UNIVERSAL/PREVENTIVE INTERVENTIONS

Parents seek knowledge about how to raise their children from many sources, including both formal programs and information they obtain on their own. Numerous books, magazine articles, and Websites provide information about parenting. Whereas earlier generations may have relied on books such as Benjamin Spock's Baby and Child Care (e.g., Spock, 1957, 1968, 1976) and later generations on guidance from T. Berry Brazelton and Harvey Karp (Brazelton, 1992; Karp, 2002; Karp and Spencer, 2004), parents today are seeking information from a more diverse array of print, online, and human resources. Some of the information that is available is not grounded in evidence.

Parents seek information and guidance in particular about actions they can take that apply to the developmental stage of their child (e.g., infancy, toddlerhood, early childhood, early school age). They naturally look to their extended family (e.g., their own parents, siblings), the community (including others who are raising their own children), faith-based institutions, and community organizations for guidance and support. All of these sources contribute to parents' knowledge, attitudes, and practices with respect to raising their children. In the best cases, parents have access to and knowledge of multiple resources and are able to draw on them as needed.

There are also a variety of formal sources of parenting information, guidance, and support. These sources include primary care practitioners who provide guidance on early learning, well-child care and guidance, and other health care for children. In some communities, this role also is filled by visiting nurses and others in both lay and professional disciplines with experience in parenting. Other formal programs discussed in this chapter include center-based child care and comprehensive early care and education (ECE) programs (e.g., Head Start and Early Head Start). These programs, sometimes referred to as universal interventions, reflect the shared needs of children and families for health care, educational preparation, and general support.

WIDELY USED INTERVENTIONS

Beyond the health care system, the most widely used approaches to strengthening and supporting parenting are home visiting programs; programs focused on helping parents provide cognitive stimulation in the home through educational activities involving reading, language, and math; efforts at providing parenting education in the context of classroom-based ECE programs; and efforts to increase parent engagement in school settings and school-related activities (prekindergarten through grade 3). These are usually voluntary programs aimed at enhancing parenting knowledge, skills, and practices; improving the parent-child relationship and the quality of parent-child interactions; improving children's school readiness and well-being; and preventing poor outcomes for children. The programs vary in their core features (e.g., requirements for staff training, number of sessions, cost to implement), target populations, and the amount of evidence of effectiveness available to guide policy and program decision making. Because these programs may cost several thousand dollars per participant per year, they often are targeted to those families considered to be in greatest need of additional support. Some programs, such as Head Start, require that families meet income requirements (e.g., a certain poverty level), and others, such as the home visiting program Durham Connects, are limited to individuals living within a specific geographic area. In addition, as described in Chapter 3, the actual numbers of families enrolled in these programs represent only a fraction of those who are eligible for them.

Home Visiting Programs

Prenatal, infant, and early childhood home visiting is a relationship-based mode of service delivery in which a professional or paraprofessional home visitor provides services in the family home using a prescribed home visiting model or curriculum. Home visiting programs have specific goals and range from truly universal programs for new parents in the community in which it is offered to targeted programs that select families based on important descriptive characteristics (e.g., first-time pregnant woman early in her pregnancy) or key risk factors. Across models, the home visitor's aims generally include supporting parents in their parenting role, facilitating positive parent-child interactions and relationships, reducing risks of harm, and promoting good parenting practices. Because the intervention is provided where families' daily lives take place, a potential benefit of home visiting is the ability to tailor services to meet families' specific needs (Johnson, 2009). Visits usually last 60 to 90 minutes and occur regularly over the course of 6 months to 2 years, with some long-term models serving families prenatally through age 5. These relatively intensive services usually are targeted to families with children at the highest risk for poor outcomes and those who are unlikely to enter kindergarten with the preacademic skills needed to make the most of formal schooling. Home visiting services generally are voluntary, although in some cases they may be court mandated (for example, in cases of child abuse and neglect). Although many home visiting programs target pregnant women and mothers, some include fathers in visits, and others provide separate visits for mothers and fathers (Sandstrom et al., 2015).

The roots of home visiting in the United States trace back to nurse and teacher home visiting in 19th-century England (Wasik and Bryant, 2001). The more than 250 home visiting programs implemented and studied at the state and local levels in the United States during the late 20th and early 21st centuries reflected those public health and education roots as well as an emphasis on prevention of child maltreatment (Boller et al., 2010; Paulsell et al., 2010). Programs focused on pregnant women and newborns often were run by public health departments and child welfare agencies, and those focused on ECE or on special education services often were run by a human service or education agency (Boller et al., 2010; Daro, 2006).

In fiscal year 2015, the federal home visiting program served about 145,500 parents and children in all 50 states, the District of Columbia, and 5 territories (Health Resources and Services Administration, 2016). There are also a number of state-based home visiting programs. In 2009, the most recent year for which the committee could find data, 40 states reported that they had state-based home visiting programs. Most states supported one or two models (Johnson, 2009), with 5 states reporting that they supported three or more, for a total of 70 state-based home visiting programs across the 40 states (Johnson, 2009). Over the past 20 years, the development of national home visiting programs with national offices and a support infrastructure for implementation has grown (Daro, 2011; Daro and Benedetti, 2014). States, counties, and municipalities around the country have implemented different models, some that are branded and have some evidence of effectiveness and some that are home grown and have not been evaluated (Johnson, 2009).

Home Visiting Logic Model: Changing Parenting Knowledge, Attitudes, and Practices to Improve Child Outcomes

As depicted by the prenatal and early childhood home visiting logic model in Figure 4-1, some of the problems home visiting is designed to address include poor birth outcomes (low birth weight), child maltreatment, and lack of school readiness. Historically, funding agencies and communities that developed home visiting programs or selected from existing programs chose models that best suited the needs of the families they served and the particular outcomes they were trying to improve. Regardless of the specific mode, the underlying assumption of these programs is that the home is a comfortable, convenient setting for expectant parents and parents of young children to receive supports and services. As described below, a growing body of research points to the importance of high-quality implementation (such as collaboration among local public and private partners, program developers, and funders and oversight of service provision [training, quality assurance]) in achieving impacts on targeted knowledge, attitudes, and practices and child outcomes. Assuming an implementation system that brings families into services and provides high-quality visits as intended, targeted short-term outcomes include decreased parenting stress, depression, and isolation and improved parenting knowledge, attitudes, and practices.

FIGURE 4-1

Illustrative prenatal and early childhood home visiting logic model. NOTE: HIV = home visiting; KAPs = knowledge, attitudes, and practices.

As depicted in Figure 4-1, home visiting programs aim to support several evidence-based parenting knowledge, attitudes, and practices identified in Chapter 2. Visits are designed to improve parents' knowledge of children's development and how adults can support children's exploration and learning. Some programs attempt to enhance parents' attitudes about their own efficacy in the parenting role, given that parents who do not believe they can be effective in supporting their child's development and learning may be unable to overcome that mind-set and engage fully in the home visits. Home visiting's primary pathway to the targeted long-term child outcomes is through improvements in the parent-child emotional relationship and the quality of parent-child interactions (e.g., how sensitive and responsive parents are when interacting with their young children). Other specific aims of programs may include increasing parents' use of positive guidance and decreasing their use of harsh punishment. Some programs target household and vehicular safety.

Throughout this section, three home visiting models are profiled to illustrate how model activities are linked to outcomes and to highlight examples of the evidence for their impacts on parenting knowledge, attitudes, and practices and child outcomes. Box 4-1 describes the Nurse-Family Partnership (NFP)®, a model rooted in a public health approach for which multiple longitudinal impact studies have been conducted. Box 4-2 describes Parents as Teachers (PAT)®, a model with roots in ECE for which a number of studies exist. Finally, Durham Connects, described in Box 4-3, is one of the newer models, focused on universal strategies for ensuring that families receive the services they need, for which two studies were included in the U.S. Department of Health and Human Services' (HHS) 2014 Home Visiting Evidence of Effectiveness (HomVee) review.³

BOX 4-1

Nurse-Family Partnership (NFP).

BOX 4-2

Parents as Teachers (PAT).

BOX 4-3

Durham Connects.

Home Visiting and Evidence-Based Policy Making

The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, funded under the Patient Protection and Affordable Care Act (ACA) of 2010, changed the national home visiting landscape considerably by providing $1.5 billion in funding to states, territories, and tribal entities to serve very high-risk families. A distinctive feature of the legislation is its emphasis on research evidence as the basis for the home visiting models states could select (75% of funds had to be allocated to models with evidence of effectiveness [see below], and the other 25% could be used to fund models that were promising if they met certain criteria and states agreed to conduct a rigorous study). In addition, the legislation identified the specific outcome areas that had to be impacted by the selected programs and the performance measures on which the states would have to report each year, which included positive parenting practices and three child outcome areas—child health, child development and school readiness, and reductions in child maltreatment.⁴ A national evaluation is also under way to assess MIECHV implementation and impacts (Michalopoulos et al., 2013).

Based on a systematic review of the evidence and the application of strict criteria for what counted as evidence (adapted in part from the U.S. Department of Education's What Works Clearinghouse), the HomVEE project team identified seven national models that met the HHS evidence criteria⁵ and to which 75 percent or more of funds had to be allocated (Paulsell et al., 2010): Early Head Start-Home Visiting (EHS-HV), Family Check-Up® for Children, Healthy Families America (HFA)®, Healthy Steps, Home Instruction for Parents of Preschool Youngsters (HIPPY)®, NFP®, and PAT®. In a second HomVEE review, published in 2012, six more models that met the evidence criteria were identified: Child FIRST, Early Intervention Program for Adolescent Mothers (EIP), Early Start (New Zealand), Oklahoma's Community-Based Family Resource and Support (CBFRS) Program, Play and Learning Strategies-Infant (PALS Infant), and SafeCare® Augmented (Avellar et al., 2012). In 2014, 40 models were reviewed, and 4 more met the HHS criteria (Avellar et al., 2014): Durham Connects/Family Connects, Family Spirit®, Maternal Early Childhood Sustained Home-Visiting (MECSH) Program, and Minding the Baby®. Two additional models were included in a September 2015 update: the Health Access Nurturing Development Services (HANDS) Program and Healthy Beginnings (Avellar et al., 2015).

Table 4-1 shows the number of favorable primary positive parent and child outcomes compared with the total number of outcomes reviewed for all of the models reviewed in 2010, 2012, 2014, and 2015.⁶ The table also notes where unfavorable or ambiguous outcomes were found.

TABLE 4-1

Number of Favorable Impacts of Home Visiting for Primary Outcomes Compared with Total Number of Outcomes Reviewed for Models with Evidence of Effectiveness, by Outcome Domain.

A Note on Program and Evaluation Logic

It is important to note that the logic of home visiting programs and their evaluations may not always align. As depicted in the generic home visiting logic model in Figure 4-1, for example, parenting knowledge, attitudes, and practices are among the hypothesized short-term outcomes en route to the longer-term outcome of child well-being. As seen in Table 4-1, positive parenting practices were not measured in the evaluations of some programs; however, this does not necessarily mean that parenting was not part of the program logic model. For example, the program description for Child FIRST states that parenting enhancements are expected as a result of the program, but parenting practices were not measured in the study that provided evidence of the program's effectiveness based on impacts on child outcomes (Lowell et al., 2011).

Home Visiting Program Impacts

In addition to findings from the HomVEE review, this section draws on findings from a paper commissioned by the committee on evidence for investing in parenting programs at scale, which includes six programs that were not included in the HomVEE review. These programs have rigorous designs that differ from MIECHV in either program delivery approach or outcomes.⁷

Positive parenting practices PALS Infant and NFP had the highest number of favorable impacts on parenting practices (Table 4-1). Across two studies, the HomVEE evidence review found 11 favorable impacts of PALS Infant on parenting behaviors such as contingent responsiveness and maintaining child foci, although it also found a negative impact on redirecting child foci (Landry et al., 2006, 2008). The HomVEE review identified favorable impacts of NFP on a number of parenting beliefs and practices, including cognitive stimulation in the home, reductions in dangerous exposures in the home, beliefs, worry, mother-infant interaction, and sensitive interaction across a number of studies (Kitzman et al., 1997; Olds et al., 1986, 1994). Among other models with impacts on parenting practices, the specific parenting outcomes affected within and across models vary, even for those programs that share a similar theoretical grounding or logic model.

In addition, as can be seen in Table 4-1 for several programs, the number of outcomes for which no impacts were found is high, exceeding the number of outcomes for which significant impacts were found; moreover, impacts may have been found at one point of measurement but not another. For example, EHS-HV participants were no more likely than controls to report reading to their children every day at the end of the program. Two years after the program ended, however, participants were significantly more likely than controls to say that they read to their children daily (Jones Harden et al., 2012). Getting Ready, an add-on to EHS-HV that provides parents with additional training in effective engagement in routine activities that support child behavior and learning, showed changes in parent warmth, encouragement of autonomy, and supports for children's skills and appropriate guidance, but no changes in the quality of behavior supporting children's learning (Knoche et al., 2012). The effect of Getting Ready on child outcomes was not assessed.

Overall, while many individual evaluations of home visiting programs have shown impacts on parenting practices tied to positive developmental outcomes, the average impacts of home visiting on parenting practices are not large. Nor is there a strong pattern of effects on parenting practices across evaluation studies and home visiting models.

Family economic self-sufficiency Relatively few home visiting programs target or measure effects of home visits on family economic self-sufficiency. The HomVEE review identified several studies in which participation in NFP was associated with reduced rates of subsequent childbearing (Kitzman et al., 1997; Olds et al., 2002, 2004) and lowered use of some forms of public assistance (Olds et al., 2010). In two impact studies, participation in HANDS was associated with significant increases in maternal receipt of WIC (Williams et al., 2014a, 2014b). Other models had positive effects on aspects of parents' self-sufficiency, such as reductions in rates of subsequent childbearing in Minding the Baby (Sadler et al., 2013). Taking into account secondary outcomes (i.e., those self-reported by means other than a standardized instrument), Early Head Start and EIP showed improvements in parents' receipt of education and training (Jones Harden et al., 2012; Koniak-Griffin et al., 2000; U.S. Department of Health and Human Services et al., 2001, 2002).

Child health Several programs, including EIP, Durham Connects (Box 4-3), HANDS, and NFP have had favorable impacts on child health, with some consistent findings across studies. Effects for measures of infant health, such as fewer hospitalizations and emergency room visits, were found for both EIP and Durham Connects (Dodge et al., 2013; Koniak-Griffin et al., 2002, 2003). Participation in HANDS was associated with reductions in preterm births and low birth weight across studies (Williams et al., 2014a, 2014b, 2014c). Two programs included not in the HomVEE review but in the commissioned paper—Rest Routine and the MOM Program—showed impacts on child health. Rest Routine, which focuses on reducing infant irritability or colic, a hypothesized precursor to child maltreatment, was found to reduce the number of hours of child crying and some aspects of parenting stress (Keefe et al., 2006a, 2006b). The MOM Program provides up to 11 home visits to encourage care for the health and development of the baby and use of well-child care and early intervention services if needed (Schwarz et al., 2012). The program had an impact on use of early intervention services, but no differences were seen in rates of developmental delays or cognitive outcomes. Parenting knowledge, attitudes, and practices were not assessed.

Child development and school readiness Family Spirit, HFA, PAT, Child FIRST, and NFP showed the greatest number of favorable impacts on child development and school readiness in the HomVEE review, although there were many null effects for each of these programs. Three programs showed clear evidence of effectiveness: Child FIRST (effects on externalizing problems and language problems [Lowell et al., 2011]); HFA (effects on some behavioral and academic outcomes in at least in two of the three trials in which child outcomes were measured [Caldera et al., 2007; Kirkland and Mitchell-Herzfeld, 2012]); and NFP (but only based on longer-term followup [Eckenrode et al., 2010; Kitzman et al., 2010; Olds et al., 2004]). In the commissioned paper, the University of California at Los Angeles Family Development Project is identified as improving child behavior but not cognitive skills (Heinicke et al., 2001). Minding the Baby (Sadler et al., 2013) also demonstrated evidence of efficacy but only for the child's security of attachment, which may or may not translate to long-term benefits (other behavioral and academic skills were not measured in the study of that program).

Effects were less clear for the EHS-HV model (U.S. Department of Health and Human Services et al., 2002), with effects being found only on parent-reported child behavioral measures and only at a later follow-up point (and no effects on cognitive skills being found at any time point). Both trials of Family Spirit showed mixed findings across parent-reported behavioral outcomes, including significant reductions in externalizing problems but not in many other similar behaviors (Barlow et al., 2013; Walkup et al., 2009); academic skills were not measured here. Effects of Healthy Steps on children were not evaluated during the intervention, and no effects were found 2 years after the intervention (Minkovitz et al., 2001, 2007).

Reductions in child maltreatment Of the programs reviewed by HomVEE, NFP showed the greatest number of favorable impacts on child maltreatment. The program had effects on hospitalizations for accidents and injuries and involvement in child protective services (CPS) in some sites and follow-ups, but not consistently across sites and studies (Administration for Children and Families, 2015b). There is also evidence of effects of Child FIRST on reductions in CPS involvement and general child maltreatment (Lowell et al., 2011). The review found improvements in measures of child maltreatment for other programs as well (e.g., HANDS and PAT).

Home Visiting Collaborative for Improvement and Innovation Network

Mary Catherine Arbour, Harvard Medical School and Brigham and Women's Hospital, was invited to present before the committee at one of its open sessions on lessons learned in continuous quality improvement from the Home Visiting Collaborative for Improvement and Innovation Network (HV CoIIN). The HV CoIIN is operated by the Education Development Center, Inc., with funding from the Health Resources and Services Administration (HRSA). Dr. Arbour is the Improvement Advisor for this national initiative that supports the work of a set of MIECHV state grantees. HV CoIIN aims to achieve improvement in outcomes in four areas targeted by home visiting programs: breastfeeding, maternal depression, family engagement, and child development.

HV CoIIN uses the Institute for Healthcare Improvement's Breakthrough Series Collaborative Model (Institute for Healthcare Improvement, 2003), which combines the Model for Improvement and a structured, time-limited collaborative learning model. This model is designed to close the gap between what is known from science about what works and what is happening on the ground to achieve results and facilitate the implementation of improved programs (Arbour, 2015). The collaborative's first step is to select a topic that has a good evidence base but is not always applied in practice. Faculty are recruited to develop a framework and set of changes expected to improve service quality and outcomes, and teams are then formed to participate in the collaborative (including leadership, front-line workers, and end-users). These teams test changes and adapt them to specific contexts, collect data on a number of indicators over time to demonstrate improvement, and share experiences to facilitate learning (Arbour, 2015). HV CoIIN is using this approach to build a culture of inquiry and improvement and enhance the implementation of improvements across a number of the home visiting models included in the MIECHV Program and across the participating states.

HV CoIIN is the first national initiative to apply continuous quality improvement (CQI) methods to evidence-based home visiting programs to improve critical outcomes for vulnerable families with young children ages 0-5. Participating home visiting teams receive training and coaching in the basic quality improvement skills of rapid-cycle hypothesis testing and data use based on the Model for Improvement. The model uses three questions to guide teams to set short-term specific aims: (1) “What are we trying to accomplish?” asks them to define aims specific to their context; (2) “What ideas do we have that can result in improvement?” asks them to use their own ideas to make home visiting work in their specific setting; and (3) “How will we know that a change is an improvement?” asks them to collect and use data to determine how well those ideas work to advance their aims. Drawing on the manufacturing and business sector, teams then subject their ideas to small, rapid-cycle testing using Plan, Do, Study, Act (PDSA).

In addition to applying the Model for Improvement in their local work, the CQI teams apply the Breakthrough Series Collaborative Model by participating in three “Learning Sessions” that bring together local teams, expert faculty, and stakeholders (including model developers and state leaders). Between Learning Sessions, CQI teams test changes in their local settings and gather data to measure the effect of those changes during 4- to 6-month-long “Action Periods.” At the first Learning Session, expert faculty presented a vision for home visiting quality and specific changes proposed by HV CoIIN, and CQI teams learned about the Model for Improvement and PDSA cycles. At the second and third Learning Sessions, teams learned from one another as they reported on successes, barriers, and lessons learned in formal presentations, workshops, and informal dialogue and exchange.

Participants in HV CoIIN commit to pursuing shared aims and to reporting a set of shared measures. Every month, data are displayed on run charts and shared transparently across the collaborative and with state and local representatives to facilitate shared learning and rapid diffusion of good ideas.

The mission of HV CoIIN is to achieve breakthrough improvements in selected process and outcome measures, including benchmark areas legislatively mandated for the federal MIECHV Program, while reducing or maintaining program costs. Its mission also includes developing the means to diffuse the learning and improvements resulting from its efforts more widely within participating organizations and to other MIECHV grantees and home visiting agencies. During its first phase (May 2014-August 2015), the collaborative enrolled 12 states and tribes and 33 home visiting agencies using five evidence-based home visiting models serving 3,500 families. HV CoIIN integrates CQI methodologies into existing evidence-based home visiting programs with the goal of disseminating practices known to work, innovating, achieving results more rapidly, building leaders in quality improvement and sustainability in home visiting, and demonstrating the effectiveness of home visiting in large-scale implementation.

Initial data indicate that the learning and improvements resulting from the HV CoIIN efforts have enabled agencies and staff to change their practices so as to affect behaviors in ways that are associated with quality improvements that support outcomes targeted by the collaborative (Arbour, 2015). The collaborative's approach shows promise as a way to work with staff in programs that target parenting knowledge, attitudes, and practices, and has been used in a variety of other health and related fields, including efforts focused on reducing infant mortality (McPherson et al., 2015; Selk et al., 2015).

Parenting Education Delivered in the Context of Classroom-Based Early Care and Education Programs

ECE programs provide full- or part-time classroom-based services (center or family child care) for children from birth to age 5. They often include parenting education and other services for families (sometimes starting prenatally) designed to improve the overall circumstances of families and promote parenting knowledge, attitudes, and practices that support children's cognitive and social-emotional development and success in school (Brooks-Gunn et al., 2000; Chase-Lansdale and Brooks-Gunn, 2014; Fantuzzo et al., 2013; Seitz, 1990). ECE programming that involves parents can be structured in several different ways, including (1) comprehensive two-generation programs with components that include multipronged, intensive classroom-based services for children, parenting education, and parent self-sufficiency support (as in Head Start, Early Head Start, and Educare); (2) primarily classroom-based services for children with some parenting education services; and (3) primarily classroom-based services for children with some parent self-sufficiency services.

The logic behind ECE programming that involves parents is the potential for additive effects for the child and family. Children's positive experiences in care can have a direct effect on their outcomes, and if parenting education or parent self-sufficiency outcomes also are achieved, additional benefits may accrue. However, coupling ECE programs with parenting components does entail costs, and with a fixed budget it is difficult to maintain high-quality efforts on both components. Indeed, a meta-analysis showed significant effects of preschool education on children's cognitive and social development but found that provision of additional services tended to be associated with smaller gains (Camilli et al., 2010). Thus, it is important to identify two-generation models likely to generate benefits that justify their added expense and administrative complications.

This section summarizes findings from studies evaluating how ECE programs support parenting and healthy child development. The committee was unable to identify clearinghouses or reviews of classroom-based ECE programs that included parenting supports and thus drew on rigorous studies published in the peer-reviewed literature. Note that the discussion in this section excludes approaches used in the early intervention/special education system.

Head Start and Early Head Start

Head Start and Early Head Start are rigorously evaluated two-generation programs. (A brief description of both programs and numbers of families served can be found in Chapter 3.) In addition to education services directed at children, Head Start and Early Head Start programs are required to provide parents with activities that may include (1) parenting education, including at least two home visits per year whereby teachers give parents information about their children's current classroom activities; (2) group parenting support classes on topics of interest to parents; and (3) opportunities to volunteer in the child's classroom (Administration for Children and Families, 2016). Parent policy councils and center committees also provide opportunities for parents to participate in program leadership. Services are intended to be responsive to the needs and cultural and linguistic heritage of families in the communities served (Administration for Children and Families, 2016).

Parental engagement and service take-up, which have become a focus of attention because of the cost of nonparticipation and the potential impact of nonengagement on school readiness outcomes, are far from 100 percent (Administration for Children and Families, 2015d).⁸ Recent data show that just 41 percent of parents whose children were enrolled in Head Start attended parenting classes, although this percentage was 14 percent higher than that for control group parents. Attendance at goal-setting classes also was significantly higher for Head Start than for non-Head Start parents, but take-up rates for nutrition, income, housing, utilities, education and job training assistance programs did not differ significantly between parents who won and lost lotteries for their children to enter the Head Start Program to which they had applied. Parents' participation in the programs offered by Early Head Start was higher than was the case for Head Start parents, and almost always significantly higher for Early Head Start parents than for their control group counterparts (based on full-sample estimates) (Auger, 2015).

Head Start impacts on knowledge, attitudes, and practices and child outcomes Puma and colleagues (2012) provide a random-assignment evaluation of parenting impacts in the National Head Start Impact Study. Parenting-related measures included disciplinary practices, educational supports, parenting styles, parent participation in and communication with the school, and parent and child time together. Two cohorts of children (those entering Head Start for the first time at ages 3 and 4) were analyzed separately.

Looking first at impacts at the end of the Head Start year, in no case did any of the parenting measures differ significantly for the two cohorts of children. Practices for which significant impacts were found for only one cohort included an unexpected negative impact on the amount of time parents reported reading to their children (for the 3-year-old cohort) and beneficial impacts on spanking, reading, and cultural enrichment for the 4-year-old cohort. None of the beneficial impacts found at the end of the Head Start year persisted across the kindergarten, 1st-, and 3rd-grade follow-ups, and in no case did safety practices differ significantly between the Head Start and control groups. For the 4-year-old cohort, only 1 of 28 parenting impacts emerged as statistically significant (time spent with child in 3rd grade). For the 3-year-old cohort, there was some indication that parenting styles were more authoritative (characterized by high warmth and control) and less authoritarian for the Head Start group, although these patterns were seen in less than one-half of the tests conducted. Overall, despite the program's stated goals of improving parenting, the Head Start evaluation found virtually no consistent evidence that this goal was achieved.

With respect to child outcomes, both cohorts showed statistically significant impacts on children's language and literacy development while they were in Head Start, although these effects dissipated when children reached elementary school. By the end of 3rd grade, the only favorable impact was on reading, and this was only for the 4-year-old cohort. Results in the social-emotional domain differed by both cohort and source of information. In the 3-year-old cohort, early favorable impacts on social-emotional measures (problem behaviors, social skills) were sustained through 3rd grade based on parent-reported measures, but data reported by teachers suggested no impacts on social-emotional outcomes in either the kindergarten or 1st-grade year. No social-emotional impacts were observed in the 4-year-old cohort through kindergarten, while favorable impacts were reported by parents and unfavorable impacts by teachers at the end of the 1st and 3rd grades. There was strong evidence of improved receipt of dental care at the end of the Head Start year in both cohorts (Puma et al., 2012).

One of the challenges of programs that include both direct and indirect pathways to child outcomes is the inability to assess the extent to which observed impacts are the result of any one component of the intervention. It is impossible to know in this case whether the parenting impacts noted (scattered as they were) had any role in the observed impacts on child outcomes. Nonexperimental analyses could provide exploratory answers to these types of questions.

Early Head Start center-based impacts on knowledge, attitudes, and practices and child outcomes Evidence of the impact of Early Head Start on parenting comes from the Early Head Start Research and Evaluation Project, a large-scale randomized evaluation following 3,001 children and families in 17 community sites. Sites delivered services primarily through home visits (discussed in the previous section), center-based services, or a mixed program approach whereby families received home visiting and/or center-based services (Love et al., 2005; U.S. Department of Health and Human Services et al., 2002).

A random-assignment evaluation of Early Head Start in four center-based programs found one positive impact of the program on the quality of parent-child play when the children were age 3 and one negative impact on parent knowledge of how to use a car seat correctly (U.S. Department of Health and Human Services et al., 2002). Mothers in the Early Head Start group reported lower levels of severe depression and were more likely than controls to be employed or in an education or training program. Overall, none of the other many parenting, parent well-being, home, and self-sufficiency outcomes studied was affected by Early Head Start among the families in the center-based sites. With regard to child outcomes at age 3, children in the Early Head Start group were less likely to show negativity toward their parent during a parent-child play task. There were no other impacts on child outcomes for the Early Head Start center-based group.

In sites using the mixed approach (center-based and/or home visiting services), families would in some cases receive home visiting services when they started in the program and then transition to center-based services when their children were older and the mother went to work. At age 3 and beyond, analysis indicated that among the three service delivery approaches, sites employing the mixed approach tended to have the greatest concentration of impacts with respect to both parenting and child outcomes (U.S. Department of Health and Human Services et al., 2002). These findings may have implications for the need for increased flexibility in programming that allows families to shift from one mode of service delivery to another as their needs change.

Smaller-Scale Classroom-based ECE Interventions

Other classroom-based ECE programs that include parenting supports also have some evidence of effectiveness and provide insights into ways to reach parents. Effective interventions target improving parents' engagement in preschool/elementary school, as well as parents' roles as collaborators with teachers in decision making about children's academic experiences. In some cases, these targets are complemented by attempts to improve alignment between home and classroom learning contexts.

The Companion Curriculum, for example, uses Head Start teachers to encourage parents' participation in the classroom and provide workshops and activity spaces in the classroom that are focused on training parents to engage in parent-child learning activities. Although the program did not demonstrate benefits for parents' involvement in the classroom or general engagement in home learning activities, it led to increased frequency of parent-child reading and improved children's vocabulary in a quasi-experimental study (Mendez, 2010).

The Kids in Transition to School (KITS) Program is a short-term, targeted, evidence-based intervention aimed at increasing early literacy, social skills, and self-regulatory skills among children who are at high risk for school difficulties. This program provides a 24-session readiness group for children that promotes social-emotional skills and early literacy as well as a 12-session parent workshop focused on promoting parent involvement in early literacy and the use of positive parenting practices. In a pilot efficacy trial with 39 families, Pears and colleagues found that children in families who received the KITS intervention demonstrated early literacy and social skill improvements as compared with their peers who did not receive the intervention (Pears et al., 2014). In randomized controlled studies, foster children who received the intervention exhibited improvements in social competence, self-regulation skills, and early literacy skills (Pears et al., 2007, 2012, 2013).

Two-Generation Approaches

One class of early intervention programs uses a two-generation approach with an explicit focus on human capital skill building. As described by Chase-Lansdale and Brooks-Gunn (2014, p. 14), these programs “intentionally link education, job training, and career-building services for low-income parents simultaneously with early education for their young children.”

Early versions of these kinds of two-generation programs focused on adolescent mothers, providing them with a host of education- and job-related services. Developed during a time when the nation was focusing on welfare reform and had not begun to appreciate the potential of high-quality early childhood education programs with respect to skill building for children, these programs typically viewed child care services as a means of supporting the self-sufficiency efforts of mothers rather than promoting the school readiness of their children.

Four prominent programs conducted during the 1980s and 1990s (Project Redirection, the New Chance Demonstration, Ohio's Learning and Earning Program, and the Teen Parent Demonstration) offered adolescent mothers a wide range of services, including, in some cases, parenting classes, job training, and mandatory schooling (Granger and Cytron, 1999; Polit, 1989). Project Redirection was the earliest. It offered education and training programs for low-income adolescent mothers combined with intensive support services that included individual counseling, training in parenting and employability skills, and referrals to community services. Its evaluation, which was not based on random assignment, showed virtually no differences in parents' education or training but some promising improvements in the quality of their children's home environments and early literacy and behavior (Polit, 1989).

Evaluations of the other three programs were based on random assignment and showed a less positive set of impacts (Granger and Cyrton, 1999). In terms of parenting knowledge, attitudes, and practices, the New Chance Demonstration provided parenting education designed to promote positive parenting practices and better mother-child relationships and to reduce the stresses associated with parenthood. The Teen Parent Demonstration also included parenting workshops. The effects of these programs on mothers were not very promising, with virtually no impacts being seen on educational advances (New Chance increased GED holding, possibly at the expense of high school diplomas) or on mothers' earning, employment, or welfare participation. Maternal mental health was assessed in evaluations of New Chance and the Teen Parent Demonstration, but in neither case did the program improve scores on the mental health measures employed. Moreover, mothers in the New Chance Demonstration experimental group reported significantly more parenting stress relative to their control counterparts.

Consistent with the view of child care as merely a support for the mother's employment and education activities, none of these three programs affected any of the assessed dimensions of children's school readiness. In fact, New Chance mothers reported higher rates of child behavioral problems relative to their control group counterparts.

Another example of a rigorously evaluated comprehensive two-generation program was the Comprehensive Child Development Program (CCDP). Developed in the 1990s, this program was an ambitious attempt to provide low-income families with a range of social services designed to support infants' and children's cognitive, social-emotional, and physical development, as well as to enhance parents' ability to support their children's development and achieve economic and social self-sufficiency (St. Pierre et al., 1997). Services were intended to extend from birth through kindergarten or 1st grade but, in contrast to Head Start and some Early Head Start programs, were not built on a high-quality classroom-based program for children. The comprehensive nature of CCDP services is reflected in the program's cost, which amounted to $15,768 per family per year, or about $47,000 per family over the entire course of the program (St. Pierre et al., 1997). (In 2014 dollars, this amounts to approximately $23,250 per family per year, or nearly $70,000 per family over the entire course of the program.)⁹

CCDP service delivery relied heavily on case managers and appeared to be implemented effectively (St. Pierre et al., 1997). For children, the program supported and in fact increased parents' use of center-based child care, although evaluators did not systematically assess the quality of this care. Most sites offered biweekly home visits by a case manager or early childhood specialist between birth and age 3 in which training was provided to parents on infant and child development and, in some cases, modeling of ways to interact with children. Results of CCDP's random-assignment evaluation 5 years after the program began showed no statistically significant impacts on parenting skills or self-sufficiency among participating mothers or on the cognitive or social-emotional development of participating children (St. Pierre et al., 1997). Nor did consistent impacts emerge for any demographic subgroups or among the families that participated in the program for most of the service period. Evaluators speculated that the lack of impacts may have been the result of some combination of the dilution of service quality caused by the overly ambitious scope of program services and, for children, the program's reliance on indirect effects through parents rather than direct effects that might have come from high-quality classroom-based early education services.

In contrast to CCDP, the Child-Parent Center (CPC) Program in Chicago is a center-based early intervention program that offers comprehensive educational and family support services designed to increase academic success among low-income children ages 3-9 residing in disadvantaged Chicago neighborhoods (University of Minnesota, 2013). CPC employs a number of components directed at children and parents to meet the program objectives, such as structured and diverse language-based instructional activities; low child-to-teacher ratios; a multifaceted program for parents that takes place under the supervision of a parent-resource teacher (e.g., volunteering in the classroom, attending school events, enrolling in educational courses); outreach activities (resource mobilization, home visitation); ongoing staff development; health and nutrition services; and supports to help children from 1st to 3rd grade transition to elementary school (Reynolds, 2000). Longitudinal analyses of CPC show participation to be associated with children's improved future performance in school, such as reading and math achievement, especially for those who remain in the program for several years (Reynolds, 1997; Reynolds and Temple, 1998; Reynolds et al., 2004). Parents' involvement in school was found to be a mediator of the program's effects, suggesting that the program components targeting parents played a role in its success (Reynolds et al., 2004).

New in two-generation programming are so-called “Two Generation 2.0” human capital programs (Chase-Lansdale and Brooks-Gunn, 2014), which assign a key role to high-quality ECE. Examples of such programs for which evaluations are planned or under way include the CareerAdvance® Community Action Project of Tulsa, Oklahoma; the Annie E. Casey Foundation Atlanta Partnership; and the Housing Opportunity and Services Together project (see Chase-Lansdale and Brooks-Gunn, 2014, for others). In effect, these programs view ECE as an important and independent source of human capital training for children rather than merely a means of providing child care in order to promote the careers of mothers. ECE is coupled with postsecondary workforce skill development for parents, with training taking place in community colleges, job training programs, or workplaces. The theory of change behind these models is focused on the education benefits to children of high-quality ECE programs and higher parental levels of education and labor force motivation. Parenting knowledge, attitudes, and practices may be improved, but the improvement comes indirectly through higher parental job skills and education and reduced household stress rather than explicit programming directed at parenting skills.

Within programs designed to enhance school readiness, a subset of programs target children's cognitive skills (language, literacy, and math) and focus as well on children's social-emotional development, given the reciprocal nature of these skills. For example, Educare, based in 12 Educare schools and on Head Start's parent involvement objectives, focuses on receptive language, vocabulary, and early reading, and children's social-emotional skills. To date, implementation studies have shown promise for the program in addressing the quality gap of service delivery and parent engagement. A randomized controlled trial currently under way is comparing children at age 3 who are cared for at home or in other settings with children who are served in Educare on cognitive, language, executive function and social-emotional measures, and examining whether performance on these measures differs for dual language learners. No strong evidence on program impacts is available, however, so it is impossible to determine whether this new generation of programs will change parenting knowledge, attitudes, and practices or improve child well-being.

A brief summary of two ECE programs developed in the latter half of the 20th century, in which children assigned to comparison groups faced different and often worse conditions than they do today, is provided in Box 4-4.

BOX 4-4

Parenting in Older-Model Early Care and Education Programs.

Parent Engagement in School Settings and School-Related Activities, Prekindergarten through Grade 3

Beyond stimulation of and support for learning activities in the home, parents engage in their children's early learning and education through an array of practices aimed collectively at promoting educational success and well-being. These practices may include participation in school functions (e.g., classroom volunteering), communication with school personnel (e.g., parent-teacher conferences), supervision and assistance with school-related home activities (e.g., help with homework), and education-related communication and connections with other families and community members (e.g., parent social networks).

Although the terminology used to describe parenting behaviors relative to children's learning and education varies in the empirical literature (e.g., parent engagement, parent involvement, family-school partnerships), most researchers emphasize the ways in which such engagement requires connections between parent and child and relationships across home, school, and community contexts. The parent engagement literature generally treats schools and communities as parents' partners and collaborators because parents' power to act on behalf of their children's educational interests is determined, in large part, by the extent to which schools and communities make parents aware of opportunities, give them access to resources, and enable them to take advantage of these opportunities and resources (Dearing et al., 2015; Henderson and Mapp, 2002). In the parent-engagement intervention literature, programs generally take one of two approaches: (1) focusing primarily on improving parents' level and quality of engagement in the home environment with regard to learning stimulation and behavior regulation, or (2) focusing on connecting parents with their children's schools to promote academic achievement and/or positive behaviors.

Theory on parent engagement is built largely on ecological systems frameworks, particularly those focused on how aligning child, family, school, and community assets can help promote positive development in contexts characterized by multipronged social and economic disadvantage (García Coll et al., 1996; Huston and Bentley, 2009). More specifically, theory on parents' engagement in children's early education has hypothesized benefits for achievement and school success through three primary mechanisms (see Figure 4-2).

FIGURE 4-2

Hypothesized benefits of parents' engagement in children's early education for children's achievement and school success. SOURCE: Dearing et al. (2015).

First, collaboration among families, schools, and communities can help build the capacity to stimulate and support children's learning. This linkage holds if (and only if) the information channels and norm reinforcement provided by the social network members emphasize knowledge, attitudes, and practices that are beneficial for children's achievement (e.g., teachers sharing with parents knowledge about best practice for promoting learning, and parents sharing with teachers nuanced information about their children as learners).

Second, it is expected that when parents are involved in their children's schooling with developmentally appropriate levels of autonomy and emotional support, they communicate positive beliefs about the children's learning potential. In turn, the children are likely to have positive feelings toward learning and themselves as learners, identify positively with their parents' achievement values, and meet learning challenges with effort and feelings of self-efficacy (Pomerantz et al., 2007).

Third, parents play a direct role in building children's learning strategies and skills, including approaches to problem solving, study skills, domain-specific and domain-general knowledge, and meta-cognitive skills. For a review, see Dearing and Tang (2010).

As noted in a recent review of parent engagement programs, policies, and practices (Sheridan et al., 2016), practice recommendations for interventions targeting parent engagement in early childhood education tend to emphasize the value of cultivating positive parenting through connections between home and school. Also emphasized is the importance of ensuring that these partnerships can be “culturally sensitive (responsive to values, priorities, and interaction styles of families), developmentally responsive (appropriate to children's needs across the developmental spectrum), intentional (focused on specific objectives), strengths-based (building on family and child competencies and interests), and collaborative (structured around mutual—parent and teacher—goals).” In turn, interventions proving successful in randomized experimental evaluations share such characteristics as a strong emphasis on (1) frequent communication and sharing of information between parents and early childhood teachers, (2) collaborative goal setting in which parents and teachers work in partnership to develop an educational plan for their children, and (3) improvements in parenting skills and parenting efficacy (Sheridan et al., 2016).

USE OF INFORMATION AND COMMUNICATION TECHNOLOGIES TO SUPPORT PARENTING

Information and communication technologies can contribute to parenting in two ways: (1) socialization with respect to what parenting is and means through the media, especially entertainment media, and (2) development and maintenance of parenting skills through interventions that use these technologies. New information and communication technologies provide numerous opportunities to deliver interventions with the potential to improve parenting. Digital delivery of parenting interventions has been explored as a way to overcome barriers to participation and to increase the reach, sustainability, and impact of interventions. In theory, at least, parents who can access a training program from a computer or mobile device when and where it is convenient for them to do so may face fewer logistical and financial barriers (e.g., child care, transportation) to participation. The new technologies also make it possible to tailor services to special parent populations.

Established and emerging communication technologies are now common in American households and are reframing the context of modern parenting. The majority of U.S. households have a computer and Internet access, making digital modes of intervention a promising strategy for improving program reach. In 2013, approximately 84 percent of households reported having a computer (with 78.5% having a desktop or laptop computer and 63.6% having a handheld computer), and approximately 74 percent of households reported Internet use (File and Ryan, 2014). According to data from the Pew Internet and American Life Project's Networked Families Survey, married parents with minor children living at home relative to other household configurations have the highest rates of Internet and cell phone usage, computer ownership, and broadband adoption (Kennedy et al., 2008). Nontraditional family arrangements, such as single-parent and unmarried multiadult households, also tend to be heavy users of these technologies, particularly with respect to text messaging and use of social media (Kennedy et al., 2008). Contrary to concerns that these technologies could divide families and impede their meaningful interaction, results of nationally representative surveys from the Pew Research Center reveal that technology—particularly mobile phones and the Internet—is enabling new forms of family connectedness (Kennedy et al., 2008). In fact, the majority of parents believe technology allows their families to be as close, or closer, than their families were when they grew up (Kennedy et al., 2008). Parents use the Internet to help research, organize, and improve various aspects of their lives. As far back as 2002, one study found that 73 percent of online parents used the Internet to learn new things, and 52 percent said their use of the Internet improved the way they connected with their family members (Allen and Rainie, 2002).

While the penetration of new information and communication technologies is widespread, significant inequalities in access to the technologies persist (Viswanath et al., 2012). For example, young adults, members of minority groups, and individuals with low educational attainment and low household income are more likely to say that their phone is their main source of Internet access. In contrast to Internet access, African Americans and whites are equally likely to own a cell phone of some kind and also have similar rates of smartphone ownership (File and Ryan, 2014; Zickuhr and Smith, 2012). Nonetheless, data suggest that low-income and minority groups are more likely to experience disruptions in service due to lack of payment of bills, relocation, or a change in phone number (Smith, 2015). Furthermore, although the Internet may be widely used (Smith, 2014), disparities in access by income, education, race/ethnicity, and other factors need to be considered in the implementation of programs for the diverse population of primary caregivers of young children (see Table 4-2). In 2013, for example, just 62 percent of households earning less than $25,000 had a computer, and only 48 percent had some form of Internet access, whereas among households earning $150,000 or more, 98 percent had a computer, and 95 percent had Internet access. Blacks and Hispanics (of any race), those with a high school education or less, those living in nonmetropolitan areas, and those living in households in which limited English is spoken also were much less likely to have computer and Internet access in 2013 (File and Ryan, 2014).

TABLE 4-2

Computer and Internet Use among U.S. Households, 2013.

Another challenge is that, compared with previous generations, parents today are exposed to a much greater amount of information via a variety of channels, including entertainment media such as television and digital platforms such as the World Wide Web and DVDs. Much of the available information is untested and sometimes contradictory, and the sheer amount of information and the fact that it may be contradictory may confuse parents and families.

As discussed in Chapter 6, despite the effectiveness of a number of various face-to-face parenting interventions, there are a number of barriers to parents' participation and retention in these programs. According to Breitenstein and colleagues (2014), studies of involvement in face-to-face interventions for parents of children in preschool through grade school show that only 10 to 34 percent of parents enroll (Baker et al., 2011; Garvey et al., 2006; Heinrichs et al., 2005; Thornton and Calam, 2011). Among those who do participate, average attendance rates range from 35 to 50 percent of sessions (Breitenstein et al., 2012; Coatsworth et al., 2006; Scott et al., 2010). Creating online-based content may be one strategy for increasing participation in interventions by providing a more convenient way to receive the information. In addition, digital delivery of parenting interventions may reduce challenges associated with uneven implementation that often occur with face-to-face interventions, including those provided across multiple sites, where adherence to protocols may vary (Breitenstein et al., 2014, 2015). Digital modes of delivery also may decrease demands on providers' time and reduce costs and other resources associated with providing the intervention in person. This can be an important advantage for some communities, as the costs of hiring, training, and maintaining professionals for evidence-based programs can be prohibitive for isolated and poorly resourced agencies (Baggett et al., 2010), while rural communities may have limited numbers of professionals available to provide evidence-based programs.

The body of research on the use of technology and media to improve parenting knowledge and skills and provide social support for parents is relatively small but growing. This research has included evaluations of parenting programs, several of which are discussed in Chapter 5, that have been adapted from a face-to-face to an online format (e.g., Triple P Online, the Incredible Years), as well as programs developed at the outset for delivery in a digital format.

A recent systematic review included 11 experimental and quasi-experimental studies of seven parent training interventions utilizing digital delivery methods (electronic text, audio, video, or interactive components delivered via the Internet, DVD, or CD-ROM) for administering a portion of or the entire program (Breitenstein et al., 2014). Eight of these interventions supplemented text and other instructional content with videos of parent-child interactions (an effective teaching strategy in face-to-face interventions that is easily translated to digital formats). In the four programs for which parent and child behavioral outcomes were reported—InfantNet, Internet-Parent Management Training, Parenting Wisely, and Triple P Online—medium to large effect sizes were observed in the areas of infant and parent positive behaviors, child behavioral problems (e.g., conduct, hyperactivity), parental disciplinary practices, parental self-efficacy and satisfaction, and postpartum depression. When reported, participants' satisfaction with the interventions was high, ranging from 87 to 95 percent (Breitenstein et al., 2014). Although these findings suggest that the programs had a positive effect, it is difficult to draw firm conclusions given the small number of studies. Furthermore, in 6 of the 11 studies, 75 percent or more of the sample was white; only one intervention had a sample with a more diverse distribution among racial groups (Scholer et al., 2010, 2012), possibly limiting the generalizability of the findings. Future studies including parents from diverse racial/ethnic and socioeconomic backgrounds are needed. The studies reviewed also relied primarily on parents' self-reports rather than electronic tracking methods to assess completion of the intervention, and parents may misreport their completion rates. In the 2 studies that did use electronic tracking, the intervention doses were 92 percent (Baggett et al., 2010) and 67 percent (Sanders et al., 2012)—as high as or higher than those reported by parents in the other studies. Finally, as none of the interventions reviewed had been formatted for mobile devices, the review showed a need for further experimental research on parenting interventions formatted for such devices.

Other studies have examined the feasibility of adapting evidence-based training in parenting skills to information and communication technologies. A recent evaluation of the adaptation of the face-to-face Chicago Parent Program (CPP), designed for low-income, diverse families, to an Android tablet application showed that it is feasible to accomplish such adaptation and maintain the core components of the original program when key stakeholders (parents, program developers, and designers) are engaged (Breitenstein and Gross, 2013; Breitenstein et al., 2015). The adapted program, eCPP, includes interactive activities, video examples and explanations of parenting strategies, reflection questions, evaluation of parent knowledge with feedback, and practice assignments.

Taylor and colleagues (2008) evaluated the feasibility of adapting the Incredible Years Program to a technology-based format. The study collaborators combined a computer and Web-based intervention that presented a large portion of the original Incredible Years content through technology (including video vignettes, sound files, and pictures) with support from a coach delivered through phone calls, electronic messages, and home visits. Ninety Head Start families with high levels of child behavior issues joined the study, which was implemented as part of a randomized controlled trial. Participation rates were comparable to those in the group-based Incredible Years Program, and among a subset of participants (45 families) 30 reported achieving at least one of their self-determined goals. Although further study is needed to demonstrate the effectiveness of the approach, this study showed the feasibility of using technology for adaptation and dissemination of evidence-based parenting interventions (Taylor et al., 2008).

Triple P Online is a Web version of the Triple P-Positive Parenting Program for parents of children ages 2 to 12 with behavioral problems that can be completed by parents at their own pace over a 16-week period. Triple P Online consists of eight interactive modules, each of which takes 30 to 60 minutes, on such topics as encouraging child behaviors that parents like, managing misbehavior and disobedience, and raising confident and capable children. Each of the eight modules includes video demonstrations of positive parenting skills and activities to help parents utilize these skills. After completing an initial module, parents gain access to such resources as worksheets, podcasts, and text message summaries (Triple P-Positive Parenting Program, 2016b). A focus group and survey study involving African American and Hispanic parents residing in economically depressed areas in Los Angeles County showed the feasibility of using social media in Triple P Online to reach high-risk, high-poverty families (Love et al., 2013). In a subsequent relatively small randomized study comparing two self-help versions of Triple P—Triple P Online and a self-help workbook—no differences in short-term intervention effects were observed for dysfunctional parenting and disruptive child behavior; both versions were associated with significant declines in levels of disruptive child behavior, dysfunctional parenting styles, risk of child maltreatment, and interparental conflict on both mother and father report measures. Results were largely sustained at 6-month follow-up (Sanders et al., 2014).

SafeCare®, designed specifically to prevent and reduce the recurrence of child maltreatment among families of children ages 0-5, has used technology-based hybrid approaches for the delivery of skills training during home visits. Cellular phone technology is incorporated into the Parent-Child Interaction (PCI) module of SafeCare, from which parents learn skills to increase positive interactions with their children. In a randomized controlled trial involving 371 mother-child dyads, mothers who received cellular phone-enhanced training from home visitors (i.e., tailored cell phone text messages about skill usage delivered twice a day and weekly phone calls to discuss the text message content and other issues raised by mothers) used significantly more positive parenting skills relative to waitlist controls. Perhaps as a result of increased contact with the home visitors due to use of the technology, these mothers showed more positive parenting strategies, reduced depression, and increased child-adaptive behaviors 6 months postintervention relative to parents who received traditional training, as well as waitlist controls. They also showed greater retention in services (Bigelow, 2014; Carta et al., 2013). In a small feasibility study involving three families, use of iPhone™ video in the SafeCare home safety module showed promise as a way to identify and reduce child safety hazards. Parents used the phone between home visits to capture video of rooms in their home. They then sent these videos to the home visitor, who evaluated them for hazards and provided feedback to parents. The safety module of SafeCare is typically completed in six in-home sessions lasting between 90 and 120 minutes. As a result of the use of this technology, face-to-face time for the home visits was progressively reduced and replaced by the video data collection (Jabaley et al., 2011).

Behavioral parent training (BPT) is designed to promote changes in attitudes and practices related to harsh discipline among parents of young children with attention deficit hyperactivity disorder who display conduct problems and antisocial behaviors (Chacko et al., 2009; Cowart-Osborne et al., 2014; Kaminski et al., 2008; van den Hoofdakker et al., 2007; Webster-Stratton et al., 2011). This training has been found to be effective for preventing child maltreatment and reducing child maltreatment recidivism (Barth, 2009; Cowart-Osborne et al., 2014; Kaminski et al., 2008; Whitaker et al., 2005). In-person, group-based BPT typically takes place over several weeks and involves instruction, modeling, and practice of positive parenting behaviors; supportive group discussions; and home practice assignments. Studies provide preliminary evidence that incorporating media, such as an Internet program, videotapes supplemented by telephone or in-person coaching, and multimedia CD-ROMs into BPT is effective for improving parenting skills (Cefai et al., 2010; Irvine et al., 2014; Webster-Stratton and Reid, 2010). For example, in a recent randomized trial of an Internet BPT program (Parenting Toolkit) using a scenario-based video hybrid instructional design conducted at urban community centers, test scores of parents of youth ages 11-14 who viewed the toolkit and completed a 1-month follow-up (N = 90) indicated that they would be less likely than controls (N = 140) to overreact and respond harshly during disciplinary interactions with their children and more likely to follow through with promised consequences. These parents also reported a reduction in their children's problem behaviors and greater gains in their own self-efficacy and intention to engage in positive parenting practices (Irvine et al., 2014).

Another emerging area of research is parents' use of technology and media as a source of social support. In a recent survey of parents by the Pew Research Institute, nearly three-quarters of respondents reported receiving social support from others on social media (Duggan et al., 2015). Forty-two percent of parents using social media (more mothers than fathers) reported that they had received social or emotional support specifically for a parenting issue on social media in the past month. Eight percent and 16 percent of parents, respectively, said they received social or emotional support for a parenting issue “frequently” or “sometimes” over the past month (Duggan et al., 2015).

The use of social media (e.g., Facebook, Twitter) among mothers with young children to share information about their children is an emerging trend. One correlational study of new mothers (N = 157) evaluated whether blogging and social networking is associated with improvement in maternal well-being by providing social support (McDaniel et al., 2012). Maternal well-being was assessed by means of psychological and emotional measures, such as marital functioning, parenting stress, and depression. The study demonstrated an association between the frequency of blogging and feelings of connection to extended family and friends, perceived social support, and maternal well-being, showing that blogging may be a powerful tool for developing a new mother's sense of increased connection to the outside world and eventually improving her well-being (McDaniel et al., 2012).

In a quasi-experimental study involving 1,300 mothers of infants, intervention participants were provided with online interactive resources that offered information and social support. These resources included an information database, an online peer discussion forum, and an online answering service staffed by nurses and midwives, covering such topics as how to respond to infants' cues and needs. The study found that the intervention had no effect on mothers' perceptions of parenting satisfaction and depressive symptoms. Yet relative to mothers in the control group, mothers in the intervention experienced higher infant centrality at 6 weeks (Salonen et al., 2014).

Differences in preferred channels of information may depend on the type of parenting information sought. In primary care settings, especially in pediatrician offices, parents' preferred channel of delivery for patient educational materials may vary based on the type of message and the complexity of the information. A review of 114 studies of patient education in primary care settings using primarily randomized controlled designs looks at parents' preference for delivery formats for information on such topics as positive parenting practices, children's behavioral self-management, and skills for improving the well-being of both children and families (Glascoe et al., 1998). The authors report that media, including advertising campaigns and office posters, helped extend parents' interests to new areas, while parents preferred verbal communication for brief and concrete messages. Modeling and role playing were particularly beneficial for addressing problematic parenting or child behavior. However, there may be challenges to delivering long, complex verbal messages to parents in primary care settings; limitations of memory and understanding of content may make the information difficult to absorb, particularly in stressful situations such as discussing problematic child behaviors or other family concerns. The authors suggest that written form may be more beneficial for communicating complex medical information.

Web-based strategies have also been tested among foster, adoptive, and kinship parents, who may need to deal with particularly difficult behavioral issues (Pacifici et al., 2006). In a pre- and post-test study, Pacifici and colleagues (2006) investigated the effectiveness of two interactive Web-based courses on lying and sexualized behavior in children developed for foster, adoptive, and kinship parents. Findings demonstrated significant improvement in parental knowledge for both courses and a significant increase in competency-based parenting perceptions for the course on lying. This Web-based program also led to new connections and interactions among users, and overall user satisfaction was high (Pacifici et al., 2006).

In summary, while early research on the use of information and communication technologies to support parenting has had promising results, much more remains to be done. Future research needs to include study populations that are more culturally and socioeconomically diverse and incorporate electronic tracking to monitor usage. In addition, more work is needed to develop formatting for mobile devices to extend the availability of interventions to those without access to a computer (Breitenstein et al., 2014). While some research supports the use of the Internet and other technologies for the delivery of parent training, interventions that utilize in-person support group formats (e.g., Triple P, the Incredible Years) have shown significant effects on parenting practices, some of which can be measured years later. It is not yet clear whether self-administered, technology-based interventions can replicate the effects of these interventions (Irvine et al., 2014). One attractive feature of technology-based interventions is providing parents with the ability to learn at their own pace, although there is a risk that parents will move too quickly without taking the time to practice new skills or too slowly so they lose momentum and interest (Breitenstein et al., 2014). If programs are to remain relevant and engage a broad population, however, they would need to adapt to Americans' growing reliance on technology for information relevant to parenting. This may be especially true for younger, including adolescent, parents, who are accustomed to communication through technologies that have been available to them their entire lives (Cowart-Osborne et al., 2014). As is the case for all parenting interventions, if technology-based parenting support interventions are to have a positive effect on parenting practices, their developers need to apply theories of behavior change (e.g., the theory of reasoned action and the theory of planned behavior) that can inform influential mechanisms through which such interventions can impact parenting knowledge, attitudes, and practices. In addition, ecological approaches that intervene at multiple levels are called for as multilevel interventions may have more lasting effects on behavior change.

Finally, a gap in the research on information and communication technologies is work on how entertainment media socialize young parents on norms of parenting. While formal avenues of classes and structured curricula are important for developing and reinforcing certain norms about parenting, entertainment media are also likely to have a significant influence. This is an area ripe for additional work.

SUPPORTING PARENTING: INCOME, NUTRITION ASSISTANCE, HEALTH CARE, AND HOUSING PROGRAMS

As described in Chapter 3, a number of programs and policies at the federal level are designed to provide resources for families. Some provide direct cash assistance, others help ensure the health of children, and some provide services and parenting education in conjunction with the material assistance. This section focuses on research evaluating the impact of these programs, both directly on children and parents and with respect to facilitating better parenting.

PARENTAL AND FAMILY LEAVE POLICIES

The United States is the only advanced industrialized nation that does not mandate paid maternity leave and one of only a few industrialized countries that do not require paid leave for children's health needs by national law. Of the 189 countries included in Heymann and McNeill's (2013) examination of the World Policy Analysis Centre Adult Labour Database, nearly all offer paid leave for new mothers, although less than one-half provide paid leave to new fathers. Moreover, 48 countries have policies that provide paid leave to parents when their child is ill. Just over half of high-income countries and one-quarter of middle-income countries have policies supporting paid leave for parents for children's health needs (Heymann and Earle, 2010; World Adult Labour, 2015). Current state and federal leave policies regarding parental and family medical leave in the United States do not cover all parents and employers; among those who are covered, the relevant policies do not cover all their needs (Schuster et al., 2011). This section characterizes the needs of new parents and the health care needs of children; existing employer, federal, and state support for families with children; and the impact of such programs and legislation on children and families.

SUMMARY

An overarching finding of this chapter is that several of the interventions discussed have shown a mix of positive and null findings in evaluation studies. In addition, the variability in the body of literature available for various approaches (e.g., some having been tested in one or two randomized controlled trials, and others having been tested in multiple evaluations that utilized different designs) makes it challenging to draw conclusions about the relative effectiveness of the various approaches. The following points emerged from the committee's review of evidence-based and evidence-informed strategies for strengthening parenting capacity in the areas of universal/preventive and widely used interventions; information and communication technologies; income, nutrition assistance, health care, and housing programs; and parental and family leave policies.

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