Preventing Adverse Outcomes for Bereaved Youth: Indirect Effects From a Randomized Trial of the Family Bereavement Program on Fear of Abandonment, Grief, and Mental Health.

OBJECTIVES: We investigated whether the self-system belief of fear of abandonment mediated the effects of intervention-induced change in 2 protective factors-positive parenting and adaptive coping-and one risk factor-stressful events-on youth mental health problems and maladaptive grief. This study extends prior research on fear of abandonment in youth who experience parental death by examining pathways through which a program reduced fear of abandonment and, in turn, affected subsequent pathways to child mental health problems in the context of a randomized experiment. METHODS: This is a secondary data analysis study. We used data from the 4-wave longitudinal 2-arm parallel randomized controlled trial of the Family Bereavement Program conducted between 1996 and 1999 in a large city in the Southwestern United States. The sample consisted of 244 offspring between 8 and 16 at the pretest. They were assessed again at posttest, 11-month follow-up, and 6-year follow-up. Offspring, caregivers, and teachers provided data. RESULTS: Mediation analyses indicated that intervention-induced reductions in stressful events were prospectively associated with a lower fear of abandonment. For girls, fear of abandonment was related to self-reported maladaptive grief and teacher-reported internalizing problems 6 years later. CONCLUSIONS: This study extends prior research on the relation between intervention-induced changes in risk and protective factors and improvements in outcomes of bereaved youth. The findings support the reduction of stressful events as a key proximal target of prevention programs for bereaved children.

When a parent dies: A scoping review of protective and risk processes for childhood bereavement.

The death of a parent can have profound effects on child development. Yet, little is known about the individual and environmental processes that contribute to heterogeneity in child bereavement outcomes. A scoping review was conducted in samples of parentally bereaved children to identify key processes, synthesize results, and determine research gaps. This scoping review identified 23 studies (mainly from the United States), published between 1990 and 2023, that reported child (ages 3-22 years) individual and/or environmental protective and/or risk processes that contributed to bereavement outcomes. Individual processes (i.e., how children manage stressors and think about themselves/their environment) included child coping and perception of themselves and/or their environment. Environmental processes (i.e., contextual resources) included family, mentorship, and stress exposure. Findings can be used to apprise clinicians, families, and policymakers of the unique nature of childhood bereavement and to identify malleable processes to target in interventions designed to prevent problematic outcomes in bereaved children.

Reducing suicide risk in parentally bereaved youth through promoting effective parenting: testing a developmental cascade model.

Children who experience parental death are at increased risk for suicide. The Family Bereavement Program (FBP) is an upstream preventive intervention for parentally bereaved families that was found to reduce suicide risk in parentally bereaved youth up to 6 and 15 years later. We tested whether FBP-induced improvements in effective parenting led to changes in multiple proximal factors that prior theory and research implicated in the cascading pathway to suicide risk, namely, aversive self-views, caregiver connectedness, peer connectedness, complicated grief, depressive symptoms, and emotion suppression. The sample was 244 bereaved youth and their surviving caregiver from 156 families. Families were randomized into the FBP (12 group-based sessions for parents, youth, and two joint sessions) or a literature control condition. Multimethod and multiinformant data were collected at baseline, posttest, 6-year and 15-year follow-up assessments. Results showed that program-induced improvements in effective parenting at posttest were associated with reduced aversive self-views and increased caregiver connectedness at the 6-year follow-up, and each mediator was in turn associated with reduced suicide risk at the 6- and 15-year follow-up. The mediated pathways via aversive self-views remained significant while controlling for caregiver connectedness. Self-related concepts may be important targets in upstream suicide prevention for at-risk youth.

Effects of a preventive parenting intervention for bereaved families on the intergenerational transmission of parenting attitudes: Mediating processes.

This study evaluated whether the Family Bereavement Program (FBP), a prevention program for parentally bereaved families, improved parenting attitudes toward parental warmth and physical punishment in young adult offspring 15 years after participation and identified mediational cascade pathways. One hundred fifty-six parents and their 244 offspring participated. Data were collected at pretest (ages 8-16), posttest, and six- and 15-year follow-ups. Ethnicity of offspring was: 67% non-Hispanic Caucasian, 16% Hispanic, 7% African American, 3% Native American, 1% Asian or Pacific Islander, and 6% other; 54% were males. There was a direct effect of the FBP on attitudes toward physical punishment; offspring in the FBP had less favorable attitudes toward physical punishment. There were also indirect effects of the FBP on parenting attitudes. The results supported a cascade effects model in which intervention-induced improvements in parental warmth led to fewer externalizing problems in adolescence/emerging adulthood, which in turn led to less favorable attitudes toward physical punishment. In addition, intervention-induced improvements in parental warmth led to improvements in anxious romantic attachment in mid-to-late adolescence/emerging adulthood, which led to more favorable attitudes toward parental warmth in emerging/young adulthood. These findings suggest that the effects of relatively brief prevention programs may persist into subsequent generations.

Feasibility, Acceptability, and Effectiveness of Adding an Evidence-Based Parent/Caregiver Program for Bereaved Families to Usual Community-Based Services.

This paper briefly describes the development of the Resilient Parenting for Bereaved Families program (RPBF) and presents an evaluation of adding the RPBF to usual care (UC) provided by community agencies supporting families of bereaved children. The RPBF was adapted from the caregiver component of a family program that demonstrated significant benefits for parentally children and their parents in a randomized controlled trial. The current study found that the implementation of the RPBF program was feasible for implementation by community providers and was highly acceptable to caregivers. Subgroups of caregivers (n = 44) who received the RPBF in addition to UC (i.e., child groups and caregiver support groups) reported greater improvement in quality of parenting and complicated grief and reductions in children's behavior problems as compared with caregivers (n = 30) who received UC only. Improvement in parenting mediated the RPBF program's effect to reduce children's behavior problems.

Longitudinal Effects of PostDivorce Interparental Conflict on Children's Mental Health Problems Through Fear of Abandonment: Does Parenting Quality Play a Buffering Role?

In a sample of 559 children (ages 9-18), researchers investigated whether: (a) fear of abandonment mediated the association between postdivorce interparental conflict (IPC) and mental health problems, and (b) parent-child relationship quality moderated the association between IPC and fear of abandonment. Mediation analyses indicated that pretest IPC predicted fear of abandonment 3 months later, which then predicted child- and teacher-reported mental health problems 10 months later. The hypothesized protective effect of a high-quality parent-child relationship was not observed. IPC predicted fear of abandonment for all children, except for those with low- and moderate-quality father-child relationships, for whom IPC was not significantly related to fear of abandonment. Findings highlight the need to optimize child coping programs and improve parenting-after-divorce programs to reduce IPC.

Developmental cascade effects of a parenting-focused program for divorced families on competence in emerging adulthood.

This 15-year longitudinal follow-up of a randomized controlled trial of a parenting-focused preventive intervention for divorced families examined cascade models of program effects on offsprings' competence. It was hypothesized that intervention-induced improvements in parenting would lead to better academic, work, peer, and romantic competence in emerging adulthood through effects on behavior problems and competencies during adolescence. Families (N = 240) participated in the 11-session program or literature control condition when children were ages 9-12. Data were drawn from assessments at pretest, posttest, and follow-ups at 3 and 6 months and 6 and 15 years. Results showed that initial intervention effects of parenting on externalizing problems in adolescence cascaded to work outcomes in adulthood. Parenting effects also directly impacted work success. For work outcomes and peer competence, intervention effects were moderated by initial risk level; the program had greater effects on youths with higher risk at program entry. In addition, intervention effects on parenting led to fewer externalizing problems that in turn cascaded to better academic outcomes, which showed continuity into emerging adulthood. Results highlight the potential for intervention effects of the New Beginnings Program to cascade over time to affect adult competence in multiple domains, particularly for high-risk youths.

Grief as a predictor of long-term risk for suicidal ideation and attempts of parentally bereaved children and adolescents.

Although children who experience the death of a parent have a heightened risk of suicidality, the long-term associations between grief and suicidality among bereaved youth have yet to be examined. Research is needed to test the specific aspects of grief associated with suicidality, after controlling for other risk factors, in this population. Grief and covariates, including age, gender, parental cause of death, time since parental death, depression, anxiety, internalizing problems, posttraumatic stress symptoms, and child treatment involvement, were assessed at baseline, 6-year, and 15-year follow-ups in a sample of 244 parentally bereaved youth aged 8-16 years. Utilizing multiple grief measures, a bifactor approach was used to identify a general factor and two uncorrelated specific factors: Intrusive Grief Thoughts and Social Detachment/Insecurity. Suicidal thoughts and attempts were assessed at both follow-ups. The Intrusive Grief Thoughts specific factor had a prospective nonlinear association with suicidality at both follow-ups after controlling for all baseline covariates. The nonlinear relation consisted of a large effect, OR > 73 (using the rescaled scores), on the increased risk of suicidality from low to moderate levels of intrusive grief, with no association from moderate to high levels. At 6-year follow-up, the specific Social Detachment/Insecurity factor was significantly associated with suicidality after controlling for covariates. Specific grief factors assessed at different points were associated with suicidal thoughts or attempts among parentally bereaved youth. These findings highlight the significance of specific aspects of child and adolescent grief that have implications for the development of upstream suicide prevention services.

A Population-Level, Randomized Effectiveness Trial of Recruitment Strategies for Parenting Programs in Elementary Schools.

Objective: A population-level, randomized controlled trial was conducted to test the effectiveness of a parent recruitment package for increasing initial engagement into a school-based parenting program and to identify strategies responsible for effects.Method: Participants were caregivers of kindergarten- to third-grade students (N = 1,276) attending one of five schools serving ethnically diverse families living in mostly low-income, urban conditions. First, families were randomly assigned to be recruited for research surveys or not, and then to a parenting program recruitment condition: 1) Engagement-as-usual (EAU) informational flyer; 2) EAU + testimonial booklet; 3) EAU + teacher endorsement; 4) EAU + recruitment call; or 5) all strategies (full package). Caregivers were offered a free parenting program at their child's school. Primary dependent variables were parenting program enrollment and attending at least one session (initiation). Exploratory analyses were conducted on program completion, attendance across sessions, homework completion, and in-session participation.Results: In the population-level sample, enrollment and initiation were higher for the full package compared to all other conditions except the recruitment call condition. Enrollment, initiation, and program completion were higher for the recruitment call and full package conditions compared to the EAU condition. In the subsample of initiators, parents in the full package condition attended fewer parenting sessions than in the EAU condition. Controlling for attendance across sessions, there were no condition effects on homework completion or in-session participation.Conclusions: The recruitment call can increase the public health impact of evidence-based parenting programs by improving enrollment, initiation, and program completion.

Initial Validation and Measurement Invariance of the Active Inhibition Scale Among Traumatized and Grieving Youth.

The Active Inhibition Scale (AIS; Ayers, Sandler, & Twohey, 1998) is an 11-item, self-report measure of emotional suppression among children and adolescents. Previous research with the AIS has linked emotional suppression to several clinically significant outcomes, such as posttraumatic stress symptoms (PTSS) and suicide, among trauma-exposed and bereaved youth; however, there are no published evaluations of its psychometric properties. We examined the factor structure and criterion validity of the AIS in two samples. Sample 1 included youth (M = 12.22 years, SD = 2.96, range: 6-18 years; 55.4% female) referred to an outpatient psychology clinic specializing in childhood trauma and grief. Sample 2 included youth (M = 13.18 years, SD = 2.58, range: 8-18 years; 61.8% female) referred to a community grief counseling center. Confirmatory factor analytic results supported a one-factor solution, Cronbach's α = .94. Additionally, AIS scores correlated positively with PTSS, depression, and maladaptive grief, rs = .43-.64. Evidence of factorial invariance was found across gender, race/ethnicity, and age group. Emotional suppression scores were higher among girls compared to boys, Black and Hispanic youth compared to White youth, and older compared to younger age groups. The magnitude of correlations between AIS and symptom measure scores was comparable across groups. These results support the reliability and criterion validity of the AIS with diverse youth populations and underscore the role that emotional suppression may play in explaining group differences in mental health symptoms.

Randomized Effectiveness Trial of the New Beginnings Program for Divorced Families with Children and Adolescents.

This study presents findings from a randomized effectiveness trial of the New Beginnings Program (NBP), which has demonstrated efficacy in 2 prior randomized efficacy trials. Family courts in 4 counties facilitated recruitment of divorcing and separating parents, and providers in community agencies delivered the program. Participants were 830 parents of children ages 3-18 who were randomized to receive either the 10-session NBP or an active 2-session comparison condition in which parents learned about the same parenting skills but did not complete home practice of these skills. Parents were ethnically diverse (59.4% non-Hispanic White, 31.4% Hispanic, 9.2% other race or ethnicity). Multiple rater assessments of parenting, interparental conflict, and child mental health problems were conducted at pretest, posttest, and 10-month follow-up. The results indicated positive moderated effects of the NBP as compared with the active control condition to strengthen parenting at posttest and to reduce child mental health problems at posttest and 10 months. Many of these moderated effects showed positive benefits for non-Hispanic White families but not for Hispanic families. The findings indicate support for the effectiveness of the NBP when delivered by community-based agencies but also indicate the need for further adaptations to make the program effective for Hispanic parents.

Effects of Therapeutic Intervention on Parentally Bereaved Children's Emotion Reactivity and Regulation 15 Years Later.

The Family Bereavement Program (FBP) is a family-based intervention for parentally bereaved children and surviving caregivers. Results are reported of a randomized controlled trial, examining intervention effects on emotional reactivity and regulation of young adults who participated in the program 15 years earlier. Participants (N = 152) completed four emotion challenge tasks: reactivity to negative images, detached reappraisal while viewing negative images, positive reappraisal while viewing negative images, and reengagement with positive images. Outcomes included cardiac interbeat interval (IBI), pre-ejection period (PEP), and respiratory sinus arrhythmia (RSA) as well as self-reported emotional experience and regulation effectiveness. Direct intervention effects and effects mediated through improved parenting were estimated. Several significant effects were observed in primary analyses; however, none remained significant after correction for familywise Type I error. Parenting mediated FBP effects on IBI during negative reactivity (b = 15.04), and on RSA during positive reengagement (b = 0.35); the latter effect was accounted for by changes in breathing. Intervention condition was a direct predictor of self-reported detached reappraisal effectiveness (b = 1.00). Intervention and gender interacted in predicting self-reported negative emotion during the negative reactivity (b = 1.04) and positive reappraisal tasks (b = 1.31) such that intervention-condition men reported more negative emotions during those tasks. Although these findings should be considered preliminary given the limited power of the corrected statistical tests, they suggest long-term effects of family intervention following the death of a parent on offspring's emotional reactivity and regulation ability that should be pursued further in future research.

Coping in context: The effects of long-term relations between interparental conflict and coping on the development of child psychopathology following parental divorce.

Exposure to high levels of postdivorce interparental conflict is a well-documented risk factor for the development of psychopathology, and there is strong evidence of a subpopulation of families for which conflict persists for many years after divorce. However, existing studies have not elucidated differential trajectories of conflict within families over time, nor have they assessed the risk posed by conflict trajectories for development of psychopathology or evaluated potential protective effects of children's coping to mitigate such risk. We used growth mixture modeling to identify longitudinal trajectories of child-reported conflict over a period of six to eight years following divorce in a sample of 240 children. We related the trajectories to children's mental health problems, substance use, and risky sexual behaviors and assessed how children's coping prospectively predicted psychopathology in the different conflict trajectories. We identified three distinct trajectories of conflict; youth in two high-conflict trajectories showed deleterious effects on measures of psychopathology at baseline and the six-year follow-up. We found both main effects of coping and coping by conflict trajectory interaction effects in predicting problem outcomes at the six-year follow-up. The study supports the notion that improving youth's general capacity to cope adaptively is a potentially modifiable protective factor for all children facing parental divorce and that children in families with high levels of postdivorce conflict are a particularly appropriate group to target for coping-focused preventive interventions.

Redesigning Implementation Measurement for Monitoring and Quality Improvement in Community Delivery Settings.

The field of prevention has established the potential to promote child adjustment across a wide array of outcomes. However, when evidence-based prevention programs have been delivered at scale in community settings, declines in implementation and outcomes have resulted. Maintaining high quality implementation is a critical challenge for the field. We describe steps towards the development of a practical system to monitor and support the high-quality implementation of evidence-based prevention programs in community settings. Research on the implementation of an evidence-based parenting program for divorcing families called the "New Beginnings Program" serves as an illustration of the promise of such a system. As a first step, we describe a multidimensional theoretical model of implementation that links aspects of program delivery with improvements in participant outcomes. We then describe research on the measurement of each of these implementation dimensions and test their relations to intended program outcomes. As a third step, we develop approaches to the assessment of these implementation constructs that are feasible to use in community settings and to establish their reliability and validity. We focus on the application of machine learning algorithms and web-based data collection systems to assess implementation and provide support for high quality delivery and positive outcomes. Examples are presented to demonstrate that valid and reliable measures can be collected using these methods. Finally, we envision how these measures can be used to develop an unobtrusive system to monitor implementation and provide feedback and support in real time to maintain high quality implementation and program outcomes.

Long-term Effects of a Parenting Preventive Intervention on Young Adults' Attitudes Toward Divorce and Marriage.

This study examined whether the New Beginnings Program (NBP), a parenting-focused preventive intervention designed to reduce children's post-divorce mental health problems, affected attitudes toward divorce and marriage in young adults whose mothers had participated 15 years earlier. Participants (M = 25.6 years; 50% female; 88% Caucasian) were from 240 families that had participated in a randomized experimental trial (NBP vs. literature control). Analyses of covariance showed that program effects on both types of attitudes were moderated by gender. Males in the NBP reported more positive attitudes toward marriage and less favorable attitudes toward divorce than males in the literature control.

Attendance Trajectory Classes Among Divorced and Separated Mothers and Fathers in the New Beginnings Program.

We examined attendance trajectories among mothers and fathers in the effectiveness trial of the New Beginnings Program, a parenting-focused prevention program for divorced and separated parents. We also investigated attendance trajectory class differences on two sets of pretest covariates: one set previously linked to participation in programs not specifically targeting divorced parents (i.e., sociodemographics, perceived parenting skills, child problem behaviors, parent psychological distress) and another that might be particularly salient to participation in the context of divorce (i.e., interparental conflict, level of parent-child contact, previous marital status to the ex-spouse). For mothers and fathers, results supported four attendance trajectory classes: (1) non-attenders (NA), (2) early dropouts (ED), (3) declining attenders (DA), and (4) sustained attenders (SA). In the final model testing multiple covariates simultaneously, mothers who were EDs and DAs were more likely to be Latina than SAs, and EDs reported more interparental conflict than SAs. Mother trajectory groups did not differ on parenting skills, child problem behavior, or mother-child contact in the final or preliminary models. In the final model for fathers, EDs rated their children higher on externalizing than DAs, had less contact with their children than DAs and NAs, and reported less distress than SAs. Father trajectory groups did not differ on fathers' age, ethnicity, income, perceived parenting skills, or interparental conflict in the final or preliminary models. Results highlight qualitatively distinct latent classes of mothers and fathers who disengage from a parenting intervention at various points. We discuss implications for intervention engagement strategies and translational science.

Effects of a Program to Promote High Quality Parenting by Divorced and Separated Fathers.

This paper reports on the effects on parenting and on children's mental health problems and competencies from a randomized trial of a parenting program for divorced and separated fathers. The program, New Beginnings Program-Dads (NBP-Dads), includes ten group sessions (plus two phone sessions) which promote parenting skills to increase positive interactions with children, improve father-child communication, use of effective discipline strategies, and skills to protect children from exposure to interparental conflict. The program was adapted from the New Beginnings Program, which has been tested in two randomized trials with divorced mothers and shown to strengthen mothers' parenting and improve long-term outcomes for children (Wolchik et al. 2007). Fathers were randomly assigned to receive either NBP-Dads or a 2-session active comparison program. The sample consisted of 384 fathers (201 NBP-Dads, 183 comparisons) and their children. Assessments using father, youth, and teacher reports were conducted at pretest, posttest, and 10-month follow-up. Results indicated positive effects of NBP-Dads to strengthen parenting as reported by fathers and youth at posttest and 10-month follow-up. Program effects to reduce child internalizing problems and increase social competence were found at 10 months. Many of the program effects were moderated by baseline level of the variable, child age, gender, and father ethnicity. This is the first randomized trial to find significant effects to strengthen father parenting following divorce. In view of recent changes in family courts to allot fathers increasing amounts of parenting time following divorce, the results have significant implications for improving outcomes for children from divorced families.

The Cascading Effects of Multiple Dimensions of Implementation on Program Outcomes: a Test of a Theoretical Model.

This study tests a theoretical cascade model in which multiple dimensions of facilitator delivery predict indicators of participant responsiveness, which in turn lead to improvements in targeted program outcomes. An effectiveness trial of the 10-session New Beginnings Program for divorcing families was implemented in partnership with four county-level family courts. This study included 366 families assigned to the intervention condition who attended at least one session. Independent observers provided ratings of program delivery (i.e., fidelity to the curriculum and process quality). Facilitators reported on parent attendance and parents' competence in home practice of program skills. At pretest and posttest, children reported on parenting and parents reported child mental health. We hypothesized effects of quality on attendance, fidelity and attendance on home practice, and home practice on improvements in parenting and child mental health. Structural Equation Modeling with mediation and moderation analyses were used to test these associations. Results indicated quality was significantly associated with attendance, and attendance moderated the effect of fidelity on home practice. Home practice was a significant mediator of the links between fidelity and improvements in parent-child relationship quality and child externalizing and internalizing problems. Findings provide support for fidelity to the curriculum, process quality, attendance, and home practice as valid predictors of program outcomes for mothers and fathers. Future directions for assessing implementation in community settings are discussed.

Addressing Methodologic Challenges and Minimizing Threats to Validity in Synthesizing Findings from Individual-Level Data Across Longitudinal Randomized Trials.

Integrative Data Analysis (IDA) encompasses a collection of methods for data synthesis that pools participant-level data across multiple studies. Compared with single-study analyses, IDA provides larger sample sizes, better representation of participant characteristics, and often increased statistical power. Many of the methods currently available for IDA have focused on examining developmental changes using longitudinal observational studies employing different measures across time and study. However, IDA can also be useful in synthesizing across multiple randomized clinical trials to improve our understanding of the comprehensive effectiveness of interventions, as well as mediators and moderators of those effects. The pooling of data from randomized clinical trials presents a number of methodological challenges, and we discuss ways to examine potential threats to internal and external validity. Using as an illustration a synthesis of 19 randomized clinical trials on the prevention of adolescent depression, we articulate IDA methods that can be used to minimize threats to internal validity, including (1) heterogeneity in the outcome measures across trials, (2) heterogeneity in the follow-up assessments across trials, (3) heterogeneity in the sample characteristics across trials, (4) heterogeneity in the comparison conditions across trials, and (5) heterogeneity in the impact trajectories. We also demonstrate a technique for minimizing threats to external validity in synthesis analysis that may result from non-availability of some trial datasets. The proposed methods rely heavily on latent variable modeling extensions of the latent growth curve model, as well as missing data procedures. The goal is to provide strategies for researchers considering IDA.

Video-Based Approach to Engaging Parents into a Preventive Parenting Intervention for Divorcing Families: Results of a Randomized Controlled Trial.

The public health impact of evidence-based, preventive parenting interventions has been severely constrained by low rates of participation when interventions are delivered under natural conditions. It is critical that prevention scientists develop effective and feasible parent engagement methods. This study tested video-based methods for engaging parents into an evidence-based program for divorcing parents. Three alternative versions of a video were created to test the incremental effectiveness of different theory-based engagement strategies based on social influence and health behavior models. A randomized controlled trial was conducted to compare the three experimental videos versus two control conditions, an information-only brochure and an information-only video. Participants were attendees at brief, court-mandated parent information programs (PIPs) for divorcing or never married, litigating parents. Of the 1123 eligible parents, 61% were female and 13% were never married to the child's other parent. Randomization to one of five conditions was conducted at the PIP class level, blocking on facilitator. All participants completed a 15-item, empirically validated risk index and an invitation form. Results of regression analyses indicated that the most streamlined version, the core principles video, significantly increased parents' interest in participating in the parenting intervention, enrollment during a follow-up call, and initiation (i.e., attending at least one session) compared to one or the other control conditions. Findings suggest that videos based on social influence and health behavior theories could provide an effective and feasible method for increasing parent engagement, which would help maximize the public health benefits of evidence-based parenting interventions.