Motivational Interviewing and Caregiver Engagement in the Family Check-Up 4 Health.

Motivational interviewing (MI) is a therapeutic style in which a provider elicits client motivation and helps strengthen commitment to change (Miller and Rollnick 2002). The original Family Check-Up (FCU; Dishion and Stormshak 2007)-and the adapted version for improving health behaviors in primary care, the Family Check-Up 4 Health (FCU4Health; Smith et al. 2018a)-are brief, assessment-driven, and family-centered preventive interventions that use MI to improve parent engagement in services to improve parenting and prevent negative child outcomes. This study examines the role of MI in the Raising Healthy Children project, a randomized trial to test the effectiveness of the FCU4Health for the prevention of obesity in pediatric primary care, with data from the 141 families assigned to receive the FCU4Health. Families were eligible for the study if the child was between 5.5 and 12 years of age at the time of identification and had a BMI ≥ 85th percentile for age and gender at the most recent visit to their primary care provider. MI skills at the first session predicted caregiver in-session active engagement, attendance at follow-up parenting sessions, and improvements in motivation to address child health and behavior goals. Baseline characteristics of the family (i.e., child health diagnosis, caregiver baseline depression, motivation, and Spanish language preference) had differential associations with responsiveness and MI skills. This study has implications for program development, provider training, and fidelity monitoring.

Facilitators and Barriers in Cross-Country Transport of Evidence-based Preventive Interventions: a Case Study Using the Family Check-Up.

This study is a qualitative analysis of facilitators and barriers in the dissemination of Family Check-Up (FCU), a U.S.-developed preventive intervention in Sweden. The FCU is inherently culturally flexible because it was designed to be tailored to each family's needs and context, including cultural norms and values. We present the FCU implementation framework (IF) as a conceptual framework for cross-country transport of the FCU and evidence-based programs (EBP) more generally. The FCU IF draws from implementation science literature and involves specifying barriers and facilitators related to implementation drivers (e.g., competency) at each implementation phase and applying these data to inform phase-specific, readiness-building activities for each driver. In addition to driver-related influences, barriers and facilitators specific to the FCU and the collaborative partnership between the U.S. and Swedish purveyors emerged in the data. The partnership's reliance on a hybrid bottom-up, top-down approach that balanced the Swedish purveyor's autonomy and cultural expertise with guidance from the U.S. purveyor facilitated adaptation of the FCU for Sweden. Relying on previously collected data, we also explored similarities and differences in barriers and facilitators to FCU scale-up in the United States versus Sweden. In general, across drivers, the same barriers and facilitators were salient. This study suggests that dissemination of culturally flexible EBPs guided by a dynamic implementation framework can facilitate cross-country transport of EBPs. This study promotes a culture of prevention by highlighting barriers, facilitators, and readiness-building strategies that influence the cross-cultural transportability of EBPs that prevent the onset and escalation of child problem behavior.

Effects of the Family Check-Up 4 Health on Parenting and Child Behavioral Health: A Randomized Clinical Trial in Primary Care.

The Family Check-Up 4 Health (FCU4Health) is an adaptation of the Family Check-Up (FCU) for delivery in primary care settings. While maintaining the original FCU's focus on parenting and child behavioral health, we added content targeting health behaviors. This study evaluated whether the adapted FCU maintained positive effects on parenting (positive behavior support, limit setting, parental warmth) and child behavioral health (self-regulation, conduct problems, emotional problems). Pediatric (6-12 years) primary care patients with a BMI ≥ 85th%ile (n = 240) were recruited from primary care clinics in Phoenix. Children were 75% Latino, 49% female, and 73% Medicaid recipients. This type 2 effectiveness-implementation hybrid trial compared families randomized to FCU4Health (n = 141) or usual care (n = 99). FCU4Health was delivered over a period of 6 months. This study focuses on a priori secondary outcomes included parenting and child behavioral health targets of the original FCU, assessed at baseline and 3, 6, and 12 months. Significant improvements were found for the FCU4Health condition, compared to usual care, in parenting from baseline to the 3-month assessment [ß = .17 (.01; .32)]. Parenting predicted improvements in child self-regulation at 6-months [ß = .17 (.03; .30)], which in turn predicted reductions in conduct problems [ß = - .38 (- .51; - .23)] and emotional problems [ß = - .24 (- .38; - .09)] at 12 months. Ethnicity and language of delivery (English or Spanish) did not moderate these effects. The FCU4Health can improve parenting and child behavioral health outcomes when delivered in primary care.Trial Registration Trial registration number: NCT03013309 ClinicalTrials.gov.

Dynamic pathways between rejection and antisocial behavior in peer networks: Update and test of confluence model.

The confluence model theorizes that dynamic transactions between peer rejection and deviant peer clustering amplify antisocial behavior (AB) within the school context during adolescence. Little is known about the links between peer rejection and AB as embedded in changing networks. Using longitudinal social network analysis, we investigated the interplay between rejection, deviant peer clustering, and AB in an ethnically diverse sample of students attending public middle schools (N = 997; 52.7% boys). Adolescents completed peer nomination reports of rejection and antisocial behavior in Grades 6-8. Results revealed that rejection status was associated with friendship selection, and adolescents became rejected if they were friends with others who were rejected. Youth befriended others with similar levels of AB. Significant patterns of peer influence were documented for AB and rejection. As hypothesized, rejected youth with low AB were more likely to affiliate with others with high AB instead of similarly low AB. In contrast, nonrejected youth preferred to befriend others with similarly high or low AB. Results support an updated confluence model of a joint interplay between rejection and AB as ecological conditions that lead to self-organization into deviant clusters in which peer contagion on problem behaviors operates.

The long-term indirect effect of the early Family Check-Up intervention on adolescent internalizing and externalizing symptoms via inhibitory control.

This study examined the long-term effects of a randomized controlled trial of the Family Check-Up (FCU) intervention initiated at age 2 on inhibitory control in middle childhood and adolescent internalizing and externalizing problems. We hypothesized that the FCU would promote higher inhibitory control in middle childhood relative to the control group, which in turn would be associated with lower internalizing and externalizing symptomology at age 14. Participants were 731 families, with half (n = 367) of the families assigned to the FCU intervention. Using an intent-to-treat design, results indicate that the FCU intervention was indirectly associated with both lower internalizing and externalizing symptoms at age 14 via its effect on increased inhibitory control in middle childhood (i.e., ages 8.5-10.5). Findings highlight the potential for interventions initiated in toddlerhood to have long-term impacts on self-regulation processes, which can further reduce the risk for behavioral and emotional difficulties in adolescence.

Child Birth Order as a Moderator of Intervention Effectiveness for the Early Childhood Version of the Family Check-Up.

Child birth order (CBO) in the family has received little attention in the field of prevention science. CBO is relevant to early interventionists from a public health perspective, as the most widely disseminated home-visiting program has traditionally targeted mothers and their first-born children. The current paper revisits a previous publication by Shaw et al. (2009) on the effectiveness of the Family Check-Up (FCU) to evaluate CBO (firstborn vs. middle vs. youngest) as a moderator of treatment effects of the FCU in relation to improvements in parenting, maternal depressive symptoms, and child outcomes from ages 2 to 4 in a sample of low-income, ethnically diverse families (N = 709) with multiple children. Results suggest that the FCU elicited improvements in observed parenting from ages 2 to 3 primarily for target children who were the youngest or middle children, but not for firstborns. Findings are discussed in the context of implications for prevention science research, dissemination, and public policy.

Supporting Strategic Investment in Social Programs: a Cost Analysis of the Family Check-Up.

High-quality evidence about the costs of effective interventions for children can provide a foundation for fiscally responsible policy capable of achieving impact. This study estimated the costs to society of the Family Check-up, an evidence-based brief home-visiting intervention for high-risk families implemented in the Early Steps multisite efficacy trial. Intervention arm families in three sites were offered 4 consecutive years of intervention, when target children were ages 2 through 5. Data for estimating total, average, and marginal costs and family burden (means and standard deviations, 2015 USD, discounted at 3% per year) came from a detailed database that prospectively documented resource use at the family level and a supplemental interview with trial leaders. Secondary analyses evaluated differences in costs among higher and lower risk families using repeated measures analysis of variance. Results indicated annual average costs of $1066 per family (SD = $400), with time spent by families valued at an additional $84 (SD = $99) on average. Costs declined significantly from ages 2 through 5. Once training and oversight patterns were established, additional families could be served at half the cost, $501 (SD = $404). On the margin, higher risk families cost more, $583 (SD = $444) compared to $463 (SD = $380) for lower risk families, but prior analyses showed they also benefited more. Sensitivity analyses indicated potential for wage-related cost savings in real-world implementation compared to the university-based trial. This study illustrates the dynamics of Family Check-up resource use over time and across families differing in risk.

Translating evidence-based parenting programs for primary care: Stakeholder recommendations for sustainable implementation.

AIMS: To translate evidence-based programs (EBP) for a new setting, attention must be given to the characteristics of the intervention and the local setting, as well as evidence that is compelling to decision-makers. This paper describes the history of a partnership and stakeholder recommendations to inform the adaptation of an EBP for primary care. METHODS: We established a community advisory board (CAB) consisting of stakeholders with expertize in primary care delivery. A thematic analysis was conducted with fieldnotes and transcriptions from CAB meetings and regular meetings with participating clinics. RESULTS: We found that (a) parenting programs with a focus on behavioral and physical health are appropriate for this setting, (b) variability in the structure of primary care means implementation must be tailorable, and (c) financial and organizational outcomes are compelling for decision-makers. CONCLUSION: Factors related to the content and structure of evidence-based programs are uniquely related to distinct implementation outcomes of interest to key stakeholders.

Family Turbulence and Child Internalizing and Externalizing Behaviors: Moderation of Effects by Race.

This study examined the impact of residential instability and family structure transitions on the development of internalizing and externalizing problems from age 2 through 10.5. Child's race was examined as a moderator. Caregiver reports of internalizing and externalizing behaviors were obtained on 665 children at ages 5 and 10.5. Early-childhood residential and family structure transitions predicted elevated internalizing and externalizing problems at ages 5 and 10.5, but only for Caucasian children. These findings suggest that residential and family structure instability during early childhood independently contribute to children's later emotional and behavioral development, but vary as a function of the child's race. Community organizations (e.g., Women, Infant, and Children) can connect turbulent families with resources to attenuate effects of residential and family structure instability.

Indirect effects of the early childhood Family Check-Up on adolescent suicide risk: The mediating role of inhibitory control.

This study investigates suicide risk in late childhood and early adolescence in relation to a family-centered intervention, the Family Check-Up, for problem behavior delivered in early childhood. At age 2, 731 low-income families receiving nutritional services from Women, Infants, and Children programs were randomized to the Family Check-Up intervention or to a control group. Trend-level main effects were observed on endorsement of suicide risk by parents or teachers from ages 7.5 to 14, with higher rates of suicide risk endorsement in youth in the control versus intervention condition. A significant indirect effect of intervention was also observed, with treatment-related improvements in inhibitory control across childhood predicting reductions in suicide-related risk both at age 10.5, assessed via diagnostic interviews with parents and youth, and at age 14, assessed via parent and teacher reports. Results add to the emerging body of work demonstrating long-term reductions in suicide risk related to family-focused preventive interventions, and highlight improvements in youth self-regulatory skills as an important mechanism of such reductions in risk.

Trajectories and Predictors of Children's Early-Starting Conduct Problems: Child, Family, Genetic, and Intervention Effects.

Several research teams have previously traced patterns of emerging conduct problems (CP) from early or middle childhood. The current study expands on this previous literature by using a genetically-informed, experimental, and long-term longitudinal design to examine trajectories of early-emerging conduct problems and early childhood discriminators of such patterns from the toddler period to adolescence. The sample represents a cohort of 731 toddlers and diverse families recruited based on socioeconomic, child, and family risk, varying in urbanicity and assessed on nine occasions between ages 2 and 14. In addition to examining child, family, and community level discriminators of patterns of emerging conduct problems, we were able to account for genetic susceptibility using polygenic scores and the study's experimental design to determine whether random assignment to the Family Check-Up (FCU) discriminated trajectory groups. In addition, in accord with differential susceptibility theory, we tested whether the effects of the FCU were stronger for those children with higher genetic susceptibility. Results augmented previous findings documenting the influence of child (inhibitory control [IC], gender) and family (harsh parenting, parental depression, and educational attainment) risk. In addition, children in the FCU were overrepresented in the persistent low versus persistent high CP group, but such direct effects were qualified by an interaction between the intervention and genetic susceptibility that was consistent with differential susceptibility. Implications are discussed for early identification and specifically, prevention efforts addressing early child and family risk.

Dysregulated Irritability as a Window on Young Children's Psychiatric Risk: Transdiagnostic Effects via the Family Check-Up.

Building on prior work using Tom Dishion's Family Check-Up, the current article examined intervention effects on dysregulated irritability in early childhood. Dysregulated irritability, defined as reactive and intense response to frustration, and prolonged angry mood, is an ideal marker of neurodevelopmental vulnerability to later psychopathology because it is a transdiagnostic indicator of decrements in self-regulation that are measurable in the first years of life that have lifelong implications for health and disease. This study is perhaps the first randomized trial to examine the direct effects of an evidence- and family-based intervention, the Family Check-Up (FCU), on irritability in early childhood and the effects of reductions in irritability on later risk of child internalizing and externalizing symptomatology. Data from the geographically and sociodemographically diverse multisite Early Steps randomized prevention trial were used. Path modeling revealed intervention effects on irritability at age 4, which predicted lower externalizing and internalizing symptoms at age 10.5. Results indicate that family-based programs initiated in early childhood can reduce early childhood irritability and later risk for psychopathology. This holds promise for earlier identification and prevention approaches that target transdiagnostic pathways. Implications for future basic and prevention research are discussed.

Group versus individual format of intervention for aggressive children: Moderators and predictors of outcomes through 4 years after intervention.

This study originated in collaboration with Thomas Dishion because of concerns that a group format for aggressive children might dampen the effects of cognitive-behavioral intervention. Three hundred sixty aggressive preadolescent children were screened through teacher and parent ratings. Schools were randomized to receive either an individual or a group format of the child component of the same evidence-based program. The results indicate that there is variability in how group-based cognitive-behavioral intervention can affect aggressive children through a long 4-year follow-up after the end of the intervention. Aggressive children who have higher skin conductance reactivity (potentially an indicator of poorer emotion regulation) and who have a variant of the oxytocin receptor gene that may be associated with being hyperinvolved in social bonding have better outcomes in their teacher-rated externalizing behavior outcomes over time if they were seen individually rather than in groups. Analyses also indicated that higher levels of the group leaders' clinical skills predicted reduced externalizing behavior problems. Implications for group versus individual format of cognitive-behavioral interventions for aggressive children, and for intensive training for group therapists, informed by these results, are discussed.

Effectiveness and Efficiency of Observationally Assessing Fidelity to a Family-Centered Child Intervention: A Quasi-Experimental Study.

Assessment of fidelity that is effective, efficient, and differentiates from usual practices is critical for effectively implementing evidence-based programs for families. This quasi-experiemntal study sought to determine whether observational ratings of fidelity to the Family Check-Up (FCU) could differentiate between levels of clinician training in the model, and from services as usual, and whether rating segments of sessions could be equivalent to rating complete sessions. Coders rated 75 videotaped sessions-complete and 20-min segments-for fidelity, using a valid and reliable rating system across three groups: (a) highly trained in FCU with universal, routine monitoring; (b) minimally trained in FCU with optional, variable monitoring; and (c) services as usual with no training in the FCU. We hypothesized that certain dimensions of fidelity would differ by training, whereas others would not. The results indicated that, as expected, one dimension of fidelity to the FCU, Conceptually accurate to the FCU, was reliably different between the groups (χ2 = 44.63, p < .001). The differences observed were in the expected direction, showing higher scores for therapists with more training. The rating magnitude of session segments largely did not differ from those of complete session ratings; however, interrater reliabilities were low for the segments. Although observational ratings were shown to be sensitive to the degree of training in the FCU on a unique and theoretically critical dimension, observational coding of complete sessions is resource intensive and limits scalability. Additional work is needed to reduce the burden of assessing fidelity to family-centered programs.

Observed Family and Friendship Dynamics in Adolescence: a Latent Profile Approach to Identifying "Mesosystem" Adaptation for Intervention Tailoring.

Nuanced understanding of adolescents' interpersonal relationships with family and peers is important for developing more personalized interventions that prevent problem behaviors and adjustment issues. We used latent profile analysis (LPA) to classify a community sample of 784 adolescents with respect to their observed relationship dynamics with friends and family using videotaped observations and five-minute audiotaped speech samples collected at ages 16-17. The resulting latent classes served to predict behavioral and emotional health in early adulthood. The LPA of the video- and audio-coded observational variables revealed a three-class model: (1) the healthy relationship group (n = 587), representing low levels of deviant and drug use talk with friends and positive, noncoercive relationship with parents; (2) the disaffected group (n = 90), representing high levels of drug use talk with friends and negativity about their parent(s) in the five-minute speech sample; and (3) the antisocial group (n = 107), representing high levels of deviant talk, drug use talk, coercive joining with friends, and coerciveness in family interactions. In contrast to the healthy relationship group, the disaffected group showed elevated risk for substance use problems and depression and the antisocial group showed higher risk for substance use problems and committing violent crimes in early adulthood. Outcome differences between disaffected and antisocial groups were mostly nonsignificant. We discuss the viability of applying these findings to tailoring and personalizing family-based interventions with adolescents to address key dynamics in the family and friendship relationships to prevent adult substance use problems, depression, and violence.

Toward Tailored Interventions: Sympathetic and Parasympathetic Functioning Predicts Responses to an Intervention for Conduct Problems Delivered in Two Formats.

Coping Power is an evidence-based preventive intervention for youth with aggressive behavior problems that has traditionally been delivered in small group formats, but because of concerns about potentially diminished effects secondary to aggregation of high-risk youth, an individual format of Coping Power has been developed. The current study examined whether physiological characteristics of the child may provide information about which intervention delivery format works best for that individual. Indicators of sympathetic and parasympathetic nervous system functioning were examined in 360 fourth-grade children (65% male; 76.4% self-reported African-American) who were randomly assigned to Group Coping Power (GCP) or Individual Coping Power (ICP) (Lochman et al. 2015). Longitudinal assessments of teacher- and parent-reported proactive and reactive aggression were collected through a 1-year follow-up. For children with higher initial levels of aggression, those with lower parasympathetic functioning at pre-intervention showed greater reductions in teacher-rated proactive aggression in the ICP condition than the GCP condition. For children with high parasympathetic functioning, there was no differential effect of intervention format. Regardless of intervention format, youth with lower levels of sympathetic functioning at pre-intervention demonstrated greater reductions in teacher-rated proactive aggression. These findings suggest that physiological indicators may be worth considering in future studies examining which youth respond best to specific types of interventions.

The Family Check-up Intervention Moderates Polygenic Influences on Long-Term Alcohol Outcomes: Results from a Randomized Intervention Trial.

Alcohol problems are influenced by both genetic and environmental factors. Evidence from twin models and measured gene-environment interaction studies has demonstrated that the importance of genetic influences changes as a function of the environment. Research has also shown that family-centered interventions may protect genetically susceptible youth from developing substance use problems. In this study, we brought large-scale gene identification findings into an intervention study to examine gene-by-intervention effects. Using genome-wide polygenic scores derived from an independent genome-wide association study of adult alcohol dependence, we examined whether an adolescent family-centered intervention would moderate the effect of genetic risk for alcohol dependence on lifetime alcohol dependence in young adulthood, approximately 15 years after the start of intervention, among European American (N = 271; 48.3% in the intervention condition) and African American individuals (N = 192; 51.6% in the intervention condition). We found that among European American individuals, the intervention moderated the association between alcohol dependence polygenic scores and lifetime alcohol dependence diagnosis in young adulthood. Among participants in the control condition, higher alcohol dependence polygenic scores were associated with a greater likelihood of receiving an alcohol dependence diagnosis; in contrast, among participants in the intervention condition, there was no association between alcohol dependence polygenic scores and alcohol dependence diagnosis. No moderation effect was found among African Americans. These results demonstrate that modifying environments of genetically vulnerable youth could reduce the likelihood of developing alcohol dependence and underscore the significance of environmentally focused prevention and intervention efforts.

How do individual predispositions and family dynamics contribute to academic adjustment through the middle school years? The mediating role of friends' characteristics.

This study examined the mediating effect of friends' characteristics (problem behavior and academic achievement) in the association between students' background (family and individual factors) and later academic adjustment, as operationalized by problem behavior and academic achievement. We recruited 998 participants in three public middle schools and used three annual waves of data collection (Grades 6, 7, and 8). We found that students' own academic achievement and problem behavior are predictors of later adjustment. Friendship choices are identified as a mediation mechanism that contributes to consistent adjustment from the beginning to the end of middle school. Specifically, high-achieving students in Grade 6 tend to associate with high-achieving friends and are unlikely to associate with friends who exhibit problem behavior in Grade 7, which results in continued achievement in Grade 8. Associating with high-achieving friends in Grade 7 also mediated the link between adolescent problem behavior in Grade 6 and academic achievement by Grade 8. Friends' characteristics in Grade 7 did not mediate the effect of any family factor measured in Grade 6. In general, our results suggest friendship selection is central to sustained success throughout the middle school years.

Considering the role of early discrimination experiences and the parent-child relationship in the development of disruptive behaviors in adolescence.

Discrimination has been shown to be related to diminished psychological adjustment and greater risk for substance use when personally experienced by adolescents and when their caregivers experience discrimination. Our research considers the impact of primary caregiver experiences of racial- and socioeconomic-based discrimination in early (age 3-5 years) and late childhood (age 9½) on adolescent disruptive behaviors (age 14) with a large sample of diverse caregiver-child dyads (N = 634). In addition, we examine the potential protective effects of parent-child relationship quality in early and late childhood in buffering the effects of caregiver discrimination on adolescent disruptive behaviors. We also explore possible gender differences in children's vulnerability to engage in disruptive behaviors in the context of caregiver experiences of discrimination. The findings from this study indicate that at trend level, early childhood experiences of primary caregiver discrimination (ages 3-5) predicted adolescent disruptive behaviors, accounting for the effects of more recent (age 9½) caregiver discrimination. In addition, parent-child relationship quality at age 9½ years was found to buffer the effects of late childhood (age 9½) primary caregiver discrimination on adolescent disruptive behaviors for both male and female youth. The findings highlight the need for prevention and intervention techniques that foster healthy and positive primary caregiver-child relationships.

Provider Readiness and Adaptations of Competency Drivers During Scale-Up of the Family Check-Up.

We used provider (n = 112) data that staff at the agency disseminating the Family Check-Up (FCU; REACH Institute) collected to profile provider diversity in community settings and to examine whether provider profiles are related to implementation fidelity. Prior to FCU training, REACH Institute staff administered the FCU Provider Readiness Assessment (PRA), a provider self-report measure that assesses provider characteristics previously linked with provider uptake of evidence-based interventions. We conducted a latent class analysis using PRA subscale scores as latent class indicators. Results supported four profiles: experienced high readiness (ExHR), experienced low readiness (ExLR), moderate experience (ME), and novice. The ExHR class was higher than all other classes on: (1) personality variables (i.e., agreeableness, conscientiousness, openness, extraversion); (2) evidence-based practice attitudes; (3) work-related enthusiasm and engagement; and (4) their own well-being. The ExHR class was also higher than ExLR and ME classes on clinical flexibility. The ME class was lowest of all classes on conscientiousness, supervision, clinical flexibility, work-related enthusiasm and engagement, and well-being. During the FCU certification process, FCU Consultants rated providers' fidelity to the model. Twenty-three of the 112 providers that completed the PRA also participated in certification. We conducted follow-up regression analyses using fidelity data for these 23 providers to explore associations between probability of class membership and fidelity. The likelihood of being in the ExHR class was related to higher FCU fidelity, whereas the likelihood of being in the ExLR class was related to lower fidelity. We discuss how provider readiness assessment data can be used to guide the adaptation of provider selection, training, and consultation in community settings.