1. Engaging Families of Young Children in Parenting Skills Interventions: Lessons Learned from the Chicago Parent Program Deborah Gross, DNSc, RN, FAAN Leonard & Helen Stulman Professor in Mental Health and Psychiatric Nursing Johns Hopkins University School of Nursing & School of Medicine (Dept of Psychiatry & Behavioral Sciences)

2. 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

3. 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

4. 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)

5. However, all of these programs were originally developed and evaluated on White, non-Latino families

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 8 Keys to Effective Discipline 1.Tied to a specific behavior 2.Punishment should fit the crime 3.Discipline is predictable 4.Discipline is controlled 5.Discipline without rage 6.Discipline without humiliation 7.Discipline with a positive ending 8.Children always know they’re loved

12. Sample Vignettes

13. 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

14. 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

15. Chicago Parent Program Effects (n=504) T2= post-intervention; T3=6-month f/up; T4=1yr f/up; * p<.05; **p<.01 VariableOverall EffectBaseline-T2T2-T3-T4T3-T4 Corporal punishment 4.24**0.481.150.50 Following through 2.74*3.78*0.003.07 Parenting self- efficacy 3.88**6.79**0.020.43 Child behavior problems (Parent) 2.63*4.44*0.180.07 Externalizing (Teacher) 3.94**3.320.279.28** Internalizing (Teacher) 2.62*1.730.006.23**

16. Chicago Parent Program Effects Observed Behavior (n=504) T2= post-intervention; T3=6-month f/up; T4=1yr f/up; * p<.05; **p<.01 VariableOverall EffectBaseline-T2T2-T3-T4T3-T4 Parent Praise2.306.56*1.270.01 Commands0.330.000.460.34 Child Aversive Behavior 2.486.78**1.230.00

17. 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

18. 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

19. 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%)

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

21. 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

22. 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

23. The High Cost of Low Enrollment Assuming Parents Attend All 12 CPP Sessions 2009 dollars Enrollment Per Group Costs per Parent Session Group Size = 3Group Size = 6Group 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%)

24. The High Cost of Low Attendance Cost per session: 15 parents enrolled, different attendance rates 2009 dollars Number of parents in attendance per group session Costs per Parent Session N = 1 parentN = 10 parentsN = 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%)

25. 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

26. 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

27. 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

28. 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

29. 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

30. Parent Interviews

31. EPIC Study Collaboration 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

32. 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

33. 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

34. 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 (3 rd 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.

35. Thank you! For more information from the presenter, email: Debgross@jhu.edu For more information about the program: www.chicagoparentprogram.org