Deborah Gross, DNSc , RN, FAAN Leonard & Helen Stulman Professor in

Engaging Families of Young Children in Parenting Skills Interventions:

Lessons Learned from the Chicago Parent Program

Deborah Gross, DNSc, RN, FAANLeonard & Helen Stulman Professor in Mental Health and Psychiatric Nursing

Johns Hopkins University School of Nursing & School of Medicine (Dept of Psychiatry & Behavioral Sciences)

Acknowledgements• Co-authors of the Chicago Parent Program: Christine Garvey, Wrenetha

Julion, and Susan Breitenstein (Rush University)• Louis Fogg, PhD, Statistician (Rush University)• Alison Ridge, RN, DNP (Rush University)• Joyce Harrison, Medical Director, Children’s Mental Health Center, Johns

Hopkins Hospital• Harolyn Belcher, MD (The Family Center at Kennedy Krieger)• Emily Hoppe and Laura Mitchell (JHU School of Nursing)• The National Institute for Nursing Research (NIH)• The Leonard & Helen R. Stulman Foundation• The Zanvyl and Isabelle Krieger Fund• The Morton and Jane Blaustein Foundation• The Robert Wood Johnson Foundation

Objectives of Presentation

To describe:1. The use of a parent advisory board to inform the creation

of a parenting skills intervention called the Chicago Parent Program

2. Research supporting the efficacy of the Chicago Parent Program for prevention in low-income communities

3. The use of the Chicago Parent Program for clinic populations

4. Lessons learned (and still learning) on strategies for increasing parent participation rates in parenting programs

There are many evidence-based parenting programs…

Some examples:• The Incredible Years (Webster-Stratton)• Parent-Child Interaction Therapy (Eyberg)• Triple P (Sanders)• Helping the Non-Compliant Child

(Forehand)

However, all of these programs were originally developed and evaluated on

White, non-Latino families

Chicago Parent Program

• To improve parenting skills & reduce child behavior problems

• Developed with an advisory board of African American and Latino parents of young children

• Designed to be culturally relevant for African American and Latino parents of young children (2-5 years)

• Designed to be contextually relevant for parents from low-income, urban communities

Chicago Parent Program Features• Social learning theory/Coercive

Process Model

• Uses video vignettes + parent group discussion

• 12 2-hour parent group sessions

• Led by 2 trained group leaders

• Detailed group leader manual

• Program’s effectiveness supported in randomized trials

12-Session Program Overview

Unit 1: The Value of Your Attention (4 weeks)

• Child-centered Time• Importance of Routines &

Traditions• Praise & Encouragement• Using Reward Programs

Unit 2: Using Your Authority Wisely (4 weeks)

• Say What You Mean, Mean What You Say

• Threats & Consequences• Ignore & Distract• Using Time-Outs

Program Overview (cont’d)

Unit 3: Managing your Stress (2 weeks)

• Reducing your Stress• Problem-solving

Unit 4: Sticking with the Program (2 weeks)

• Putting it All Together• Booster Session (1 month

later)

What Makes This Program Different?

• ~160 vignettes, 75% are families of color• Managing misbehavior in public and at home• Parenting strategies reframed to enhance

relevance:• “Child-Directed Play” vs “Child-Centered Time”• Reframing Praise: “10 years from now, how do you

want your children to feel deep down inside about themselves?”

• Reframing Spanking: The 8 Keys to Effective Discipline

8 Keys to Effective Discipline

1. Tied to a specific behavior2. Punishment should fit the crime3. Discipline is predictable4. Discipline is controlled5. Discipline without rage6. Discipline without humiliation7. Discipline with a positive ending8. Children always know they’re loved

Sample Vignettes

Chicago Prevention Research: Sample Descriptions from two RCTs

• 90% mothers• All families of color

• 58% African American • 42% Latino

• All receiving childcare subsidies based on low income• 60% report annual incomes < $20,000

• 72% unmarried• Median education: High School/GED• M child age = 3 yr (range 2-4 yrs)• 54% boys

RCT Design (n=504)

• 8 childcare centers• Centers matched, randomized– Control n = 237– CPP n = 267

• Intent to treat design• RM-MANOVA with planned contrasts

Chicago Parent Program Effects (n=504)T2= post-intervention; T3=6-month f/up; T4=1yr f/up; * p< .05; **p<.01

Variable Overall Effect Baseline-T2 T2-T3-T4 T3-T4

Corporal punishment

4.24** 0.48 1.15 0.50

Following through

2.74* 3.78* 0.00 3.07

Parenting self-efficacy

3.88** 6.79** 0.02 0.43

Child behavior problems (Parent)

2.63* 4.44* 0.18 0.07

Externalizing (Teacher)

3.94** 3.32 0.27 9.28**

Internalizing (Teacher)

2.62* 1.73 0.00 6.23**

Chicago Parent Program Effects Observed Behavior (n=504)

T2= post-intervention; T3=6-month f/up; T4=1yr f/up; * p< .05; **p<.01

Variable Overall Effect Baseline-T2 T2-T3-T4 T3-T4

Parent Praise 2.30 6.56* 1.27 0.01

Commands 0.33 0.00 0.46 0.34

Child Aversive Behavior

2.48 6.78** 1.23 0.00

Summary (2002-2011)

Compared to controls, CPP parents:• used less corporal punishment• used more consistent discipline• reported higher parenting self-efficacy• had children with greater reductions in

behavior problems

However….Parent participation rates were low (2002-2006)– M enrollment = 35% of eligible families– M attendance = 36% of group sessions– 37.5% of enrolled parents never attended

Low participation rates affect validity and sustainability:– ↓ treatment effects– ↓ generalizability– ↓ the number of families receiving help– ↑ the cost of program delivery

2006-2011: Effect of Childcare Discounts on Parent Participation Rates

Purpose: Test the cost-effectiveness of giving low-income parents childcare discounts contingent on attendance in CPP

8 Chicago childcare centers randomized:– Standard centers: ↓ barriers to participation but

no discount– Discount centers: ↓ barriers to participation +

discount ($5 + 20%)

Barrier Reduction Strategies

• On-site parent groups at childcare center• Free childcare during parent groups• Siblings included in free childcare• Dinner for parents and children• Held on week-day evenings• Research evaluations conducted at convenient

locations• Personable recruiters• Toll free number if any problems

Results (n=323)• M discount = $8.92/wk

(range = 0-$35)• 24% of eligible families

enrolled• 15% more parents enrolled

in discount (p = NS)• M attendance in both

conditions = 50% of sessions• Parent engagement high in

both conditions

Results: Post-Interviews

Parents interviewed after CPP ended (n=61)– 56% reported getting discounts while still

attending CPP– 23% reported getting discount after CPP ended– 21% had no recollection of getting discount

Administrators interviewed (n=4 centers)– cost of administering discounts: $2.78/parent– For some centers, discounts were an added

burden

The High Cost of Low EnrollmentAssuming Parents Attend All 12 CPP Sessions

2009 dollars

Enrollment Per Group

Costs per Parent Session

Group Size = 3 Group Size = 6 Group Size = 15

Group Cost $129.91 (83%) $95.46 (78%) $60.80 (69%)

Parent Opportunity Cost

$27.28 (17%) $27.28 (22%) $27.28 (31%)

Total Cost (per parent session)

$157.10 (100%) $122.74 (100%) $88.08 (100%)

The High Cost of Low AttendanceCost per session: 15 parents enrolled, different attendance

rates 2009 dollars

Number of parents in attendance per group session

Costs per Parent Session

N = 1 parent N = 10 parents N = 15 parents

Group Cost $911.93 (97%) $91.19 (77%) $60.80 (69%)

Parent Opportunity Cost

$27.28 (17%) $27.28 (22%) $27.28 (31%)

Total Cost (per parent session)

$939.21 (100%) $118.47 (100%) $88.08 (100%)

Conclusions, so far:

• CPP is effective for improving parent and child behavior as a preventive intervention

• Like most preventive interventions, participation rates are low

• Childcare discounts are not effective if they are too small and too delayed

• Administering discounts is a burden for agencies• But, the cost of low participation rates is substantial• We need to continue to think of innovative ways to

improve parent participation rates

Chicago Parent Program in Baltimore: The Preschool Therapeutic Learning Center*

The Children– 2-5 years olds– 43% African American– 51% male– 40% exposed to drugs in

utero– 53% protective services

involvement– 36% out of home

placements– 38% domestic violence

exposure– 83% developmental delays

The Parents• 42% incarcerated• 66% current or past history of

substance abuse• 71% of mothers have a

psychiatric illness• 50% of fathers have a

psychiatric illness

* 2009-2010

Preschool Therapeutic Learning Center Program

• Parents required to attend with their child • 3 - 5 days/week, 9am to 12 noon• Services currently include: – child groups (life skills, socialization, movement, OT)– parent groups– individual therapy – family therapy – medication management

• August 2009: Chicago Parent Program added to treatment program

Child behavior problem score* changes (from pre- to post-treatment)

with/without Chicago Parent Program Before CPP** included

• 19% decrease in aggression and hyperactivity

• 15% decrease in anxiety, depression, social withdrawal

*Child Behavior Checklist

After CPP** included

• 32% decrease in aggression and hyperactivity

• 40% decrease in anxiety, depression, social withdrawal

**Chicago Parent Program

2010-Present: Extending the Chicago Parent Program into

Outpatient Treatment

• March 2010-Dec 2010 (Bayview)• Jan 2011-present (CMHC at JHH)– High parent satisfaction– Improvements in child behavior problems– improvements in parenting stress

Parent Interviews

EPIC StudyCollaboration with the Family Center at Kennedy Krieger Institute

• Funded by the NINR (2011-2016)• Comparative effectiveness trial of two PT delivery models for

treating behavior disorders• CPP vs Parent-Child Interaction Therapy• Parents of 2-5 year olds referred for treatment• Primary variables of interest:

– Child behavior problems (parent report + observed)– Parenting self-efficacy– Parent Discipline– Parent and Clinician Satisfaction with treatments– Cost

Lessons Learned: The Challenge of Teaching Parenting Skills to

At-Risk Families• Parents want to be good

parents but many have no history of good parenting to draw from

• Groups are very beneficial for parents but difficult to do well

• Parents must practice the new skills, but don’t

• Parents need to see change in their children’s behavior

• Parents learn there’s no “quick fix,” which is demoralizing

• Family stress and psychopathology make it difficult to learn, practice, persevere

Future Directions for Practice & Research

• Develop short-term incentives to sustain parent engagement in treatment

• Better understand how to match parent needs with evidence-base treatments

• Create strong methods for replicating evidence-based treatments in under-resourced communities

• Need to invest in intensive treatments for parents and preschool children with serious mental health problems

• Parenting skills training should be a standard part of early childhood mental health services

Selected References• Gross, D. et al. (in press) Cost effectiveness of childcare discounts on parent

participation in preventive parent training in low-income communities. Journal of Primary Prevention

• Gross, D. & Crowley, AA (2011). Health promotion and prevention in early childhood: The role of nursing research in shaping policy and practice. In AS Hinshaw and P. Grady (eds), Health policy through nursing research. NY: Springer

• Breitenstein, S. et al. (2010) Measuring implementation fidelity in a community-based parenting intervention. Nursing Research, 59, 158-165.

• Gross, D. et al. (2009). Efficacy of the Chicago Parent Program with low-income African American and Latino parents of young children. Prevention Science, 10, 54-65.

• Gross, D., et al. (2007). Preventive parent training with low-income ethnic minority parents of preschoolers. In JM Briesmeister & CE Schaefer (Eds). Handbook of parent training (3rd ed.). NY: Wiley.

• Garvey, C. et al. (2006). Measuring participation in a prevention trial with parents of young children. Research in Nursing & Health, 29, 212-222.

Thank you!For more information from the presenter, email: [email protected] more information about the program: www.chicagoparentprogram.org