills) and family navigation services to increase parental support (e.g., emotional support, coping skills) through the child's treatment trajectory. Overall, this study provides evidence of a disparity in flourishment in America's youth with MEB disorders, and despite this adversity, families are resilient.

Adaptation and Acceptability of a Digitally Delivered Intervention for Parents of Very Low Birth Weight Infants.

BACKGROUND: Very low birth weight (VLBW) infants are at elevated risk for behavioral problems as early as the second year of life. The purpose of this feasibility study was to evaluate the adaptation and acceptability of an existing digitally delivered behavioral parent training program-the ezParent program, with the addition of weekly coaching calls-for parents of former VLBW infants in their second year of life. OBJECTIVES: To assess the adaptation of ezParent for this population, we assessed parent access and use of ezParent and coaching calls, parent learning of strategies from ezParent, and changes in parenting practices or child behavior after using ezParent plus coaching calls. For acceptability, we assessed if parents viewed ezParent content as applicable to their experiences of parenting a former VLBW infant and how parents viewed coaching calls. METHODS: Ten parents of VLBW infants (20 months of age adjusted for prematurity) were recruited from a neonatal intensive care follow-up clinic. Parents completed the six modules of ezParent plus weekly coaching calls over 10-week intervention period. ezParent usage data were electronically uploaded to secure servers. Completion and timing of coaching calls were monitored using a tracking log. Parents completed child behavior and parenting belief and practice questionnaires pre- and postintervention. Calls were recorded and transcribed to assess for learning of parenting strategies, acceptability with the VLBW population, and acceptability of coaching calls. RESULTS: On average, parents completed 85% of the ezParent modules and 89% of the scheduled coaching calls, respectively. Parents spontaneously introduced 44% of the ezParent strategies during their coaching calls. Modest within-group effect sizes were detected for improvement in parenting self-efficacy and child externalizing behavior. Parents felt the ezParent content applied to their experiences parenting a preterm infant and had high satisfaction with coaching calls as a method of reinforcing program content and assessing knowledge and supporting accountability for program participation. DISCUSSION: ezParent with coaching calls is a feasible method of delivering behavioral parent training to parents of former VLBW infants in their second year of life. Coaching calls have high potential to be a low-cost, time-efficient component of digitally delivered programs that would allow for rapid integration into clinical practice.

Uncovering Indicators of Commercial Sexual Exploitation.

It is estimated that annually 100,000 to 300,000 youth are at risk for sex trafficking; a commercial sex act induced by force, fraud, or coercion, or any such act where the person induced to perform such an act is younger than 18 years of age. Increasingly, such transactions are occurring online via Internet-based sites that serve the commercial sex industry. Commercial sex transactions involving trafficking are illegal; thus, Internet discussions between those involved must be veiled. Even so, transactions around sex trafficking do occur. Within these transactions are innuendos that provide one avenue for detecting potential activity. The purpose of this study is to identify linguistic indicators of potential commercial sexual exploitation within the online comments of men posted on an Internet site. Six hundred sixty-six posts from five Midwest cities and 363 unique members were analyzed via content analysis. Three main indicators were found: the presence of youth or desire for youthfulness, presence of pimps, and awareness of vulnerability. These findings begin a much-needed dialogue on uncovering online risks of commercial sexual exploitation and support the need for further research on Internet indicators of sex trafficking.

Referral to Digital Parent Training in Primary Care: Facilitators and Barriers.

Objective: Parent training (PT) programs for parents of preschool-aged children promote effective parenting practices and reduce the risk for the development of child behavior problems. Digital platforms and self-administered formats can expand access to preventive PT and complement traditional behavioral services. Primary care provides an ideal environment to refer patients to prevention-focused PT; however, effective integration of a referral process requires an understanding of implementation facilitators and barriers. The current study is a secondary analysis of facilitators and barriers to the implementation of a referral to ezParent, a self-administered, digital PT program, in four primary care clinics from the perspective of clinic personnel. Method: Personnel from participating clinics took part in semi-structured group interviews to share their experiences of referral to ezParent. Researchers extracted themes using the Consolidated Framework for Implementation Research. Results: Clinic personnel support preventive PT, but time, workflow, and organizational barriers impede consistent referral implementation. Conclusions: The authors discuss recommendations for harnessing facilitators for referring primary care patients to digital PT using the strengths of multidisciplinary clinical teams and organizational structures.

Implementation findings from an effectiveness-implementation trial of tablet-based parent training in pediatric primary care.

INTRODUCTION: The use of mobile delivery to deliver parent training can address barriers to access and improve the translation of interventions in existing settings like pediatric primary care. Studying implementation provides critical information to identify and address barriers and facilitators and inform sustainability efforts. METHOD: This study was a descriptive evaluation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework as part of a Hybrid Type I Effectiveness-Implementation trial of the ezParent Program within 4 pediatric primary care clinics. We collected data before, during, and after implementation to evaluate provider implementation and their perspectives on program benefits and barriers to implementation. RESULTS: On average, 14% of eligible parents were introduced to the study. Of these parents, 78% expressed interest in participating and 37% enrolled in the study. Seventy-eight percent of staff providers (n = 36) implemented the procedures at least once, and among those who implemented 3 or more times (n = 24), 79% maintained implementation for 6 months. Barriers to implementation include limited time, lack of information, and full practice buy-in and engagement. DISCUSSION: Implementation fidelity may improve with additional education and training of the interdisciplinary team, clear messaging regarding the purpose and content of the ezParent program, defining roles within the care team, identifying practice champions, and use of the electronic health record. Findings from this evaluation, including data from the randomized controlled trial and literature to support intervention effectiveness and implementation, will be used to develop an implementation toolkit to include specific strategies for implementation and ideas for local adaptations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).