Parenting Support in Small Doses Improves Child Conduct and More
The following article was published in the January 2009 issue of OCD's newsletter Developments. To download a PDF of the issue, click here.

Seven years ago, researchers began investigating whether they could, in only a few sessions, promote more effective and positive parenting among at-risk families and, in turn, help prevent young children from developing problem behaviors later in life. What they didn’t anticipate was that important school readiness skills would also improve for many children in those families.

The intervention, known as the Family Check-Up, ad- dresses disrupted and unskilled family management practices in early childhood by motivating and helping parents to make constructive changes.

More than 730 families eligible for a national food supplement program in Pittsburgh, rural Virginia and a suburban Oregon community were offered the intervention beginning when their child or children were 2-years-old. The intervention is relatively brief with parents averaging about four in-home sessions with a therapist a year.

In recently published studies, researchers report that those parents made gains in positive parenting and their children showed a decrease in behavior problems compared to children in families who did not participate in the intervention. Researchers also report that a family’s participation promoted self-regulation and literacy skills among children aged 2 to 4 years.

"The beauty of this to me is that we are getting families who traditionally had been very hard to reach. We are getting them to start to connect with us and, despite all of their adversity, they are making the effort to do something about the trajectory of their children’s behavior before it gets out of control," said Daniel Shaw, PhD, Professor of Psychology at the University of Pittsburgh.

Dr. Shaw, Thomas Dishion, PhD, of the University of Oregon and several of their colleagues began investigating the use of the Family Check-Up to reduce child conduct problems in 2001.

Recently, human service officials in a few states and the nations of Australia and Sweden have expressed an interest in adapting the Family Check-Up as part of the family services they offer.

Parenting’s Key Role?

For the studies, researchers narrowed participation to families dealing with poverty and other serious risk factors. Families must be income-eligible for the federal Women, Infants and Children Nutrition program. Parents can’t have completed more than two years of college. They must have a child they believe has behavior problems. And they are screened for other deficits such as maternal depression, having become a parent while a teenager and a history of drug or alcohol abuse.

In addition to struggling with such circumstances, these families usually don’t have primary care physicians or a regular pediatrician for their children and they don’t typically seek help from mental health professionals.

Researchers designed the Family-Check Up as a brief intervention to strengthen these parents’ use of positive behavior support strategies during the early years of a child’s life.

Its focus on parenting is supported by substantial scientific evidence that suggests parenting practices are central to behavior and adjustment problems that develop in children. Studies have found, for example, that negative and neglectful parenting can predict problem behavior later in children’s lives. And harsh and punitive parenting has found to make it much more likely that children already at genetic risk of problem behaviors will develop them.

On the other hand, promoting appropriate parenting practices during early childhood has emerged as a solution to the development of problem behaviors.

Helping parents develop warm, trusting relationships with their young children, become more attentive and involved and to reinforce skill development in positive ways have all been found to help prevent later conduct problems. Studies suggest, for example, that when parent-child play and social contact is increased during the ages of 1 and 2 years children show fewer conduct problems at age 4.

Family Check-Up

The Family Check Up begins with a comprehensive assessment of family functioning, that includes observation of parenting practices, relationships, child characteristics and other factors related to the family, child and home environment. Families were randomly chosen to participate in the intervention and a non-intervention control group.

Those offered the intervention also initially receive a Get-To-Know-You visit during which parents explore their perceptions and concerns related to their family setting and children’s behavior. This visit is followed by a longer feed-back visit, at which time parent consultants share data obtained from the comprehensive assessment, focusing on the parent’s and family’s strengths and possible areas of change. Skills commonly emphad include using positive reinforcement to promote children’s prosocial behavior, and learning to anticipate and prepare for situations when behavior might become a problem, such as going to the grocery store or when a parent is preoccupied with making dinner.

“The idea is to motivate positive parent behavior,” said Dr. Shaw. “We try to channel most issues parents bring up into parenting and everything is framed around the child’s welfare. If we talk about the depression of the parent, instead of saying, ‘You’re depressed and should do something about it,’ we say, ‘You know, that could be affecting your child’s welfare.’ It’s all about the child.”

Families are offered the option to take part in additional interventions to address “red areas”—issues identified as needing improvement that they decide to work on. Their participation helps to link them to services they may need and provides them with a contact who they can call if they need help or advice.

The intervention, which is based on a health maintenance model, also provides for an annual check-up, which gives families an opportunity to address previously identified concerns they initially chose not to work on.

‘Terrible Twos’ A Concern

Behaviors associated with children around the age of two years are among the most common concerns of parents participating in the intervention. These include children not listening or minding their parents, oppositional behavior and aggression.

“Most of it is aggression toward siblings and not listening to parents, which is normative for that period,” Dr. Shaw said. “We know that a lot of kids will just grow out of it. We also know parental response can magnify the original problem, making it much worse than the initial complaint, so we want parents to get a handle on it.”

The most common identified concern families tend not to address in the first year is the issue of a parent’s depression. Instead, families often chose to address parental depression during subsequent annual check-ups.

Outcomes Show Promise

Researchers recruited the 731 families who agreed to participate in the Family Check-Up at WIC sites in Pittsburgh, Eugene, Ore. and Charlottesville, VA. Of those families, 90% were available for the first-year follow-up and 85% were still involved at the end of the second year when children were age 4.

Overall results suggest their decision to participate paid off. Parents improved their ability to provide positive behavior support at child ages 2 and 3 years. And problem behavior among children decreased at ages 2, 3 and 4 years. The percentage of children with high scores for problem behavior, for example, fell from more than 48% at age 2 years to less than 24% at age 4.

In a follow-up study, researchers reported that children in families who received the Family Check-Up also showed improved inhibitory control and improvement in language development from age 3 to 4, suggesting that the benefits children enjoy from improved positive parenting practices are not limited to reducing problem behavior.

The outcomes were seen among families who averaged only 3.7 sessions with a therapist during the first year. One of those sessions was devoted to assessment and observation and another was the feedback session. In other words, families averaged two or fewer additional intervention sessions to work on specific concerns.

The precise reasons for the outcomes are unclear. “In terms of the intervention, it seems to be loaded around parents learning to be more positive to their kids and learning to anticipate, which are skills that are fairly easy to teach,” Dr. Shaw said. He also said the feedback sessions, parents having contact with a therapist and their knowing someone is available to call, if needed, all likely played key roles in achieving the outcomes.

Another interesting finding is that there appears to be a dose-response – the number of sessions parents participate in does not predict better outcomes. In a recent, about-to- be-published study, researchers analyzed individual factors, such as single-parent status, maternal depression and poverty to determine whether the brief intervention only works well with families who are not as badly off as others. The data suggest it is just as effective for families facing extreme poverty and social risks as it is for families with less severe levels of risk.

Researchers also looked at cumulative risk, analyzing families with multiple stressors and those with fewer. They determined that the Family Check-Up works equally well for both.?“What these families are doing is doing the work themselves,” Dr. Shaw said. “They must be, given the small number of sessions. We don’t believe things just happen overnight and are sustained. So, they are finding some kind of meaning in these changes – that it makes sense to praise my child five times for every time I yell at him or to know not to give a 15-minute time out to a 3-year-old. Little hints like that are making their lives a little easier.”

TO LEARN MORE about the Family Check-Up and reported outcomes, see the following publications:

Dishion, T.J., Shaw, D., Connell, A., Gardner, F., Weaver, C., & Wilson, M. (2008). The Family Check-Up with high risk indigent families: Preventing problem behavior by increasing parents’ positive behavior support in early childhood. Child Development, 79 (5), 1395-1414.

Lunkenheimer, E. S., Dishion, T.J., Shaw, D., Connell, A., Gardner, F., Wilson, M., & Skuban, E.M. (2008). Collateral benefits of the Family Check-Up on early childhood school readiness: Indirect effects of parents’ positive behavior support. Developmental Psychology, 44 (6), 1737-1752.