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Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009

Preventing Child Abuse and Neglect with Parent Training: Evidence and Opportunities
Authors: Richard P. Barth

The Design of Parent Training Programs

Each of the interventions discussed so far includes a manual that communicates how parent training should be delivered. As such, these interventions are certainly likely to be an advance over the existing ad hoc ways in which many child welfare agencies now develop parent training programs.

Common Elements of Effective Programs
John Piacentini observes that identifying and building on the effective common elements of parent training programs offers considerable advantages.68 Among the common elements that he notes are potential use in multiple clinical and service applications, including the development of benchmarks for assessing quality of care; simplified therapy training efforts focused on key techniques as opposed to individual treatment manuals; and use in developing individualized modular or stepped-care interventions that fit the unique characteristics of the clients rather than the vision of the treatment designer.

A team of British researchers has recently completed a review of parenting education programs that isolates a number of effective components.69 Early intervention, for example, results in better and more durable outcomes for children, though late intervention is better than none and may help parents deal with parenting under stress. Having a strong theory base and having a clearly articulated model of the predicted mechanism of change are also likely to make interventions effective, as is targeting: aiming interventions at specific populations or individuals deemed to be at risk for parenting difficulties. Including explicit strategies to recruit, engage, and retain parents is also a core element of promising parenting programs. Interventions should also have multiple components, such as a variety of referral routes for families and more than one method of delivery. Group work, where the issues involved are suitable to be addressed in a “public” format and where parents can benefit from the social aspect of working in groups of peers, are preferable to individual work, unless the problems are severe or entrenched or parents are not ready or able to work in a group. Individual work should, typically, include an element of home visiting as part of a multi-component service, providing one-to-one, tailored support. Programs that carefully structure and control the services delivered to maintain program integrity appear to be successful, as are interventions delivered by appropriately trained and skilled staff, backed up by good management and support. Interventions of longer duration, with follow-up and booster sessions, are recommended for problems of greater severity or for higher-risk groups. Behavioral interventions that focus on specific parenting skills and practical “take-home tips” for changing more complex parenting behaviors and affecting child behaviors are also considered effective. Finally, interventions that work in parallel (though not necessarily at the same time) with parents, families, and children are considered best practice.

In the United States, Ann Garland and several colleagues reviewed all the evidence-based treatment programs for disruptive child behavior and identified the common elements, which they confirmed with an expert panel.70 Garland and her team were able to distinguish treatment elements directed to children and those directed to parents and to separate therapeutic content from therapist techniques. Perhaps most significant, they added practice elements such as frequency and intensity of treatment. The five fundamental working alliance and treatment parameters common to effective interventions were: consensually set goals, a minimum of twelve sessions, meeting at least once weekly, building rapport and an effective bond with the therapist, and active participation by the child and parent.

Michael Hurlburt and colleagues derived a list of eight key components of three leading parent education programs—the Incredible Years, Parent-Child Interaction Therapy, and Parent Management Training—with a history of some success with child maltreatment populations.71 What the three programs had in common was that each strengthened positive aspects of parent-child interaction, decreased the use of parent directives and commands, used specific behavioral approaches, included detailed materials to support parent skill building, included homework, monitored changes in parenting practices, required role-playing, and lasted at least twenty-five hours.

Video Feedback to Parents
Other intervention elements that may be important to program design have not been fully evaluated. Researchers, for example, recently subjected parent education programs that use video playback of parent-child interactions to a meta-analysis.72 They found that these programs have a sizable positive effect on parent behavior and a modest but significant effect on children’s behavior— no less for children referred to clinics for conduct problems than for children referred from other sources.

Parents and Children Together
Returning to the effect of parenting practices on maladapted child behavior and the reciprocal influence of children’s behavior on parenting practices, a promising avenue for future research would involve testing concurrent interventions for parents and for children. For example, it might be valuable to pair an evidence-based parent training group with a concurrent child group focused on social skills, social information processing, and interpersonal problem-solving skills. Such child-focused groups alone have been shown to influence significantly both parenting behavior and child behavior in school settings.73 Pairing the child group with the parent group could test to see whether they act synergistically when run concurrently. Making good use of children’s time may also act as yet another incentive for parents to attend and benefit from parent training groups.

Parent Education on Focused Issues
Parent education need not be comprehensive to be helpful in preventing child abuse. A focused program to reduce abusive head trauma, for example, has shown that providing vivid information and requesting a commitment from parents to refrain from shaking babies can substantially reduce child maltreatment—even when no other effort is made to address substance abuse, poverty, or the use of positive parenting principles.74

Adaptations for Racial, Ethnic, and Cultural Groups
For the most part these evidence-supported interventions seem robust across cultures although researchers have conducted few definitive evaluations. Three reviews, bridging somewhat different topics and using different methods for comparing the efficacy across groups, have all concluded that minority children and families appear to benefit as much as or more than other groups from evidence-based interventions like those proposed here.75 At the same time, because the success of a program depends importantly on participants’ remaining engaged until they complete the program, as well as the fidelity with which the program is delivered, cultural adaptations that increase the likelihood of optimal delivery and receipt of these programs to practitioners, parents, and children would seem well warranted.76

New Directions for Parent Training and Child Welfare Services
Overall, child welfare services and evidence-based parent training are in a period of transformation. Evidence-based methods are rapidly emerging from a development phase that has primarily involved local and highly controlled studies, into more national implementation and greater engagement with child welfare services. At the same time, the field of child welfare services is showing new awareness of the importance of evidence-based methods. Journals are publishing special issues on the topic, the Administration for Children and Families (ACF) launched a major round of funding in 2004 to promote testing of evidence-based methods, several states (for example, Maryland, Washington, and California) are developing statewide initiatives, and this past year ACF created five regional resource centers on implementation to expedite the dissemination of best practices. Although these efforts are not focused on child abuse prevention per se, the infrastructure to create prevention programs, based on the campaign model, is emerging.

The next major step is to implement effectiveness trials. The programs are mature enough and have enough experience with similar populations of high-risk families caring for children at home,77 as well as foster families,78 to justify immediate testing. Child welfare agencies have demonstrated that they can be the setting for randomized clinical trials. They can build on experience with the Social Security Act Title IV-E waivers, which allow dollars that ordinarily go to out-of-home care to go instead for cost-effective in-home services, and on experience with recent trials funded by ACF, the Centers for Disease Control and Prevention (CDC), and the National Institute of Mental Health. Such trials will help researchers better understand implementation constraints and will clarify which families are most likely to benefit from parent training programs.

Providing effective and evidence-based parent services is the fulcrum of fairness in the American approach to child welfare services delivery. Investing federal and state funds in trials to test interventions for improving parent training and providing the necessary support to deliver those that succeed offers the opportunity for uncomplicated policymaking.