6

Elements of Effective Parenting Programs and Strategies for Increasing Program Participation and Retention

Parenting programs in the United States are reaching millions of parents and their children annually, but as discussed in Chapters 4 and 5, only a limited number of evidence-based, high-quality trials of the effects of these programs have been carried out. It is costly to conduct such evaluations, and they often are difficult to implement. Very few programs have undergone multiple evaluations using such designs. Other parenting interventions have been assessed through smaller studies, observational research, and case-control studies. Those studies indicate that these interventions may be effective, achieving improvements in outcomes similar to those found for the manualized parent training programs that have been studied experimentally (Chorpita et al., 2013).

This chapter identifies major elements of those programs that have been found to be effective through randomized controlled trials and other approaches. The identification of these elements is based on the committee’s review of multiple studies, literature reviews (Axford et al., 2012), information provided by a number of invited speakers at open sessions held for this study, and committee members’ own expertise and experiences. It should be noted that even those programs involving manualized interventions—with their relatively strict ordering of treatment components, each with a prescribed length—can be broken down into those components, which can be used more flexibly with success (Nakamura et al., 2014). Thus, in assessing current and developing new programs for strengthening and supporting parenting, a state policy maker or community service provider could use these components as benchmarks in determining the likelihood that a program will be effective. The identified elements may be especially important

in programs aimed at strengthening parenting in families that face multiple adversities. Engaging and retaining these parents in parenting programs is a challenge. They often live in areas without sufficient evidence-based services, and they often lack the transportation needed to access such services. For these families, providing programs that have not been shown to be effective through experimental or quasi-experimental research but include elements that are common to such programs may be necessary. Given that parent participation and retention alone, however, cannot guarantee positive parent and child outcomes, these programs must have a sound theoretical approach to helping parents acquire the positive parenting knowledge, attitudes, and practices discussed in Chapter 2.

Clearly, a parenting program cannot be successful unless parents participate and remain in the program. As described earlier in this report and by Breitenstein and colleagues (2014), studies of face-to-face parent training interventions indicate that 10 to 34 percent of parents of children in the preschool to grade school age range enroll to participate (Baker et al., 2010; Garvey et al., 2006; Heinrichs et al., 2005; Thornton and Calam, 2011). Among those who do enroll, average attendance ranges from 34 to 50 percent of sessions (Breitenstein et al., 2012; Coatsworth et al., 2006; Scott et al., 2010). It has been estimated that between 20 and 80 percent of families drop out of mental health prevention and intervention programs prematurely with many of them receiving less than one-half of the intervention (Armbruster and Kazdin, 1994; Ingoldsby, 2010; Masi et al., 2003). Lower participation and retention rates limit program reach and dilute program benefits for parents and families. Throughout the discussion in this chapter of elements of effective parenting programs, therefore, approaches that have shown success in increasing parents’ participation and retention in such programs are noted. The following section of the chapter then describes some additional strategies for increasing participation and retention. The final section presents a summary.

ELEMENTS OF EFFECTIVE PROGRAMS

The elements of effective parenting programs include parents being treated as partners with providers, tailoring of interventions to the needs of both parents and children, service integration and interagency collaborative care, peer support, trauma-informed services, cultural relevance, and inclusion of fathers.

Parents as Partners

A critical element of all parenting programs is viewing parents as equal partners with the provider, experts in what both they and their children

need. The importance of this approach is evident in programs ranging from patient-centered medical care to joint decision-making interventions for parents’ engagement in children’s education (see Chapter 4).

Research has found that treating parents as partners enhances the quality of interactions between parents and providers and increases parents’ trust in providers (Jago et al., 2013). This idea was supported by parent commentaries offered as part of the information gathering for this study. Findings from longitudinal and semi-structured interview research suggest that the level of therapeutic engagement with parents, empathic interaction style, and parents’ feelings of being valued are related to participation in and completion of program activities (Jago et al., 2013; Orrell-Valente et al., 1999). In a review of 26 qualitative studies (Mytton et al., 2014), having an intervention delivered by individuals trusted by or already known to parents was important in parents’ decisions to participate. (See also the discussion of participation and retention later in this chapter.)

Tailoring of Interventions to Parent and Child Needs

Because the needs of individual parents and children vary greatly and often depend on family context, strong programs, including those using manualized approaches, generally try to tailor the services to fit individual needs. The importance of such tailored approaches is widely recognized. For example, organizations providing Part C services under the Individuals with Disabilities Education Act (IDEA) look to individual family needs and child characteristics in designing interventions. The importance of personalized approaches to parenting skills also is central in working with parents with mental illness. Depressed parents, for example, may benefit particularly from training in dealing with conflict and difficult child behaviors, whereas those with borderline personality disorder may gain the most from education in providing a consistent routine and nurturing (Beeber et al., 2014; Stepp et al., 2012). Certain mental health disorders, such as schizophrenia, can lead to difficulty responding to emotional cues from infants and children, so programs that promote coaching to increase these skills may be particularly useful for individuals with those disorders, especially given the importance of early infant attachment (see Chapter 2) (Craig, 2004; Gearing et al., 2012; Nicholson and Miller, 2008; Stepp et al., 2012). This tailoring of treatment requires highly qualified and trained staff.

In addition, tailoring programs requires understanding and responding to gender differences in both the needs and the receptivity of parents. For example, mothers and fathers are likely to respond differently to program support based not only on their gender and role differences but also such factors as their engagement with the child and family, the level of respon-

siveness of program staff, the nature of familial and community expectations and supports, and their residential status.

As discussed in Chapter 1, many children are raised by a same-sex couple or a sexual minority parent. Few studies have explored the parenting experience of sexual minority adults. Studies that have been done suggest that lesbian and gay parents adjusting to parenthood generally experience levels of stress comparable to those experienced by their heterosexual counterparts (Goldberg and Smith, 2014). Lesbian and gay parents, particularly when new to parenthood, have many of the same concerns as any other new parents and could benefit from the same support structures (e.g., those provided by parent support groups/classes, medical professionals, teachers, or community groups). It is important for these programs to recognize that some parents whom they are serving might be sexual minorities and to adjust programming and terminology to be inclusive of sexual minority parents and nontraditional families more generally. Some studies have indicated that certain subsets of sexual minority parents (e.g., female partners of biological lesbian mothers) might have increased stress upon becoming parents, and it is important for programs to offer support to these groups in particular (Tornello et al., 2011; Wojnar and Katzenmeyer, 2014). In addition to experiencing the routine stresses of parenting, sexual minority parents and their children may face social stigma and discrimination.

Parents report that several of the barriers to participation in parenting programs are practical, such as not having transportation to reach the site where the intervention is being provided, being unable to arrange for child care, and having work and scheduling conflicts (Morawska et al., 2011). Many evidence-based parenting interventions provide transportation assistance and child care (Snell-Johns et al., 2004), and there is evidence that matching program scheduling with parents’ own schedules is associated with higher rates of participation (Gross et al., 2001). In a recent systematic review of 26 qualitative studies in which parents were asked about why they did or did not enroll in or complete a parenting program, the time and place of the program delivery and the lack of collocation of classes with child care emerged as major factors related to participation (Mytton et al., 2014). Transportation is a primary barrier across multiple types of programs, not just those focused on parenting, particularly for those with limited income and access to personal and reliable public transportation.

Service Integration and Inter-agency Collaborative Care

Service integration continues to be particularly important in the provision of services for families facing multiple challenges, including histories of trauma, substance use, relationship instability, and lack of social supports (Hernandez-Avila et al., 2004; Howell and Chasnoff, 1999). Integrated care often includes using a centralized access point for treatment of the parents’ condition(s), combined with services to improve their parenting skills, such as parent training or child-related interventions (Niccols et al., 2012). Integration of services gives parents easier access to resources that address multiple needs and improves collaboration and continuity of care (Krumm et al., 2013; Schrank et al., 2015), and may help to reduce the stigma that can be associated with targeted interventions (Cortis et al., 2009). Service integration can also ease scheduling and transportation challenges for families (Ingoldsby, 2010).

Families contending with an array of adversities often also need services to address such needs as job training, housing, and income support, as well as active support to help them access and utilize those services (Gearing et al., 2012; Hinden et al., 2005, 2006). Helping parents deal with these stressors may free up personal resources, enabling them to focus better on improving their parenting skills (Ingoldsby, 2010). Indeed, lower economic stress and interparental conflict have been found to be associated with increased enrollment and participation in parenting interventions (Wong et al., 2013). Likewise, mothers in a study that included “family coaches” who helped link parents to other services in addition to direct parenting support reported strong satisfaction with the program (Nicholson et al., 2009). Conversely, interventions that fail to address coping mechanisms for family issues and parental stressors can drive families out of programs (Prinz and Miller, 1994).

Peer Support

Engagement in services and positive outcomes can be increased by linking behavioral supports with peer support (Axford et al., 2012; Barrett et al., 2008). Beyond increased engagement, strengthening social support among parents can have multiple benefits, including reduced stigma, increased sense of connection, and reduced isolation. For example, research using various methodologies indicates that interventions have successfully addressed both the stigma of mental illness and the social isolation of many parents by providing peer support via groups, classes, or even the Internet (Cook and Mueser, 2014; Craig, 2004; Kaplan et al., 2014; Schrank et al., 2015; Wan et al., 2008).

Parenting programs using a multifamily or multiparent group format allow participants to share their parenting experiences with others who serve as a source of social support and peer learning (Coatsworth et al., 2006; Levac et al., 2008; McKay et al., 1995). The opportunity to exchange ideas and receive support from peers may be an important reason why parents join and attend group parenting classes (Jago et al., 2012, 2013; Mytton et al., 2014). In experimental research, parents with serious mental illness, for example, report that peer groups help them feel understood and safe, and this may motivate them to return to the groups (Dixon et al., 2001, 2011). Peer support helps parents learn how others successfully provide guidance and set limits for and engage in other positive interactions with their children. Including spouses or partners in mental health visits is another way of decreasing stigma and encouraging support, based on findings from randomized controlled trials (Dennis, 2014). Notably, peer support services may be reimbursable by Medicare, Medicaid, states, and private health plans (Daniels et al., 2013). While peer support can be valuable in engaging and sustaining parent participation, however, it is not a substitute for professional staff with training in working with parents facing specific adversities.

Finally, it is important to note that, despite the limitations of evidence-based approaches for fathers, fatherhood programs incorporating peer support have shown success (Fagan and Iglesias, 1999). Evidence-based approaches now being implemented in fatherhood programs are likely to yield important data on the efficacy of peer support among fathers.

Trauma-Informed Services

Considerable research over the past 10 years has demonstrated the significant impact of traumatic experiences on a variety of outcomes during childhood and into adulthood. The Adverse Childhood Experiences (ACEs) study, which surveyed more than 17,000 members of a health maintenance organization in California, found that a large percentage had experienced traumatic experiences and demonstrated the connection between such experiences in early childhood and later adverse health outcomes (Anda et al., 2009). Relevant to the present context, trauma can have a significant impact on parenting ability. According to Banyard and colleagues (2003, p. 334) “cumulative exposure to trauma is associated with less parenting satisfaction, greater levels of neglect, child welfare involvement, and using punishment.” Cumulative exposure to trauma is predictive of parents’ potential for child abuse, more punitive behavior, and psychological aggression in correlational research (Cohen et al., 2008).

Trauma has a particularly damaging effect on children’s development. Children exposed to trauma often experience problems with regulation of affect and impulses, constricted emotions, and an inability to express or experience feelings (Armsworth and Holaday, 1993; van der Kolk, 2005). Children who have experienced significant trauma without adequate parental support tend to have a heightened sense of vulnerability and sensitivity to environmental threats; experience high levels of guilt and shame; and have high rates of anxiety and depressive symptoms, including hyper-vigilance, hopelessness, anhedonia, suicidal ideation, and suicide attempts (Armsworth and Holaday, 1993; van der Kolk, 2005).

Based on these findings, many parenting programs now adopt a trauma-informed approach. Trauma-informed services are not about a specific intervention or set of interventions. According to the Substance Abuse and

Mental Health Services Administration, a trauma-informed approach “realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization” (Substance Abuse and Mental Health Services Administration, 2015b).

Trauma may affect provider relationships with parents and therefore their children. In trauma-informed services, an understanding of trauma permeates services, and all staff have the ability to view clients in the context of their life histories. It is important that providers be able to recognize signs and symptoms of trauma, a history of trauma, and traumatic stress, and have training in how to provide trauma-informed care (Institute for Health and Recovery, 2016). Interventions for parents may include present-focused trauma-specific therapies, such as Seeking Safety, Risking Connection, and Sanctuary. All of these are considered present-focused therapies, because they focus on developing skills to cope with trauma in the present. These therapies teach such skills as self-soothing, grounding, and engaging in healthy relationships, as well as other skills necessary for coping with trauma (Substance Abuse and Mental Health Services Administration, 2015b).

It is important to note that trauma can occur within typical interactions between parents and children or may be brought about as a result of unusual circumstances. In both instances, parents must find safe places for their children and navigate the turmoil that can have potentially deleterious effects on their children and themselves. Considering the high prevalence of trauma among at-risk parents and the impact of traumatic events on parenting and child development, assessing for past traumatic experiences and providing trauma-informed care for all at-risk parents can improve outcomes and may be cost effective in the long run (Hornby Zeller Associates, 2011).

Cultural Relevance

Parenting programs have historically had low utilization, especially among culturally diverse parents (Cunningham et al., 2000; Eisner and Meidert, 2011; Katz et al., 2007; Sawrikar and Katz, 2008). If intervention components and providers are not sensitive to cultural variations among families with respect to their coping styles and expression of problems, parents may be less likely to participate (Brondino et al., 1997; Moodie and Ramos, 2014; Prinz and Miller, 1994). Baumann and colleagues (2015) examine the extent to which researchers and developers of several commonly used evidence-based parent training programs (Parent-Child Interaction

Therapy [PCIT], Incredible Years, Parent Management Training-Oregon [PMT-O], and Triple P) have used culturally adapted models. Of 610 articles on these programs, only 8 document a rigorous cultural adaptation process, and just 2 of these programs used rigorous methods to test the program implementation. Recent efforts to rigorously test cultural adaptations of PCIT (McCabe and Yeh, 2009), PMT-O (Parra Cardona et al., 2012), and ParentCorps (Dawson-McClure et al., 2015) indicate growing awareness of the importance of developing and testing innovative ways to engage, retain, and educate Latino families.

At the same time, parenting programs delivered without significant modification and not incorporating tested cultural adaptations are sometimes viewed as highly attractive by local communities. This was the case with the implementation of SafeCare® in American Indian communities in Oklahoma, where researchers found that their manualized, structured, evidence-based model was a reasonable fit with American Indian parents in child welfare. SafeCare had higher client ratings of cultural competency, working alliance, service quality, and service benefit than services as usual (Chaffin et al., 2012). The Huey and Polo (2008) review of evidence-based psychosocial interventions for children found no pressing need for such adaptations. The culturally adapted interventions that have been tested have shown little added benefit, and outcomes for minority children and families who receive unadapted services generally are good, although this is not to minimize the need for cultural sensitivity and clinical expertise in order to engage families in treatment (Huey et al., 2014).

Inclusion of Fathers

As noted previously, fathers are underrepresented in research on parenting-related interventions. Moreover, relatively few fatherhood studies have examined the relationships between specific fathering behaviors and desired child outcomes. Although further research is needed, available studies indicate that parenting interventions would benefit from the use of approaches giving greater priority to fathers’ participation, such as starting with an expectation that they will participate and using content and activities that they will find pertinent, in addition to using strategies that may improve participation more generally (e.g., providing financial incentives [discussed below] and scheduling sessions at times that are convenient) (Administration for Children and Families, 2015; Zaveri et al., 2015).

The data are clear and poignant regarding the lack of evidence-based strategies in fatherhood programs. In a study by Bronte-Tinkew and colleagues (2008), only 4 of 18 programs reviewed had rigorous enough designs to be considered model and promising. Much of the research on fathers and programs that include them has examined low-income, non-

residential fathers but has not monitored effectively how fathers negotiate the core problems they face (e.g., unemployment, alienation of children and families, low schooling) or examined the effects of fathers’ program participation on children over a sustained period of early development. Recent attention to programs for fathers and the need for systematic and grounded research should ultimately yield greater understanding of how fathers are affected by their involvement in such programs (see Box 6-1), but still may not illuminate with evidence-based data complex issues related to father-child interactions.

ADDITIONAL STRATEGIES FOR INCREASING PROGRAM PARTICIPATION AND RETENTION

As noted above, evidence indicates that parenting programs often experience substantial difficulty in engaging and retaining parents, especially those facing multiple adversities. Some of the reasons for this difficulty are discussed in Chapter 5 and above. In recent years, two strategies—monetary incentives and motivational interviewing—have been used to address this problem. Although these are promising practices, more research is needed to determine how they might best be utilized. Also important to engaging and retaining parents in parenting programs is appropriate preparation of the workforce, discussed in this section as well.

Monetary Incentives

Some parenting programs offer families modest monetary incentives in an effort to improve enrollment and retention, but few randomized studies have assessed the effectiveness of such incentives in increasing participation. In one randomized study, Dumas and colleagues (2010) evaluated the effect of a small monetary incentive on low-income parents’ engagement in sessions of the Parent and Child Enrichment (PACE) Program over an 8-week period. (PACE is a manualized intervention designed to address parents’ challenges related to childrearing.) The monetary incentive encouraged some parents to enroll but not to attend sessions. Among parents who both enrolled in the study and attended sessions (N = 483), attendance over eight sessions was comparable between groups who did and did not receive the incentive. There also was no major difference between the two groups in the percentage of parents who dropped out of the program at any point after the first session. Similarly, in a European randomized study (Heinrichs, 2006), low-income families who were offered a small payment to attend a series of Triple P parent trainings did not attend at a significantly higher rate than families who were not offered payment. Payment did appear to result in a large increase in recruitment compared with the unpaid condition,

leading the authors to conclude that payment may be an effective strategy for increasing recruitment and initial attendance for some populations (see also Guyll et al., 2003). Older research on financial incentives and attrition in parent education has yielded mixed findings, with some studies showing a positive effect (Mischley et al., 1985; Rinn et al., 1975) and others not (Lochman and Brown, 1980; Sadler et al., 1976; Snow et al., 2002).

Some evidence indicates that the use of an incentive that exceeds an individual’s perception of the value of an intervention may result in distrust and be counterproductive (Snow et al., 2002). Consistent with cognitive dissonance theory (Festinger and Carlsmith, 1959), if a potential participant thinks the incentive is too large, the value of the intervention may be compromised by the person’s discomfort stemming from the feeling that his or her beliefs/values and behavior are incongruent. Moreover, while some experimental research suggests that modest monetary incentives help attract families that otherwise would not participate (Dumas et al., 2010; Guyll et al., 2003; Heinrichs, 2006; Heinrichs and Jensen-Doss, 2010), these payments do little to mitigate practical (e.g., child care, transportation) and other obstacles to parents’ attendance and retention over time.

Another approach to incentives is the use of conditional cash transfers (CCTs). This approach entails providing cash payments to families living in poverty based on the parents’ or children’s engagement in specific activities. CCT programs traditionally have focused on improving children’s health and well-being and conditioned families’ receipt of cash transfers on receipt of recommended preventive health services or nutrition education and/or children’s school attendance. CCTs are increasingly being used to promote other behaviors as well (Fernald, 2013).

Building on some successes in developing countries (Engle et al., 2011; Fernald, 2013; Rasella et al., 2013), the first demonstration of CCTs in the United States was launched in New York City in 2007. Called Opportunity NYC-Family Rewards, it provided cash assistance to families in the city’s highest-poverty communities with the goal of reducing intergenerational economic hardship. Payments were conditioned on families’ efforts to improve their health, increase parents’ employment and income, and support children’s education. Children also were paid in response to their educational activities and performance.

An experimental analysis of this program involving 4,800 families who participated for 3 years found that the families were transferred more than $8,700 during the 3-year period and that poverty, hunger, and housing-related hardships were reduced, but these effects weakened as the cash transfers ended. Parents’ self-reported full-time employment also increased, but not in jobs covered by unemployment insurance (Riccio et al., 2013). Results for children varied by their age. Neither school attendance nor overall achievement improved among elementary and middle school students

whose families received the payments. But children in these families who entered high school as proficient readers attended school more frequently, earned more course credits, were less likely to repeat a grade, scored higher on standardized tests, and had higher graduation rates. Families’ receipt of preventive dental care increased, but there was no improvement in receipt of other preventive medical care (which was already high) or in health outcomes (Riccio et al., 2013).

Building on the findings from the Family Rewards demonstration, in 2011 Family Rewards 2.0 was initiated in the Bronx, New York, and Memphis, Tennessee. This version offers fewer rewards in each domain (health, employment/income, and child education), offers rewards for education only to high school students, provides payment on a more frequent basis (once a month), and offers families guidance on how to earn rewards. Findings from a randomized evaluation of the first 2 years of implementation involving 2,400 families show that by year 2, almost all families had received rewards (totaling $2,160 on average in year 2). Perhaps as a result of the guidance they received, moreover, parents understood the rewards more completely and were more likely to earn rewards than families in the original program. A follow-up analysis of Family Rewards 2.0 as an improvement over the earlier version is pending (DeChausay et al., 2014).

Significant gaps in knowledge about CCTs remain. These include, for example, differences in effects among subpopulations, strategies for increasing efficiency, how the programs can be adapted to cultural contexts, and longer-term outcomes (Marshall and Hill, 2015).

Motivational Interviewing

Motivational interviewing is an evidence-based, client-centered style of counseling. Based on the assumption that an ambivalent attitude is an obstacle to behavior change, motivational interviewing helps clients explore and resolve ambivalence to improve their motivation to change their behavior (Miller and Rollnick, 1991; Resnicow and McMaster, 2012; Substance Abuse and Mental Health Services Administration, 2015a). Key features of motivational interviewing include nonjudgmental reflective listening on the part of the counselor, with the client doing much of the work him- or herself. A concrete action plan for behavior change with measurable goals is developed, and sources of support are identified. Motivational interviewing was initially developed and is still used to treat addiction and recently has been used for other types of behavior change (Resnicow and McMaster, 2012; Substance Abuse and Mental Health Services Administration, 2015a).

Motivational interviewing has been proposed as a potential strategy for enhancing parents’ motivation to engage and remain in parenting programs (Watson, 2011). Studies not focused specifically on parents have shown

that individuals who receive motivational interviewing, or therapy based on its principles (e.g., motivational enhancement therapy), have improved treatment adherence (Montgomery et al., 2012). But only a few randomized trials have tested the use of motivational interviewing to improve parents’ motivation to attend and adhere to mental health and substance use treatment, and these trials have yielded mixed findings.

Although motivational interviewing is a core component of effective programs designed for parents and families, such as Homebuilders and Family Check-Up, very little research has evaluated the specific effects of motivational practices on parents’ participation. In a study of 192 parents that used a double randomized design, a self-motivational orientation intervention combined with PCIT increased retention in child welfare parenting services (Chaffin et al., 2009). The benefits were concentrated among parents whose initial level of motivation to participate was low to moderate; negative effects on participation were found for participants whose initial motivation was relatively high (Chaffin et al., 2009).

Drawing on research on motivation enhancement and barriers to treatment participation, Nock and Kazdin (2005) developed a brief intervention designed to increase parents’ attendance at Parenting Management Training (PMT) sessions. (PMT is a well-supported program designed to help parents prevent internalizing and externalizing conduct behaviors in their children.) In a randomized controlled study, compared with controls who received PMT alone, families receiving the intervention in combination with PMT had greater treatment motivation, attended more sessions (completing 6.4 versus 5.2 sessions), and had higher retention in the training (56% versus 35%) in training according to parent and therapist reports (Nock and Kazdin, 2005).

Workforce Preparation

A central contributor to parents’ participation and retention in evidence-based programs and services is a workforce that is appropriately trained in how to refer families to programs, engage them in receiving services, and deliver evidence-based parenting interventions.

As reviewed in earlier chapters, parents’ engagement in their children’s learning, both in the school environment and at home, is associated with improvements in measures of young children’s development and academic readiness (Cabrera et al., 2007; Hart and Risley, 1995; Institute of Medicine and National Research Council, 2015; Rodriguez and Tamis-LeMonda, 2011). A central component of effective parental engagement in children’s learning is reinforcement of classroom material in the home, which can be facilitated by positive relationships between families and teachers and other providers (Porter et al., 2012; U.S. Department of Health and Human Services and U.S. Department of Education, 2016). Thus, practitioners serving young children and their parents need skills in communicating and partnering with diverse families (Institute of Medicine and National Research Council, 2015). Parents’ engagement in their children’s health care also is important. In pediatric care, family engagement focuses on parents understanding and using information about their children’s health, engaging in shared decision making, and participating in quality assessment aimed at improving care (Schuster, 2015). And enabling parents to play an effective role in reducing children’s behavioral health problems likewise can benefit from professionals’ understanding of the common elements of engagement (Lindsey et al., 2014) as well as of treatment (Barth and Liggett-Creel, 2014). The recent Institute of Medicine and National Research Council (2015) report Transforming the Workforce for Children Birth through Age 8: A Unifying Foundation reflects these research findings, identifying “the ability to communicate and connect with families in a mutually respectful, reciprocal way, and to set goals with families and prepare them to engage in complementary behaviors and activities that enhance development and early learning” as knowledge and competencies important for all professionals who provide direct, regular care and education for young children to support their development and early learning.

The importance of professionals having skills in working with families is currently reflected in several laws and policies pertinent to programs supporting children’s education and in core competencies for care and education professionals. The U.S. Department of Education’s Dual Capacity Building Framework for Family-School Partnerships offers research-based guidance to states, districts, and schools on improving staff and family capacity to work together to improve student outcomes (U.S. Department of Health and Human Services and U.S. Department of Education, 2016).

IDEA emphasizes that services for young children with disabilities involve children’s families and that services provided should improve families’ ability to meet their children’s developmental needs. For 20 years, the Adoption and Safe Families Act has required that child welfare agencies engage families and endeavor to maintain children in their own families whenever it is reasonably safe to do so and, similarly, work to reunify children with their parents, when safe, as a preference over long-term foster care or adoption. Also, statements of core competencies for educators and health care providers who work with young children often identify partnering with families to support children’s development as a core area of focus (Institute of Medicine and National Research Council, 2015). And as recommended in a recent policy statement on family engagement in children’s education from the U.S. Department of Health and Human Services and the U.S. Department of Education, preservice and continuing in-service professional development should include concrete strategies for building positive relationships with families (U.S. Department of Health and Human Services and U.S. Department of Education, 2016).

Despite the important role of families in children’s learning and development and the fact that family engagement is acknowledged in several laws, policies, and core competencies as central to the success of programs, workforce preparation for early childhood teachers and providers often does not address working with families. When family engagement is implemented, it may fail to take into account differences among families, such as culture and variations in family forms (U.S. Department of Health and Human Services and U.S. Department of Education, 2016). The committee’s scan of state, territory, and tribal credentialing for early childhood education professionals revealed that only 12 states require a course or workshop on families, and just 5 states require a course on addressing ethnic and cultural difference or the needs of culturally and ethnically diverse families.

Professional schools (e.g., nursing, education, social work, medicine) training health and human service providers rarely offer courses that prepare students to work with parents of young children. For example, virtually all of nearly 250 graduate schools of social work have courses on working with families for their clinical students and taking diversity and difference into account in social work practice. These courses focus on family therapy, which is typically used for families with older children who can participate in family communication. Many also have courses in “school social work,” which emphasize working with families in relation to special education services (Council on Social Work Education, 2012). Few have courses on parenting or working with parents of young children. A similar situation exists in education. Prospective teachers are required to take courses focused on diversity, multiculturalism, and families, but the requirement varies across context. In health care, challenges also have been

identified with respect to communicating with children and families in the pediatric setting, such as about psychosocial and practical issues in families (Levetown, 2008).

There are indications that effective intervention approaches often are not used to the extent that they could be. For example, a recent Institute of Medicine report notes that evidence-based interventions frequently are not available as part of routine care for individuals with substance use and mental health disorders (Institute of Medicine, 2015). The story is similar with regard to parent training interventions in child welfare and other service settings (Barth et al., 2005; Garland et al., 2010). It is important for practitioners who work with families to be aware of evidence-based programs and services that support families and how they can refer families to and implement those programs and services. However, graduate schools that train providers of children’s services and behavioral health (e.g., schools of social work and nursing) have limited or no coursework on leading evidence-based parenting programs. With few exceptions, health and human service professionals also are not trained in the common components that make up most evidence-based practices (Barth et al., 2014). One result of this neglect of appropriate training is that few child welfare agencies refer parents to parenting programs delivered by professionals trained in evidence-based practices (Barth et al., 2005). Indeed, mental health providers typically offer a low-intensity dose of treatments with inconsistent application of evidence-based components when working with children and their parents (Garland et al., 2010). Absent an expanded workforce prepared to deliver the evidence-based practices described in this report, these programs cannot be brought to scale.

SUMMARY

The following key points emerged from the committee’s examination of elements of effective parenting programs and strategies for increasing participation and retention.

• Although no single approach is applicable to and will yield the same positive results for all parents, elements that the committee found to be successful across a wide-range of programs and services for parents are
  1. — viewing parents as equal partners in determining the types of services that would most benefit them and their children;
  2. — tailoring interventions to meet the specific needs of families;
  3. — integrating services for families with multiple service needs;
  4. — creating opportunities for parents to receive support from peers to increase engagement, reduce stigma, and increase their sense of connection to other parents with similar circumstances;

• 1. — addressing trauma, which affects a high percentage of individuals in some communities and can interfere with parenting and healthy child development;
  2. — making programs culturally relevant to improve their effectiveness and participation across diverse families; and
  3. — enhancing efforts to involve fathers, who are underrepresented in parenting research.
• Studies of the effectiveness of the use of modest monetary incentives to improve participation and retention in parenting programs have had mixed findings. Some indicate that monetary incentives may enhance initial interest in and recruitment into programs for some parents, but do not necessarily lead to improvements in attendance.
• Preliminary experimental data on the use of conditional cash transfers to incentivize low-income families’ engagement in behaviors that can enhance their well-being show an association between receipt of cash transfers and improvements in some economic outcomes, such as reduced poverty, food insecurity, and housing hardships and increased employment. These positive outcomes were not sustained when the cash transfers ended.
• Although available studies show that motivational techniques used in combination with other supportive strategies may improve attendance and retention in programs and services for some individuals, there is a lack of data focusing specifically on these outcomes in parents and identifying those populations of parents for which these techniques are most effective.
• Having a workforce that is trained in how to engage diverse families in activities and decision making pertaining to their children and how to refer parents to and implement evidence-informed parenting programs and services is essential to uptake. However, the committee found that professionals who work with young children and their families often lack appropriate training in these areas.

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