Improving Child Outcomes by Targeting Parents: Easier Said Than Done Messier Than One Would Like

1. Improving Child Outcomes by Targeting Parents:  Easier Said Than DoneMessier Than One Would Like John D. McLennan University of Calgary Sept 24, 2008

3. Disclosures & Biases Priority should be placed on child outcomes Research program Global objective: Connecting vulnerable children with effective services Approach: Working on the services gaps

4. Outline Issues 1: Focusing on parents, parenting, and parenting programs to improve child outcomes Issue 2: Factors undermining the impact of parenting programs on improving child outcomes Issues 3: It gets messy

5. Assumptions in focusing on the parent

6. What do you mean by child outcomes? Good physical growth No head injuries Socially competent Mentally healthy

7. Parenting practices contribution to child mental health problems McLeod, Wood & Weisz, 2007 Association between parenting and child anxiety Meta-analysis (47 studies) Parenting accounted for only 4% of the variance in childhood anxiety McLeod, Weisz, & Wood, 2007 Association between parenting and child depression Meta-analysis (45 studies) Parenting accounted for only 8% of the variance in childhood depression

8. More on parenting practice contribution Rothbaum & Weisz (1994) Parenting & externalizing behaviour Meta-analysis (47 studies) Parenting associated with <6% of externalizing behaviour

9. Other factors linking parents to child outcomes

10. Assumption behind parenting programs

11. But you could intervene elsewhere to improve child outcomes

12. But let�s focus on aiming at parenting practices

13. Getting exposure to good parenting practices Parenting books sections (e.g., Chapters) Parenting magazines Parent recommendations everywhere Parenting experts�..

14. Parenting programs galore Specific parenting programs Canadian Association of Family Resource Programs/Parents Matter Parenting program inventory: 82 programs http://www.parentsmatter.ca

15. Why might parenting programs not lead to improve parenting practices?

16. Access Gaps (1) Who is attending the parenting programs? Who�s not attending? Who are your target group? Are the attendees your target population? What fraction of the target group? All welcome Universal programs (see Offord et al, 1998)

17. Use Gaps (2) How much of a program are participants exposed to? What is the drop out rate? What is enough exposure?

20. Research Practice gapS

21. Examples of research-practice gaps 1. Failure to use program with positive effect [The Incredible Years] 2. Use of a program with evidence of harm [increasing parent conflict?]; [Scared Straight-Petrosino et al, 2002] 3. Use of a program with evidence of no effect [Families and Schools Together (FAST)?]; [DARE?] 4. Use of a program without evidence of effect [Nobody�s Perfect?]

22. But wait, it�s more complicated than that 4 X 2 table has heuristic value, but �. �Has it been proven effective�? Has what been proven effective? Proven effective for what problem? Proven effective for whom? E.g., Does program X decrease the rate of conduct disorder in the children of those parents participating in =80% the program?

23. Is what effective? Home visitation works! Hmmmm? �..All of them???? Nurse-Family Partnership (David Olds) Pre and post natal home visits (>20) By nurses Trained in a specific curriculum

24. What do you mean by Home Visitation? Do you really need 20+ visits The need for dosing studies Powell & Grantham-McGregor (1989) Do you really need nurses? Lay visitors vs. Nurses study (Olds et al 2002) Do you really need a set curriculum? Fidelity/adherence & Multi-systemic therapy (Schoenwald et al., 2003)

25. For what problem? Decreased child abuse Increased self esteem Parent satisfaction Not a proxy for child outcomes (Lambert et al., 1998)

26. For whom? Everyone? Old�s program At risk 1st time mothers High-risk within at risk, 1st time mothers Not for preventing re-abuse MacMillian et al (2005)

27. But wait, its not that simple What Lay home visitors some late emerging benefits (Olds et al 2004) Component piece vs. packages Garland et al., 2007; John Weisz (pc) For What Old�s Home visitation program Child externalizing problem not improved for those receiving nursing OR paraprofessional home visits; OR high-risk subgroup (Olds et al., 2004) For Whom Incredible-Years & ethnic minorities (Reid et al., 2001) African, Asian, Hispanic, Caucasian Americans

28. References Farrelly A, McLennan (under review) Participation in a parent education program in the Dominican Republic: Utilization and barriers Garland A, Hawley K, Brookman-Frazee L, Hurlburt M (2008) Identifying common elements of evidence-based psychosocial treatments for children�s disruptive behavior problems. Journal of the American Academy of Child and Adolescent Psychiatry 47(5): 505-514 Lambert W, Salzer M, Bickman L (1998) Clinical outcome, consumer satisfaction, and ad hoc ratings of improvement in children�s mental health. Journal of Consulting and Clinical Psychology 66 (2): 270-279 MacMillan H et al (2005) Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: a randomised controlled trial. Lancet 365:1786-93

29. References (2) McLennan et al (2006) Research-practice gaps in child mental health. Journal of the American Academy of Child and Adolescent Psychiatry 45(6): 658-665 McLeod, B. D., Weisz, J.R., & Wood, J. J. (2007). Examining the association between parenting and childhood depression: A meta-analysis. Clinical Psychology Review, 27, 986-1003 McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review, 27, 155-172.

30. References (3) Offord et al (1998) Lowering the burden of suffering from child psychiatric disorders: trade-offs among clinical, targeted and universal interventions. Journal of the American Academy of Child and Adolescent Psychiatry 37(7): 686-694 Olds et al (2002) Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics 110:486-496. Olds et al (2004) Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial. Pediatrics 114: 1560-1568 Olds et al (2007) Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial. Pediatrics 120(4): e832-45. Olds et al (1997) Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA 278: 637-43

31. References (4) Petrosino A et al (2002) �Scared Straight� and other juvenile awareness programs for preventing juvenile delinquency. Cochrane Database of Systematic Reviews 2, CD002796. Powell C, Grantham-McGregor S (1989) Home visiting of varying frequency and child development. Pediatrics 84(1): 157-64. Reid MJ, Webster-Stratton C, Beauchaine T (2001) Parent training in Head Start: A comparison of program response among African American, Asian American, Caucasian, and Hispanic Mothers. Prevention Science 2(4): 209-227. Rothbaum, F., & Weisz, J. R. (1994). Parental caregiving and child externalizing behavior in nonclinical samples: A meta-analysis. Psychological Bulletin, 116, 55-74. Schoewald et al (2003) Transportability of multisystemic therapy: evidence for multilevel influence. Mental Health Services Research 5(4): 223-239.