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PARENTING
MATTERS
SUPPORTING PARENTS OF CHILDREN AGES 08
Committee on Supporting the Parents of Young Children
Vivian L. Gadsden, Morgan Ford, and Heather Breiner, Editors
Board on Children, Youth, and Families
Division of Behavioral and Social Sciences and Education
A Report of

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COMMITTEE ON SUPPORTING THE

PARENTS OF YOUNG CHILDREN
VIVIAN L. GADSDEN (Chair), School of Education, University of

Pennsylvania
CLARE ANDERSON, Chapin Hall, University of Chicago
OSCAR A. BARBARIN, III, Department of African American Studies,
University of Maryland, College Park
RICHARD P. BARTH, School of Social Work, University of Maryland,
Baltimore
WILLIAM R. BEARDSLEE, Department of Psychiatry, Boston Childrens
Hospital and Harvard Medical School
KIMBERLY BOLLER, Mathematica Policy Research, Princeton, New Jersey
NATASHA J. CABRERA, Department of Human Development and
Quantitative Methodology, University of Maryland, College Park
ERIC DEARING, Department of Counseling, Developmental, and
Educational Psychology, Boston College
GREG J. DUNCAN, School of Education, University of California, Irvine
NORMA FINKELSTEIN, Institute for Health and Recovery, Cambridge,
Massachusetts
ELENA FUENTES-AFFLICK, Department of Pediatrics, University of
California, San Francisco
IHEOMA U. IRUKA, Buffett Early Childhood Institute, University of
Nebraska
SAMUEL L. ODOM, Frank Porter Graham Child Development Institute,
University of North Carolina, Chapel Hill
BARBARA ROGOFF, Department of Psychology, University of
California, Santa Cruz
MARK A. SCHUSTER, Department of Pediatrics, Harvard Medical
School, and Department of Medicine, Boston Childrens Hospital
SELCUK R. SIRIN, Department of Applied Psychology, New York
University
KASISOMAYAJULA (VISH) VISWANATH, Department of Social and
Behavioral Sciences, Harvard School of Public Health, and Health
Communications Core, Dana-Farber/Harvard Cancer Center
MICHAEL S. WALD, School of Law, Stanford University
MORGAN A. FORD, Study Director

HEATHER BREINER, Associate Program Officer
SARAH TRACEY, Research Associate (until April 2016)
KELSEY GEISER, Research Assistant
STACEY SMIT, Senior Program Assistant

ANTHONY JANIFER, Program Assistant (until December 2015)

PAMELLA ATAYI, Administrative Assistant
BRIDGET KELLEY, Acting Director, Board on Children, Youth, and
Families (from July to September 2015)
KIMBER BOGARD, Director, Board on Children, Youth, and Families
(until July 2015)
NATACHA BLAIN, Director, Board on Children, Youth, and Families
(from November 2015)
KATHERINE J. GOLD, James C. Puffer /American Board of Family
Medicine Fellow
LISA ALSTON, Financial & Administrative Officer (starting July 2015)
FAYE HILLMAN, Financial Associate (until July 2015)
vi

BOARD ON CHILDREN, YOUTH, AND FAMILIES
ANGELA DIAZ (Chair), Departments of Pediatrics and Preventive

Medicine, Icahn School of Medicine at Mount Sinai
SHARI BARKIN, Monroe Carell Jr. Childrens Hospital, Vanderbilt
University
THOMAS F. BOAT, College of Medicine, University of Cincinnati
W. THOMAS BOYCE, Faculty of Medicine, University of British Columbia
DAVID A. BRENT, Western Psychiatric Institute and University of
Pittsburgh School of Medicine
DAVID V.B. BRITT, Retired CEO, Sesame Workshop
DEBBIE I. CHANG, Nemours Health and Prevention Services
PATRICK H. DELEON, F. Edward Hebert School of Medicine and the
Graduate School of Nursing Uniformed Services University of the
Health Sciences
ELENA FUENTES-AFFLICK, University of California, San Francisco,
and San Francisco General Hospital
EUGENE E. GARCIA, Mary Lou Fulton Teachers College, Arizona State
University
J. DAVID HAWKINS, School of Social Work, University of Washington
JEFFREY W. HUTCHINSON, Uniformed Services University of the
Health Sciences
JACQUELINE JONES, Foundation for Child Development, New York, NY
ANN S. MASTEN, Institute of Child Development, University of
Minnesota
VELMA MCBRIDE MURRY, Peabody College, Vanderbilt University
BRUCE S. MCEWEN, Harold and Margaret Milliken Hatch Laboratory
of Neuroendocrinology, The Rockefeller University
MARTIN J. SEPULVEDA, IBM Fellow (retired), Research Division, IBM
Corporation
TAHA E. TAHA, Bloomberg School of Public Health, Johns Hopkins
University
NATACHA BLAIN, Director, Board on Children, Youth, and Families
vii


Acknowledgments
The committee and project staff would like to express their sincere
gratitude to all of those who generously contributed their time and exper-
tise to inform the development of this report.
To begin, we would like to thank the sponsors of this study for their
guidance. Support for the committees work was provided by the Admin-
istration for Children and Families, the Bezos Family Foundation, the
Bill & Melinda Gates Foundation, the Centers for Disease Control and
Prevention, the David and Lucile Packard Foundation, the U.S. Depart-
ment of Education, the Foundation for Child Development, the Health
Resources and Services Administration, the Heising-Simons Foundation,
and the Substance Abuse and Mental Health Services Administration.
Many individuals volunteered significant time and effort to address and
educate the committee during our public sessions (see Appendix A) and our
interviews with parents. Their willingness to share their perspectives was
essential to the committees work. We express gratitude to those who pro-
vided support in identifying parents for the interviews and public session
in Irvine, California, including Sunnah Kim at the American Academy of
Pediatrics, Yolie Flores at The Campaign for Grade-Level Reading, Sandra
Gutierrez and Debbie Ignacio at Abriendo Puertas/Opening Doors, and
Michael Duncan at Native Dad Networks. We are grateful to Lucy Rivero
for providing interpretation services during the public session in Irvine. We
also thank the many stakeholders who offered input and shared informa-
tion and documentation with the committee over the course of the study,
including the Center for Law and Social Policy, the Center for the Study of
Social Policy, Futures Without Violence, the National Parenting Education
ix

x ACKNOWLEDGMENTS
Network, and ZERO TO THREE. In addition, we appreciate the generous

hospitality of the organizations and providers in Omaha, Nebraska, and
Washington, D.C., who opened their doors to provide us space to conduct
interviews with parents. We are also immensely grateful for the planning
assistance and logistical support for site visits provided to us by Lori Koker
at the Buffett Early Childhood Institute, University of Nebraska. Further-
more, we extend our appreciation to the many assistants who provided
scheduling, communication, and travel support for the committee members.
The committee also expresses its deep appreciation for the opportunity
to work with the dedicated members of the staff of the National Academies
of Sciences, Engineering, and Medicine on this important project. We are
thankful to the project staff: Morgan Ford, Heather Breiner, Sarah Tracey,
Kelsey Geiser, Stacey Smit, Anthony Janifer, and Katherine Gold. The com-
mittee is also thankful to Pamella Atayi, Faye Hillman, and Lisa Alston
for their assistance on this project. The committee gratefully acknowledges
Kimber Bogard and Bridget Kelly of the Board on Children, Youth, and
Families; Robert Hauser, executive director of the Division of Behavioral
and Social Sciences and Education; Mary Ellen OConnell, deputy executive
director of the Division of Behavioral and Social Sciences and Education;
and Clyde Behney, executive director of the Health and Medicine Division
for their leadership and the guidance they provided throughout this study.
The committee would like to thank staff of the Office of Reports and Com-
munication of the Division of Behavioral and Social Sciences and Education
for their assistance with the preparation of this report, including Eugenia
Grohman, Viola Horek, Patricia L. Morison, Kirsten Sampson-Snyder,
Douglas Sprunger, and Yvonne Wise. We also wish to thank the staff at the
Research Center for their research assistance. In addition, we thank the staff
of Kentlands Travel for their assistance with the travel needs of this project.
The committee is grateful to Lauren Tobias of Maven Messaging &
Communications for her work as a consultant for this study. We greatly
appreciate Jessica F. Harding, Joanne Nicholson, Karen Bierman, Kyla
Liggett-Creel, Lisa A. Gennetian, Pamella Morris, and Tumaini Coker
for their valuable commissioned work. We thank Rona Briere and Alisa
Decatur at Briere Associates, Inc., for the diligent editorial assistance they
provided in preparing this report.

Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with pro-
cedures approved by the National Academies of Sciences, Engineering, and
Medicine. The purpose of this independent review is to provide candid and
critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report: Anthony Biglan, Education and
Training, Oregon Research Institute, Eugene; Deborah Daro, Hall Center
for Children, University of Chicago; Julia Mendez, Department of Psychol-
ogy, University of North Carolina at Greensboro; Bennett A. Shaywitz,
Center for Dyslexia and Creativity, Yale University; Susan J. Spieker, Family
and Child Nursing and Barnard Center for Infant Mental Health and Devel-
opment, University of Washington; William H. Teale, Center for Literacy,
University of Illinois; Ross A. Thompson, Department of Psychology, Uni-
versity of California, Davis; Richard Wasserman, Department of Pediatrics,
University of Vermont College of Medicine.
Although the reviewers listed above provided many constructive com-
ments and suggestions, they were not asked to endorse the reports conclu-
sions or recommendations, nor did they see the final draft of the report
before its release. The review of this report was overseen by Nancy E. Adler,
Departments of Psychiatry and Pediatrics and Center for Health and Com-
munity, University of California, San Francisco, and Jeanne Brooks-Gunn,
xi

xii REVIEWERS
Teachers College and College of Physicians and Surgeons, Columbia Uni-

versity. Appointed by the Academies, they were responsible for making
certain that an independent examination of this report was carried out in
accordance with institutional procedures and that all review comments
were carefully considered. Responsibility for the final content of this report
rests entirely with the authoring committee and the institution.

Contents
SUMMARY 1
1 INTRODUCTION 15
Purpose of This Study, 17
What Is Parenting? 19
Study Context, 23
Study Approach, 29
Terminology and Study Parameters, 34
Guiding Principles, 35
Report Organization, 36
References, 37
2 PARENTING KNOWLEDGE, ATTITUDES, AND PRACTICES 45

Desired Outcomes for Children, 45
Parenting Knowledge, Attitudes, and Practices, 47
Parenting within Family Systems, 79
Summary, 80
References, 81
3 FEDERAL POLICIES AND INVESTMENTS SUPPORTING

PARENTS AND CHILDREN IN THE UNITED STATES 101
Public Health Successes, 104
Federal Budget Supporting Parents and Children, 106
Federal Policies and Investments Supporting Parents and
Children, 107
xiii

xiv CONTENTS
Summary, 119
References, 120
4 UNIVERSAL/PREVENTIVE AND WIDELY USED

INTERVENTIONS 125
Universal/Preventive Interventions, 125
Widely Used Interventions, 141
Use of Information and Communication Technologies to Support
Parenting, 172
Supporting Parenting: Income, Nutrition Assistance, Health Care,
and Housing Programs, 181
Parental and Family Leave Policies, 192
Summary, 199
References, 203
5 TARGETED INTERVENTIONS SUPPORTING PARENTS

OF CHILDREN WITH SPECIAL NEEDS, PARENTS FACING
SPECIAL ADVERSITIES, AND PARENTS INVOLVED WITH
CHILD WELFARE SERVICES 229
Parents of Children with Special Needs, 230
Parents Facing Special Adversities, 248
Families Involved with Child Welfare Services, 282
Summary, 290
References, 297
6 ELEMENTS OF EFFECTIVE PARENTING PROGRAMS

AND STRATEGIES FOR INCREASING PROGRAM
PARTICIPATION AND RETENTION 325
Elements of Effective Programs, 326
Additional Strategies for Increasing Program Participation and
Retention, 335
Summary, 341
References, 342
7 TOWARD A NATIONAL FRAMEWORK 351

Criteria to Consider in Developing a System for Parenting
Support, 352
Core Elements of a Framework, 357
Concluding Thoughts, 374
References, 375

CONTENTS xv
8 CONCLUSIONS AND RECOMMENDATIONS 381

Scaling Effective Interventions, 381
Communicating Evidence-based Parenting Information, 386
Addressing Gaps in the Research-to-Practice/Practice-to-Research
Pipeline, 387
Strengthening the Evidence on Strategies for Supporting Parents
with Special Needs, 389
Strengthening the Evidence on Fathers, 389
Strengthening the Evidence for Diverse Populations, 391
References, 392
APPENDIXES
A Public Session Agendas 395
B Clearinghouses Used to Identify Interventions with Evidence
of Effectiveness 401
C Table of Parenting Interventions 413
D Biographical Sketches of Committee Members 499


Boxes, Figures, and Tables
BOXES
1-1 A Mothers Story, 16
1-2 Statement of Task, 20
3-1 The Founding and Evolution of the Childrens Bureau: The First
Agency Focused Solely on Children and Families, 102
4-1 Nurse-Family Partnership (NFP), 146

4-2 Parents as Teachers (PAT), 146
4-3 Durham Connects, 147
4-4 Parenting in Older-Model Early Care and Education
Programs, 168
5-1 The Triple P-Positive Parenting Program, 240
6-1 A Fathers Story, 334
B-1 Previous National Registry of Evidence-based Programs and

Practices (NREPP) Criteria for Rating Programs, 403
B-2 Four Dimensions Used to Review Outcomes in the National
Registry of Evidence-based Programs and Practices (NREPP), 404
B-3 Basic Criteria for Inclusion in Blueprints Registry, 406
B-4 Specific Criteria for Each CEBC Classification System
Category, 410
xvii

xviii BOXES, FIGURES, AND TABLES
FIGURES
1-1 Human brain development: Rate of synapse formation by age, 24
1-2 Living arrangements of children under age 18 in the United
States, 1960-2015, 27
3-1 Share of federal budget outlays spent on children (ages 0-18),

2014, 107
3-2 Share of federal expenditures (in billions) on children (ages 0-18)
by program type, 2014, 108
4-1 Illustrative prenatal and early childhood home visiting logic

model, 144
4-2 Hypothesized benefits of parents engagement in childrens early
education for childrens achievement and school success, 169
5-1 Linkage among family-centered practices, early childhood

intervention practices, and child outcomes, 232
5-1-1 Schematic of the Triple P system of tiered levels of intervention
(in Box 5-1), 241
B-1 Diagram of how the final outcome rating is determined for the
National Registry of Evidence-based Programs and Practices, 405
B-2 Scientific Rating Scale for the California Evidence-Based
Clearinghouse for Child Welfare, 409
TABLES
3-1 Federal Expenditures on Children by Program, 2014 (in billions
of dollars), 109
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, 149
4-2 Computer and Internet Use among U.S. Households, 2013, 174
C-1 Evidence-Based Interventions That Support Parenting, 414

Summary
Decades of research have demonstrated that the parent-child dyad and

the environment of the familywhich includes all primary caregiversare
at the foundation of childrens well-being and healthy development. From
birth, children are learning and rely on parents and the other caregivers in
their lives to protect and care for them. The impact of parents may never
be greater than during the earliest years of life, when a childs brain is
rapidly developing and when nearly all of her or his experiences are created
and shaped by parents and the family environment. Parents help children
build and refine their knowledge and skills, charting a trajectory for their
health and well-being during childhood and beyond. The experience of
parenting also impacts parents themselves. For instance, parenting can
enrich and give focus to parents lives; generate stress or calm; and create
any number of emotions, including feelings of happiness, sadness, fulfill-
ment, and anger.
Parenting of young children today takes place in the context of signifi-
cant ongoing developments. These include a rapidly growing body of sci-
ence on early childhood that has provided a more nuanced understanding
of the critical periods in early childhood development and parenting. In
addition, while child poverty has increased in recent years, there have been
increases in funding for programs and services for families, such as early
childhood education, home visiting, and income support programs, which
have implications for the development of a framework for better supporting
parents of young children.
In addition, the demographic characteristics of the U.S. population are
changing rapidly. As of 2014, 25 percent of children ages 0-5 had at least

2 PARENTING MATTERS
one immigrant parent, compared with just under 14 percent in 1990. Re-
lated in part to immigration, the racial and ethnic diversity of families has
increased over the past several decades, a trend that is anticipated to con-
tinue. For example, between 2000 and 2010, the percentage of Americans
identifying as black, Hispanic, Asian, or other increased from 15 percent
to 36 percent, and the percentage of children under age 10 of Hispanic
ethnicity (of any race) grew from about 19 percent to 25 percent.
There also is greater diversity in family structure as a result of increases
in divorce, cohabitation, new types of parental relationships (e.g., same-sex
parents), and involvement of grandparents and other relatives in the rais-
ing of young children. Between 1960 and 2015, the percentage of children
and youth under age 18 who lived with two married parents (biological,
nonbiological, or adoptive) decreased from approximately 85 percent to
65 percent. In 2014, 7 percent of children lived in households headed by
grandparents, compared with 3 percent in 1970.
Finally, parenting is increasingly being shaped by technology and in-
creased access to information about parenting, some of which is not based
in evidence. All of the above changes have implications for how best to
support the parents and other caregivers of young children.
It is against this backdrop that in fall 2014 multiple federal agencies
and private foundations requested that the National Academies of Sciences,
Engineering, and Medicine form the Committee on Supporting Parents of
Young Children to assess the research on parenting and strategies for sup-
porting parenting in the United States. The committees major tasks were
to identify parenting knowledge, attitudes, and practices associated with
positive developmental outcomes in children ages 0-8; universal/preventive
and targeted strategies used in a variety of settings that have been effective
with parents of young children and that support the identified knowledge,
attitudes, and practices; and barriers to and facilitators for parents use of
practices that lead to healthy child outcomes as well as their participation
in effective programs and services. Based on this assessment, the committee
was asked to make recommendations directed at an array of stakeholders,
for promoting the wide-scale adoption of effective programs and services
for parents and on areas that warrant further research to inform policy and
practice. The resulting report would serve as a roadmap for the future of
parenting policy, research, and practice in the United States.
PARENTING KNOWLEDGE, ATTITUDES, AND PRACTICES

Research reviewed by the committee revealed that certain areas of
knowledge and parenting practices are associated with childrens favor-
able developmental outcomes, although there are some limitations to this
research.

SUMMARY 3
In the area of parenting knowledge, the extant research suggests that

parental knowledge of child development is positively associated with
quality parent-child interactions and the likelihood of parents engagement
in practices that promote their childrens healthy development. Research
also indicates that parents with knowledge of evidence-based parenting
practices, especially those related to promoting childrens physical health
and safety (e.g., injury prevention, how to sooth a crying infant), are more
likely than those without such knowledge to engage in those practices.
Parents attitudes about the roles of parents and others in the raising
of young children, as well as about specific practices (e.g., breastfeeding,
the role of parents in childrens education), contribute to some variation in
practices and in the uptake of services for families among individuals and
subpopulations. The committee concluded that empirical studies on parent-
ing attitudes do not allow for the identification of core parenting attitudes
consistently associated with positive child outcomes. However, the avail-
able evidence points to a need for taking parents attitudes and beliefs into
consideration in the design and implementation of programs and services
to ensure that they are sensitive to parents needs and to extend their reach.
The committee identified a number of parenting practices associated
with positive child outcomes in the areas of physical health and safety,
emotional and behavioral competence, social competence, and cognitive
competence:
contingent responsiveness (serve and return)adult behavior that

occurs immediately after a childs behavior and that is related to the
childs focus of attention, such as a parent smiling back at a child;
showing warmth and sensitivity;
routines and reduced household chaos;
shared book reading and talking to children;
practices that promote childrens health and safetyin particular
receipt of prenatal care, breastfeeding, vaccination, ensuring chil-
drens adequate nutrition and physical activity, monitoring, and
household/vehicle safety; and
use of appropriate (less harsh) discipline.
Much of the research on parenting knowledge, attitudes, and prac-

tices is correlational, making it difficult to draw firm conclusions about
causation. In addition, most studies are focused on mothers, with a lack of
research on fathers and other caregivers (e.g., grandparents).
Although studies suggest some variation in parenting knowledge, atti
tudes, and practices among racial/ethnic, cultural, and other subgroups of
parents, more attention is needed as to whether and how these differences
matter for child outcomes.

4 PARENTING MATTERS
INTERVENTIONS TO SUPPORT PARENTS AND PARENTING
Scaling Effective Interventions

The committee identified a number of interventions that promote the
parenting practices described above. These include well-identified formal
sources of parenting support for many parents, such as well-child care,
center-based child care (Head Start and Early Head Start), and home visit-
ing programs that are largely preventive in their approach. Other inter-
ventions are targeted to specific populations of parents, such as parents
of children with special needs (e.g., those with developmental disabilities)
and parents facing adversities, such as mental illness, substance abuse, and
intimate partner violence. Federal efforts also support parents through in-
come assistance, nutrition assistance (e.g., the Special Supplemental Nutri-
tion Program for Women, Infants, and Children [WIC]), health care, and
housing programs. These programs aid large numbers of parents, primarily
those with low incomes, in ensuring their own and their childrens physical
health and safety.
Yet many families that could benefit from these interventions neither
seek out nor are referred to them. To better support parents and children,
then, improved referral mechanisms are needed. Millions of parents interact
with health care (e.g., well-child and mental and behavioral health care),
education (e.g., early care and education and formal prekindergarten to
grade 3), and other community services each year. Along with improve-
ments in workforce preparation (see Recommendations 3 and 4 below),
better leveraging the services with which many parents already have ongo-
ing connections as points of intervention and referral would help improve
the reach of effective strategies.
Recommendation 1: The U.S. Department of Health and Human Ser-

vices, the U.S. Department of Education, state and local agencies, and
community-based organizations responsible for the implementation of
services that reach large numbers of families (e.g., health care, early care
and education, community programs) should form a working group to
identify points in the delivery of these services at which evidence-based
strategies for supporting parents can be implemented and referral of
parents to needed resources can be enhanced. Based on its findings, the
working group should issue guidance to service delivery organizations
on increasing parents access to evidence-based interventions.
Research on how to bring effective parenting programs to scale is lim-

ited. Although a number of programs are effective in supporting parents,
their potential for helping large numbers of families often depends on fac-

SUMMARY 5
tors specific to the families served and to the organizations and communi-
ties in which they will be implemented. Additional evidence is needed to
inform the creation of a system for efficiently disseminating evidence-based
programs and services to the field and for ensuring that communities learn
about them, are able to assess their fit with community needs, develop
needed adaptations, and monitor fidelity and progress toward targeted
outcomes. Findings from this research could be used in an ongoing way
to inform the integration of evidence-based interventions into widely used
service platforms.
Recommendation 2:1 The U.S. Department of Health and Human

Services, the Institute of Education Sciences, the Patient-Centered Out-
comes Research Institute, and private philanthropies should fund re-
search focused on developing guidance for policy makers and program
administrators and managers on how to scale effective parenting pro-
grams as widely and rapidly as possible. This research should take into
account organization-, program-, and system-level factors, as well as
quality improvement. Supports for scaling efforts developed through
this research might include cost tools, measurement toolkits, and imple-
mentation guidelines.
Enhancing Workforce Competence in Delivering

Evidence-Based Parenting Interventions
A professional workforce with knowledge about and competencies for
implementing evidence-based interventions to support parents is essential
to the successful scale-up of effective approaches. Evidence-based parent-
ing interventions often are not available as part of either routine services
for parents or services not designed specifically for parents but with the
potential to benefit many parents, such as treatments for mental illness and
substance abuse. One reason for this is that providers of these services often
lack knowledge and competencies in evidence-based parenting interven-
tions. Graduate training for providers of childrens services and behavioral
health care (e.g., in schools of social work and nursing) currently includes
limited or no coursework on evidence-based parenting programs or their
core elements. A viable way to increase the availability of evidence-based
parenting interventions is to build on the commonality of specific and non-
specific elements across interventions.
1This recommendation, along with Recommendations 4, 6, and 10 were modified following
the transmittal of the report to the study sponsors. In particular, the U.S. Department of Health
and Human Services (HHS) was inserted to replace the names of specific agencies within HHS
to allow HHS to decide the most appropriate agencies to carry out the recommendations.

6 PARENTING MATTERS

vices should continue to promote the use of evidence-based parent-
ing interventions. In so doing, it should support research designed
to further operationalize the common elements of effective parenting
interventions and to comparethe benefits of interventions based on
the common elements of effective parenting programs with the specific
evidence-based programs from which the elements originated. These
efforts also should encompass (1) development of a common termi-
nology for describing common elements and creation and testing of
corresponding training materials; (2) development of an open-source
curriculum, fidelity-checking strategies, and sustainability strategies for
use in educating health and human service professionals in the d elivery
of evidence-based parenting interventions; and (3) creation of a vari-
ety of incentives and training programs to ensure knowledge of effec-
tive parenting interventions among professional groups working with
young children and their families.
Enhancing Workforce Knowledge and Competence in Parent Engagement

Parents engagement in young childrens learning is associated with im-
provements in childrens literacy, behavior, and socioemotional well-being.
Parent engagement is a process that can be facilitated by provider skills in
communication and joint decision making with diverse families about their
childrens education, but programs designed to prepare individuals to work
with young children do not always include evidence-informed strategies for
creating successful partnerships with families. Despite growing recognition
that partnerships with families contribute to the success of early childhood
programs and schools in preparing children for academic success, as well
as an emphasis on family engagement in statutes and policies, programs de-
signed to prepare teachers and providers often do not include professional
development related to working with parents.

vices and the U.S. Department of Education should convene a group of
experts in teaching and research and representatives of relevant practice
organizations and research associations to review and improve profes-
sional development for providers who work with families of young
children across sectors (e.g., education, child welfare, health). Profes-
sional development should be evaluated as to whether its core elements
include best practices in engagement of and joint decision making
with parents, across diverse family structures with other parental care
givers, as well as evidence-informed programs that support parents.
The expert group should identify appropriate courses to address issues

SUMMARY 7
of parents and develop appropriate course plans and frameworks for

professional development where they are lacking. Courses and course-
work on parent engagement for educators of young children should
be aligned with the knowledge and competencies outlined in the 2015
Institute of Medicine and National Research Council report Transform-
ing the Workforce for Children Birth through Age 8.
Developing and Disseminating Best Practices in Parent Engagement

Studies have documented the effectiveness of joint decision making
(parents as partners) and other approaches to parent-teacher collaboration
in education. Accordingly, the Elementary and Secondary Education Act
requires that school districts develop and implement parent engagement
policies designed to bolster student outcomes. Yet despite the availability of
evidence-based approaches for increasing parent engagement in childrens
learning and thereby improving child development outcomes, limited offi-
cial guidance is available on how to do so. In addition to obstacles related
to workforce preparation, the implementation and sustained use of best
practices in parent engagement are limited by a dearth of official guidance
at the local, state, and federal levels, as well as a lack of attention to how
families culture and language may moderate the effectiveness of school
districts engagement plans.

vices and the U.S. Department of Education should convene experts in
parent engagement to create a toolbox of evidence-informed engage-
ment and joint decision-making models, programs, and practices for
implementation in early education settings. The U.S. Department of
Health and Human Services and the U.S. Department of Education
should disseminate this toolbox to support state and district adher-
ence to requirements for parent engagement such as those described
in the Elementary and Secondary Education Act, as well as to support
the effective use of parenting interventions by health, behavioral health,
and community programs with which parents and their children often
have sustained and important connections. Toolbox development and
disseminationefforts should include parents from diverse language
and cultural backgrounds.
Elements of Effective Interventions

The committee identified features and practices of parenting interven-
tions that appear to influence success in engaging parents and increasing
their use of effective parenting practices and in promoting parents par-

8 PARENTING MATTERS
ticipation and retention in programs and services. No single approach will

yield the same positive results for all parents; rather, the diversity of parent
beliefs, needs, and resources requires a menu of approaches. Nonetheless,
the committee found a number of elements to be successful across a wide
range of programs and services for parents:
viewing parents as equal partners in determining the types of ser-

vices that would most benefit them and their children;
tailoring interventions to meet the specific needs of families;
integrating and collaborating in services for families with multiple
service needs;
creating opportunities for parents to receive support from peers to
encourage engagement, reduce stigma, and increase the sense of
connection to other parents with similar circumstances;
addressing trauma, which affects a high percentage of individuals
in some communities and can interfere with parenting and healthy
child development;
making programs culturally relevant to improve their effectiveness
and participation across diverse families; and
enhancing efforts to involve fathers, who are underrepresented in
parenting research.
On the effectiveness of monetary incentives in improving parents par-

ticipation and retention in programs and services, the committee found
mixed results. More recent research suggests that while monetary incen-
tives may enhance parents initial interest in parenting programs, they do
not necessarily improve attendance over time. This outcome may reflect the
fact that monetary incentives do little to address some of the most common
barriers to participation cited by parents, such as irregular work sched-
ules and a lack of transportation or child care. Preliminary experimental
studies on the use of conditional cash transfers to incentivize low-income
families engagement in behaviors that can enhance their well-being show
an association between receipt of cash transfers and improvements in some
economic outcomes such as reduced poverty, food insecurity, and housing
hardships and increased employment. However, further work is needed to
confirm these findings.
Some studies show that interventions incorporating the use of moti-
vational techniques (e.g., motivational interviewing) in combination with
other supportive strategies improve attendance and retention in programs
and services for some individuals. Yet, there is a lack of research focused
specifically on parents and identifying for which populations of parents
these techniques are most effective.

SUMMARY 9
COMMUNICATING EVIDENCE-BASED
PARENTING INFORMATION
As noted above, parents with knowledge of child development com-
pared with parents without such knowledge have higher-quality interac-
tions with their young children and are more likely to engage in parenting
practices associated with childrens healthy development. Moreover, parents
with knowledge of parenting practices that lead to healthy outcomes in
children, particularly practices that facilitate childrens physical health and
safety, have been found to be more likely to implement those practices.
Although simply knowing about parenting practices that promote healthy
child development or the benefits of a particular parenting practice does
not necessarily translate into the use of such practices, awareness is foun-
dational for behavior that supports children.
When designed and executed carefully in accordance with rigorous sci-
entific evidence, public health campaigns are a potentially effective low-cost
way to reach large and heterogeneous groups of parents. Moreover, infor-
mation and communication technologies now offer promising opportunities
to tailor information to the needs of parents based on their background
and social circumstances. Several important ongoing efforts by the federal
government and private organizations (e.g., the Centers for Disease Control
and Prevention, ZERO TO THREE) communicate information to parents
on developmental milestones and parenting practices grounded in evidence.
Yet inequalities exist in how such information is generated, manipulated,
and distributed among social groups, as well as at the individual level in
the ability to access and take advantage of the information. Parenting in-
formation that is delivered via the Internet, for example, is more difficult
to access for some parents, including linguistic minorities, families in rural
areas, and parents with less education.

vices and the U.S. Department of Education, working with state and
local departments of health and education and private partners, in-
cluding businesses and employers, should lead an effort to expand and
improve the communication to parents of up-to-date information on
childrens developmental milestones and parenting practices associated
with healthy child development. This effort should place particular
emphasis on communication to subpopulations that are often under-
served, such as immigrant families; linguistic, racial, and ethnic minori-
ties; families in rural areas; parents of low socioeconomic status; and
fathers. Given the potential of public health campaigns to promote
positive parenting practices, this effort should draw on the latest state
of the science of such campaigns. The effectiveness of communication

10 PARENTING MATTERS
efforts also should be evaluated to enhance their success and to inform

future efforts.
ADDRESSING GAPS IN RESEARCH

The committee identified a number of interventions that show promise
in supporting parenting knowledge, attitudes, and practices for specific
groups of parents and children. Further research is needed to understand
whether and how these interventions should be scaled up to serve all par-
ents who would benefit from them.
To best guide policy and practice, it is important that such research
focus on major gaps in current knowledge and that it use those method-
ologies most likely to produce evidence that can inform policy or practice.
These gaps include interventions previously subjected to rigorous evalua-
tion but not tested in diverse populations; interventions that may have been
limited by their mother-only focus; and interventions focused on parents
needing services for personal issues, such as mental illness.
More research also is needed on cases in which parenting interventions
have been layered onto another intervention and (1) their unique benefit
(separate from that of the primary intervention) has not been adequately
assessed, or (2) the parenting component was found to have no impact.
Examples of parenting interventions that fall into one or both of these
categories are enhanced anticipatory guidance, which can be provided as
part of well-child care; parenting interventions delivered in conjunction
with treatment for parents who have mental illness or substance abuse or
are experiencing interpersonal violence; parenting interventions delivered
using new information and communication technologies; and parenting
components in Head Start, Early Head Start, and WIC. Although evalua-
tion of these layered parenting interventions has been limited, many of them
have shown promising initial findings and are supported by sizable public
and private investment; thus it is important for both research and practice
to optimize opportunities to learn from these investments and build on this
existing work. Each of the above examples offers multiple opportunities
for researchers to learn from practitioners and for practitioners to work
with researchers to identify possibilities for improving both research and
interventions and engaging parents.
To generate research that would produce policy-relevant findings, the
federal government could sponsor a relatively small number of studies
involving large and diverse samples. Most likely to produce findings that
would be cumulative and translatable into policy and practice would be a
research agenda based on selected parenting behaviors clearly related to
child outcomes, entailing studies that would utilize the same small number
of measures and instruments. This research also could focus on evaluating

SUMMARY 11
the cost of programs and avenues through which evidence-based programs

could be funded.
The evidence-based process used by HHS to design, fund, and im-
plement the Maternal, Infant, and Early Childhood Home Visitation
(MIECHV) Program could serve as a model for future research and practice
aimed at improving programs designed to support parents and parenting
knowledge, attitudes, and practices associated with positive child outcomes.
MIECHV began with a systematic review of the evidence, followed by a
state competition for funding that required the use of a consistent small set
of performance measures, rigorous local evaluation, and participation in
a national evaluation. The Health Resources and Services Administration
also has implemented collaborative improvement and innovation networks
to facilitate ongoing learning and improve models for supporting parenting
knowledge, attitudes, and practices in the areas of home visiting and infant
mortality prevention that could inform the refinement and implementation
of other types of parenting supports.
Recommendation 7: The secretary of the U.S. Department of Health

and Human Services and the secretary of the U.S. Department of Edu-
cation should launch a national effort to address major gaps in the
research-to-practice/practice-to-research pipeline related to parenting.
This effort should be based on an assessment aimed at identifying the
gaps in knowledge that if filled would most advance parenting-related
policy and practice. The effort should include (1) systematic review of
the evidence for the selected areas; (2) further development and testing
of the most promising interventions; (3) research on newly developed
and existing interventions conducted through collaborative improve-
ment and innovation networks; and (4) rigorous efficacy, effectiveness,
and implementation studies of promising programs and policies. In
funding decisions, priority should be given to examining interventions
delivered in the context of services that reach large numbers of families,
such as prenatal care, well-child care, Head Start and Early Head Start,
and parent engagement in the early grades.
Three important areas of need for additional research are described in

Recommendations 8, 9, and 10 below, all of which address populations of
parents on which relatively little evidence-based research has been conducted
and for which few evidence-based interventions have been developed.
Strengthening the Evidence on Parents with Special Needs

Many parents in the United States cope with personal challenges, such
as mental illness, substance abuse, or intimate partner violence, as well as

the associated stigma, that can reduce their ability to use effective parent-
ing practices and their access to and participation in evidence-based par-
enting interventions. Relatively little is known about how best to support
parents and parenting practices grounded in evidence for families with
such special needs. Research is needed to realize the potential of available
interventions that show promise for parents with special needs, as well as
to develop new interventions that reflect emerging knowledge of how to
support these parents. The strengths of evidenced-based training in parent-
ing skills offer a foundation for improving existing and developing new
interventions that can serve greater numbers of families with special needs,
including by providing a setting of trust in which parents can reveal their
needs.

vices and the U.S. Department of Education, in coordination with pri-
vate philanthropies, should fund research aimed at evaluating existing
interventions that have shown promise and designing and evaluating
new interventions for parents with special needs. The design of new
interventions should be informed by elements of successful programs,
which include treating parents as equal partners, tailoring interventions
to meet families needs, making programs culturally relevant, ensuring
service integration and collaboration for families with multiple needs,
providing opportunities for peer support, addressing trauma, and tar-
geting both mothers and fathers. Funders should incentivize the use of
state and local data to support this research.
Strengthening the Evidence on Fathers

Childrens development is shaped by the independent and combined
effects of myriad influences, especially their mothers and fathers and the
interactions between them. During the early years, parents are the most
proximaland most importantinfluence on childrens development.
Substantial evidence shows that young children have optimal develop-
mental outcomes when they experience nurturing relationships with both
fathers and mothers. Research also demonstrates that children benefit when
the parents who are living in the same household are supportive of each
other and are generally consistent in their expectations for the child and in
their parenting behaviors. Further, there is evidence that when parents live
apart, children generally benefit if they have supportive relationships with
each parent, at least in those cases in which the parents do not have negative
relationships with each other. In contrast, children are placed at risk when
their parents experience conflict or when they have very different expecta-
tions for the child, regardless of whether the parents are living together or

SUMMARY 13
apart. Yet despite the importance of the father-child relationship, fathers

continue to be underrepresented in research on parenting and parenting
support. Moreover, very few interventions aimed at improving mother-child
relationships also target father-child or mother-father-child relationships,
whether the parents are living together or apart. When parents are living
apart, fatherhood programs typically focus on building fathers economic
capacity to parent, such as through employment or counseling, rather than
on fostering father-child relationships that can promote development.
More research is needed on how to design parenting programs so
they better engage fathers and enhance the parenting of both parents. Few
studies have evaluated how the dyadic and reciprocal interactions between
fathers and mothers and between fathers and their children affect childrens
development. Research is needed to identify promising interventions for
fathers and mothers both in their individual relationships with their chil-
dren and in their co-parenting role.
Research also is needed to understand how nonresident fathers can
establish long-lasting warm and nurturing relationships with their children.
Although steps have been taken to increase evidence-based and empirically
rigorous evaluations of fathering programs serving noncustodial fathers
(e.g., the federally funded Fatherhood Research and Practice Network),
these studies are still in their early stages and may be minimally focused on
changes in child outcomes.

vices, in coordination with the U.S. Department of Education and
other relevant federal agencies, private philanthropies and foundations,
researchers, and research associations focused on children and families,
should increase support for studies that can inform the development
and improvement of parenting interventions focused on building par-
ents capacity to parent both individually and together. Such studies
should be designed to identify strategies that can improve fathers
knowledge and use of parenting practices associated with positive child
outcomes, and should examine the unique and combined effects of
individual and co-parenting practices, with special attention to build-
ing strong relationships between parents and within diverse parenting
relationships. The research should focus not only on adult but also on
child outcomes, and should be designed to shed light on the specific
ways in which greater investments in co-parenting can lead to better
outcomes for children. Existing efforts to provide parenting support for
both mothers and fathers should be reinforced and expanded in such
programs as the Maternal, Infant, and Early Childhood Home Visita-
tion Program, Head Start, and Early Head Start.

Strengthening the Evidence on Diverse Populations

The U.S. population of young children and their parents is demo-
graphically, culturally, linguistically, and socially diverse. As noted above,
although research suggests that some parenting knowledge, attitudes, and
practices vary across groups, little is known about whether and how these
differences matter for childrens development. Moreover, relatively little is
known about how engagement with, acceptance of, retention in, and the
efficacy of interventions for parents vary across culturally and linguistically
diverse subgroups. Finally, despite increasing diversity in family struc-
ture, data are lacking on how parenting, engagement in interventions and
services, and efficacy of services may vary for diverse family forms, kin-
ship providers (e.g., grandparents), stepparents, and other adults assuming
parental roles (e.g., foster or adoptive parents). Filling these gaps would
improve the ability of evidence-based programs and policies to support the
needs of the range of families and children while addressing the needs of
parents from historically marginalized and underrepresented populations.
Recommendation 10: The U.S. Department of Health and Human

Services and the U.S. Department of Education should launch a multi
pronged effort to support basic research on parenting and applied
research on parenting interventions across diverse populations and
family forms. Basic research should include the identification of (1) key
constructs and measures related to successful parenting among different
populations; (2) important gaps in knowledge of how parenting prac-
tices and parent-child interactions affect child outcomes in culturally,
ethnically, and socially diverse groups; and (3) constraints that produce
disparities in access to and utilization of resources that support parent-
ing across groups and contribute to negative outcomes for parents and
children. Applied intervention research should include the formation of
a collaborative improvement and innovation network to develop new
and adapt existing interventions for diverse groups, and support for
rigorous efficacy, effectiveness, and implementation studies of the most
promising programs and policies conducted in a manner consistent
with Recommendation 7 above.

Introduction
Parents are among the most important people in the lives of young chil-
dren.1 From birth, children are learning and rely on mothers and fathers, as
well as other caregivers acting in the parenting role, to protect and care for
them and to chart a trajectory that promotes their overall well-being. While
parents generally are filled with anticipation about their childrens unfold-
ing personalities, many also lack knowledge about how best to provide for
them. Becoming a parent is usually a welcomed event, but in some cases,
parents lives are fraught with problems and uncertainty regarding their
ability to ensure their childs physical, emotional, or economic well-being.
At the same time, this study was fundamentally informed by recogni-
tion that the task of ensuring childrens healthy development does not rest
solely with parents or families. It lies as well with governments and organi-
zations at the local/community, state, and national levels that provide pro-
grams and services to support parents and families. Society benefits socially
and economically from providing current and future generations of parents
with the support they need to raise healthy and thriving children (Karoly et
al., 2005; Lee et al., 2015). In short, when parents and other caregivers are
able to support young children, childrens lives are enriched, and society is
advantaged by their contributions.
To ensure positive experiences for their children, parents draw on the
resources of which they are aware or that are at their immediate disposal.
1In this report, parents refers to the primary caregivers of young children in the home.
In addition to biological and adoptive parents, main caregivers may include kinship (e.g.,
grandparents), foster, and other types of caregivers.
15

However, these resources may vary in number, availability, and quality

at best, and at worst may be offered sporadically or not at all. Resources
may be close at hand (e.g., family members), or they may be remote (e.g.,
government programs). They may be too expensive to access, or they may
be substantively inadequate. Whether located in early childhood programs,
school-based classrooms, well-child clinics, or family networks, support for
parents of young children is critical to enhancing healthy early childhood
experiences, promoting positive outcomes for children, and helping parents
build strong relationships with their children (see Box 1-1).
The parent-child relationship that the parent described in Box 1-1
sought and continues to work toward is central to childrens growth and
BOX 1-1
A Mothers Story
A mother of a second grader shared her story with the committee during one
of its open sessions. She presented a poignant picture of the isolation and fear
she experienced during the first few years of her sons life. At the time of his birth
and afterward, she had little knowledge of the community resources available to
support her in her parenting role. In overcoming the challenges she faced over the
next several years, she came to understand that parents need shared knowledge,
access to resources and services, and strong community bonds. She believes
these are essential components of a complex system of governmental and non-
governmental services, such as child care, that support parents. She explained,
I was able to see my problems as connected to larger structural problems, as
information about the complex system of services available for parents was not
easily accessible.
This parents story is one of persistence and resilience, which makes her
both similar to and different from many other parents experiencing the same prob-
lems. She found information through a program from which she learned the cost
of child care for her son, was introduced to the supports and services available to
her as a low-income parent, and was assisted in navigating the various services
and programs. Her participation in a number of services required appointments
in different areas of town. Without convenient transportation, she spent much
of her time commuting on the bus with her son. The stressors in her life were
compounded when her son began exhibiting symptoms of asthma, which made
her dread returning home to be with her son. Depressed, lonely, and afraid, she
faced struggles every single day, dealing with these challenges on top of just try-
ing to make a living while trying to build a strong relationship with her child. This
parents story illustrates how many parents who are uncertain about their ability
to care for their children face multiple issues in having to use different services,
all with distinctive points of entry.
SOURCE: Open session presentation (2015). See Appendix A for additional information.

INTRODUCTION 17
developmentto their social-emotional and cognitive functioning, school

success, and mental and physical health. Experiences during early child-
hood affect childrens well-being over the course of their lives. The impact
of parents may never be greater than during the earliest years of life, when
childrens brains are developing rapidly and when nearly all of their experi-
ences are created and shaped by their parents and by the positive or difficult
circumstances in which the parents find themselves. Parents play a signifi-
cant role in helping children build and refine their knowledge and skills,
as well as their learning expectations, beliefs, goals, and coping strategies.
Parents introduce children to the social world where they develop under-
standings of themselves and their place and value in society, understandings
that influence their choices and experiences over the life course.
PURPOSE OF THIS STUDY

Over the past several decades, researchers have identified parent-
ing-related knowledge, attitudes, and practices that are associated with
improved developmental outcomes for children and around which parent-
ing-related programs, policies, and messaging initiatives can be designed.
However, consensus is lacking on the elements of parenting that are most
important to promoting child well-being, and what is known about effec-
tive parenting has not always been adequately integrated across different
service sectors to give all parents the information and support they need.
Moreover, knowledge about effective parenting has not been effectively
incorporated into policy, which has resulted in a lack of coordinated and
targeted efforts aimed at supporting parents.
Several challenges to the implementation of effective parenting prac-
tices exist as well. One concerns the scope and complexity of hardships that
influence parents use of knowledge, about effective parenting, including
their ability to translate that knowledge into effective parenting practices
and their access to and participation in evidence-based parenting-related
programs and services. Many families in the United States are affected by
such hardships, which include poverty, parental mental illness and sub-
stance use, and violence in the home. A second challenge is inadequate
attention to identifying effective strategies for engaging and utilizing the
strengths of fathers, discussed later in this chapter and elsewhere in this
report. Even more limited is the understanding of how mothers, fathers, and
other caregivers together promote their childrens development and analysis
of the effects of fathers parenting on child outcomes. A third challenge is
limited knowledge of exactly how culture and the direct effects of racial
discrimination influence childrearing beliefs and practices or childrens
development (National Research Council and Institute of Medicine, 2000).
Despite acknowledgment of and attention to the importance of culture in

the field of developmental science, few studies have explored differences in

parenting among demographic communities that vary in race and ethnicity,
culture, and immigrant experience, among other factors, and the implica-
tions for childrens development.
In addition, the issue of poverty persists, with low-income work-
ing families being particularly vulnerable to policy and economic shifts.
Although these families have benefited in recent years from the expansion of
programs and policies aimed at supporting them (discussed further b elow),
the number of children living in deep poverty has increased (Sherman and
Trisi, 2014).2 Moreover, the portrait of Americas parents and children
has changed over the past 50 years as a result of shifts in the numbers
and origins of immigrants to the United States and in the nations racial,
ethnic, and cultural composition (Child Trends Databank, 2015b; Migra-
tion Policy Institute, 2016). Family structure also has grown increasingly
diverse across class, race, and ethnicity, with fewer children now being
raised in households with two married parents; more living with same-sex
parents; and more living with kinship caregivers, such as grandparents, and
in other household arrangements (Child Trends Databank, 2015b). Lastly,
parenting increasingly is being shaped by technology and greater access to
information about parenting, some of which is not based in evidence and
much of which is only now being studied closely.
The above changes in the nations demographic, economic, and tech-
nological landscape, discussed in greater detail below, have created new
opportunities and challenges with respect to supporting parents of young
children. Indeed, funding has increased for some programs designed to
support children and families. At the state and federal levels, policy makers
recently have funded new initiatives aimed at expanding early childhood
education (Barnett et al., 2015). Over the past several years, the number
of states offering some form of publicly funded prekindergarten program
has risen to 39, and after slight dips during the Great Recession of 2008,
within-state funding of these programs has been increasing (Barnett et al.,
2015). Furthermore, the 2016 federal budget allocates about $750 mil-
lion for state-based preschool development grants focused on improved
access and better quality of care and an additional $1 billion for Head
Start programs (U.S. Department of Education, 2015; U.S. Department of
Health and Human Services, 2015). The federal budget also includes addi-
tional funding for the expansion of early childhood home visiting programs
($15 billion over the next 10 years) and increased access to child care for
low-income working families ($28 billion over 10 years) (U.S. Department
2Deep poverty is defined as household income that is 50 percent or more below the federal
poverty level (FPL). In 2015, the FPL for a four-person household was $24,250 (Office of the
Assistant Secretary for Planning and Evaluation, 2015).

INTRODUCTION 19
of Health and Human Services, 2015). Low-income children and families

have been aided as well in recent years by increased economic support from
government in the form of both cash benefits (e.g., the Earned Income Tax
Credit and the Child Tax Credit) and noncash benefits (e.g., Temporary
Assistance for Needy Families and the Supplemental Nutrition Assistance
Program), and millions of children and their families have moved out of
poverty as a result (Sherman and Trisi, 2014).
It is against this backdrop of need and opportunity that the Adminis-
tration for Children and Families, the Bezos Family Foundation, the Bill &
Melinda Gates Foundation, the Centers for Disease Control and Preven-
tion, the D avid and Lucile Packard Foundation, the Health Resources and
Services Administration, the U.S. Department of Education, the Foundation
for Child Development, the Heising-Simons Foundation, and the Substance
Abuse and Mental Health Services Administration (SAMHSA) requested
that the National Academies of Sciences, Engineering, and Medicine em-
panel a committee to conduct a study to examine the state of the science
with respect to parenting knowledge, attitudes, and practices tied to posi-
tive parent-child interactions and child outcomes and strategies for sup-
porting them among parents of young children ages 0-8. The purpose of
this study was to provide a roadmap for the future of parenting and family
support policies, practices, and research in the United States.
The statement of task for the Committee on Supporting the Parents of
Young Children is presented in Box 1-2. The committee was tasked with
describing barriers to and facilitators for strengthening parenting capacity
and parents participation and retention in salient programs and services.
The committee was asked to assess the evidence and then make recom-
mendations whose implementation would promote wide-scale adoption
of effective strategies for enabling the identified knowledge, attitudes, and
practices. Given the multi- and interdisciplinary nature of the study task,
the 18-member committee comprised individuals with an array of expertise,
including child development, early childhood education, developmental and
educational psychology, child psychiatry, social work, family engagement
research, pediatric medicine, public and health policy, health communica-
tions, implementation science, law, and economics (see Appendix D for
biosketches of the committee members).
WHAT IS PARENTING?
Conceptions of who parents are and what constitute the best conditions
for raising children vary widely. From classic anthropological and human
development perspectives, parenting often is defined as a primary mecha-
nism of socialization, that is, a primary means of training and preparing
children to meet the demands of their environments and take advantage

BOX 1-2
Statement of Task
An ad hoc committee will conduct a study that will inform a national frame-
work for strengthening the capacity of parents* of young children birth to age 8.
The committee will examine the research to identify a core set of parenting knowl-
edge, attitudes, and practices (KAPs) tied to positive parent-child interactions and
child outcomes, as well as evidence-based strategies that support these KAPs
universally and across a variety of specific populations. These KAPs and strate-
gies will be brought together to inform a set of concrete policy recommendations,
across the private and public sectors within the health, human services, and edu-
cation systems. Recommendations will be tied to promoting the wide-scale adop-
tion of the effective strategies and the enabling of the identified KAPs. The report
will also identify the most pressing research gaps and recommend three to five
key priorities for future research endeavors in the field. This work will primarily in-
form policy makers, a wide array of child and family practitioners, private industry,
and researchers. The resulting report should serve as a roadmap for the future
of parenting and family support policies, practices, and research in this country.
Specific populationsof interest include fathers, immigrant families, parents
with substance abuse and/or mental health issues, low-income families, single-
mother headed households, and parents of children with disabilities. Given the
diversity of family characteristics in the United States, the committee will examine
research across diverse populations of families and identify the unique strengths/
assets of traditionally underrepresented groups in the literature, including Native
Americans, African Americans, and Latinos.
Contextual areas of interest include resource poor neighborhoods, unsafe
communities,rural communities, availability of quality health care and education
systems and services(including early childhood education), and employment
opportunities.
The committee will address the following questions:
1. What are the core parenting KAPs, as identified in the literature, that
support healthy child development, birth to age 8? Do core parenting
KAPs differ by specific characteristics of children (e.g., age), parents, or
contexts?
2. What evidence-informedstrategies to strengthen parenting capacity, in-
cluding family engagement strategies, invarious settings (e.g., homes,
of opportunities within those environments. As Bornstein (1991, p. 6) ex-

plains, the particular and continuing task of parents and other caregivers
is to enculturate children . . . to prepare them for socially accepted physical,
economic, and psychological situations that are characteristic of the culture
in which they are to survive and thrive.
Attachment security is a central aspect of development that has been

INTRODUCTION 21
schools, health care centers,early childhoodcenters)have been shown

to be effective with parents of young childrenprenatal to age 8? Are there
key periods of intervention that are more effective in supporting parenting
capacitybeginning in high school or even earlier?
3. What types of strategies work at the universal/preventive, targeted, and in-
tensive levels (e.g., media campaigns, information sharing, text reminders;
social support groups, self-monitoring and tracking online; modeling and
feedback coaching, intensive home visiting), and for which populations of
parents and children?The committee will consider the appropriate balance
between strategies tailored to unique parent and child needs and common
strategies that can be effective and accepted with parents across groups.
4. What are the most pronounced barriers, including lack of incentives,
to strengthening parenting capacity and retention in effective programs
and systems designed to improve developmental,health, and education
outcomesfor children birth to age 8? How can programs and systems be
designed to remove these barriers?
5. Are there evidence-based models of systems and programs that support
parenting capacity and build upon existing assets of families, including
underserved, low-income families of color?
6. What are three to five research areas that warrant further investigation,
in order to inform policy and practice?
Specific recommendations to strengthen parenting capacity should target

federal, state, and local governments; the private sector (e.g., faith-based com-
munities, philanthropy, business, employers, insurance companies); public educa-
tion systems; and health and human service systems. The report will recommend
policies to be implemented across all levels of the public sector within the health,
human services, and education systems to support parents in their parenting role.
For the private sector, the report may recommend specific actions they can take
to enact, implement, or fund the outlined strategies or policies. In addition, the
committee will make specific recommendations about how programs and policies
can be paid for (e.g., insurance waivers, family co-pay subsidies, layering on other
government programs, etc.).
*The term parents in this study includes the main caregivers of children in the home. In
addition, this report will include a special emphasis on fathers.
defined as a childs sense of confidence that the caregiver is there to meet his
or her needs (Main and Cassidy, 1988). All children develop attachments
with their parents, but how parents interact with their young children, in-
cluding the extent to which they respond appropriately and consistently to
their childrens needs, particularly in times of distress, influences whether
the attachment relationship that develops is secure or insecure. Young chil-

dren who are securely attached to their parents are provided a solid foun-
dation for healthy development, including the establishment of strong peer
relationships and the ability to empathize with others (Bowlby, 1978; Chen
et al., 2012; Holmes, 2006; Main and Cassidy, 1988; Murphy and Laible,
2013). Conversely, young children who do not become securely attached
with a primary caregiver (e.g., as a result of maltreatment or separation)
may develop insecure behaviors in childhood and potentially suffer other
adverse outcomes over the life course, such as mental health disorders and
disruption in other social and emotional domains (Ainsworth and Bell,
1970; Bowlby, 2008; Schore, 2005).
More recently, developmental psychologists and economists have
described parents as investing resources in their children in anticipation of
promoting the childrens social, economic, and psychological well-being.
Kalil and DeLeire (2004) characterize this promotion of childrens healthy
development as taking two forms: (1) material, monetary, social, and
psychological resources and (2) provision of support, guidance, warmth,
and love. Bradley and Corwyn (2004) characterize the goals of these in-
vestments as helping children successfully regulate biological, cognitive,
and social-emotional functioning.
Parents possess different levels and quality of access to knowledge
that can guide the formation of their parenting attitudes and practices. As
discussed in greater detail in Chapter 2, the parenting practices in which
parents engage are influenced and informed by their knowledge, including
facts and other information relevant to parenting, as well as skills gained
through experience or education. Parenting practices also are influenced by
attitudes, which in this context refer to parents viewpoints, perspectives,
reactions, or settled ways of thinking with respect to the roles and impor-
tance of parents and parenting in childrens development, as well as parents
responsibilities. Attitudes may be part of a set of beliefs shared within a
cultural group and founded in common experiences, and they often direct
the transformation of knowledge into practice.
Parenting knowledge, attitudes, and practices are shaped, in part, by
parents own experiences (including those from their own childhood) and
circumstances; expectations and practices learned from others, such as
family, friends, and other social networks; and beliefs transferred through
cultural and social systems. Parenting also is shaped by the availability of
supports within the larger community and provided by institutions, as well
as by policies that affect the availability of supportive services.
Along with the multiple sources of parenting knowledge, attitudes, and
practices and their diversity among parents, it is important to acknowledge
the diverse influences on the lives of children. While parents are central
to children development, other influences, such as relatives, close family
friends, teachers, community members, peers, and social institutions, also

INTRODUCTION 23
contribute to childrens growth and development. Children themselves are

perhaps the most essential contributors to their own development. Thus,
the science of parenting is framed within the theoretical perspective that
parenting unfolds in particular contexts; is embedded in a network of re-
lationships within and outside of the family; and is fluid and continuous,
changing over time as children and parents grow and develop.
In addition, it is important to recognize that parenting affects not only
children but also parents themselves. For instance, parenting can enrich
and give focus to parents lives; generate stress or calm; compete for time
with work or leisure; and create combinations of any number of emotions,
including happiness, sadness, fulfillment, and anger.
STUDY CONTEXT
As attention to early childhood development has increased over the past
20 years, so, too, has attention to those who care for young children. A
recent Institute of Medicine and National Research Council report on the
early childhood workforce (Institute of Medicine and National Research
Council, 2015) illustrates the heightened focus not only on whether young
children have opportunities to be exposed to healthy environments and
supports but also on the people who provide those supports. Indeed, an im-
portant responsibility of parents is identifying those who will care for their
children in their absence. Those individuals may include family members
and others in parents immediate circle, but they increasingly include non-
family members who provide care and education in formal and informal
settings outside the home, such as schools and home daycare centers.
Throughout its deliberations, the committee considered several ques-
tions relevant to its charge: What knowledge and attitudes do parents of
young children bring to the task of parenting? How are parents engaged
with their young children, and how do the circumstances and behaviors
of both parents and children influence the parent-child relationship? What
types of support further enhance the natural resources and skills that par-
ents bring to the parenting role? How do parents function and make use
of their familial and community resources? What policies and resources at
the local, state, and federal levels assist parents? What practices do they
expect those resources to reinforce, and from what knowledge and attitudes
are those practices derived? On whom or what do they rely in the absence
of those resources? What serves as an incentive for participation in parent-
ing programs? How are the issues of parenting different or the same across
culture and race? What factors constrain parents positive relationships
with their children, and what research is needed to advance agendas that
can help parents sustain such relationships?
The committee also considered research in the field of neuroscience,

which further supports the foundational role of early experiences in healthy

development, with effects across the life course (Center on the Developing
Child, 2007; National Research Council and Institute of Medicine, 2009;
World Health Organization, 2015). During early childhood, the brain un-
dergoes a rapid development that lays the foundation for a childs lifelong
learning capacity and emotional and behavioral health (see Figure 1-1).
This research has provided a more nuanced understanding of the impor-
tance of investments in early childhood and parenting. Moreover, advances
in analyses of epigenetic effects on early brain development demonstrate
consequences of parenting for neural development at the level of DNA,
and suggest indirect consequences of family conditions such as poverty
that operate on early child development, in part, through the epigenetic
consequences of parenting (Lipinia and Segretin, 2015).
This report comes at a time of flux in public policies aimed at support-
ing parents and their young children. The cost to parents of supporting
their childrens healthy development (e.g., the cost of housing, health care,
child care, and education) has increased at rates that in many cases have
offset the improvements and increases provided for by public policies. As
noted above, for example, the number of children living in deep poverty has
grown since the mid-1990s (Sherman and Trisi, 2014). While children rep-
resent approximately one-quarter of the countrys population, they make
up 32 percent of all the countrys citizens who live in poverty (Child Trends
Databank, 2015a). About one in every five children in the United States
is now growing up in families with incomes below the poverty line, and 9
percent of children live in deep poverty (families with incomes below 50%
FIGURE 1-1 Human brain development: Rate of synapse formation by age.

SOURCE: Nelson (2000).

INTRODUCTION 25
of the poverty line) (Child Trends Databank, 2015a). The risk of growing
up poor continues to be particularly high for children in female-headed
households; in 2013, approximately 55 percent of children under age 6 in
such households lived at or below the poverty threshold, compared with 10
percent of children in married couple families (DeNavas-Walt and Proctor,
2014). Black and Hispanic children are more likely to live in deep poverty
(18 and 13%, respectively) compared with Asian and white children (5%
each) (Child Trends Databank, 2015a). Also noteworthy is that child care
policy, including the recent increases in funding for low-income families,
ties child care subsidies to employment. Unemployed parents out of school
are not eligible, and job loss results in subsidy loss and, in turn, instability
in child care arrangements for young children (Ha et al., 2012).
As noted earlier, this report also comes at a time of rapid change in
the demographic composition of the country. This change necessitates new
understandings of the norms and values within and among groups, the
ways in which recent immigrants transition to life in the United States,
and the approaches used by diverse cultural and ethnic communities to
engage their children during early childhood and utilize institutions that
offer them support in carrying out that role. The United States now has the
largest absolute number of immigrants in its history (Grieco et al., 2012;
Passel and Cohn, 2012; U.S. Census Bureau, 2011), and the proportion
of foreign-born residents today (13.1%) is nearly as high as it was at the
turn of the 20th century (National Academies of Sciences, Engineering, and
Medicine, 2015). As of 2014, 25 percent of children ages 0-5 in the United
States had at least one immigrant parent, compared with 13.5 percent in
1990 (Migration Policy Institute, 2016).3 In many urban centers, such as
Los Angeles, Miami, and New York City, the majority of the student body
of public schools is first- or second-generation immigrant children (Surez-
Orozco et al., 2008).
Immigrants to the United States vary in their countries of origin, their
reception in different communities, and the resources available to them. Re-
searchers increasingly have called attention to the wide variation not only
among but also within immigrant groups, including varying premigration
histories, familiarity with U.S. institutions and culture, and childrearing
3Shifting demographics in the United States have resulted in increased pressure for service
providers to meet the needs of all children and families in a culturally sensitive manner. In
many cases, community-level changes have overwhelmed the capacity of local child care pro-
viders and health service workers to respond to the language barriers and cultural parenting
practices of the newly arriving immigrant groups, particularly if they have endured trauma.
For example, many U.S. communities have worked to address the needs of the growing
Hispanic population, but it has been documented that in some cases, eligible Latinos are
less likely to access available social services than other populations (Helms et al., 2015;
Wildsmith et al., 2016).

strategies (Crosnoe, 2006; Fuller and Garca Coll, 2010; Galindo and Fuller,
2010; Surez-Orozco et al., 2010; Takanishi, 2004). Immigrants often bring
valuable social and human capital to the United States, including unique
competencies and sociocultural strengths. Indeed, many young immigrant
children display health and learning outcomes better than those of children
of native-born parents in similar socioeconomic positions ( Crosnoe, 2013).
At the same time, however, children with immigrant parents are more likely
than children in native-born families to grow up poor (Hernandez et al.,
2008, 2012; National Academies of Sciences, Engineering, and Medicine,
2015; Raphael and Smolensky, 2009). Immigrant parents efforts to raise
healthy children also can be thwarted by barriers to integration that include
language, documentation, and discrimination (Hernandez et al., 2012;
Yoshikawa, 2011).
The increase in the nations racial and ethnic diversity over the past
several decades, related in part to immigration, is a trend that is expected
to continue (Colby and Ortman, 2015; Taylor, 2014). Between 2000 and
2010, the percentage of Americans identifying as black, Hispanic, Asian,
or other increased from 15 percent to 36 percent of the population (U.S.
Census Bureau, 2011). Over this same time, the percentage of non-Hispanic
white children under age 10 declined from 60 percent to 52 percent, while
the percentage of Hispanic ethnicity (of any race) grew from about 19 per-
cent to 25 percent (U.S. Census Bureau, 2011); the percentages of black/
African American, American Indian/Alaska Native, and Asian children
under age 10 remained relatively steady (at about 15%, 1%, and 4-5%,
respectively); and the percentages of children in this age group identifying
as two or more races increased from 3 percent to 5 percent (U.S. Census
Bureau, 2011).
The above-noted shifts in the demographic landscape with regard to
family structure, including increases in divorce rates and cohabitation,
new types of parental relationships, and the involvement of grandparents
and other relatives in the raising of children (Cancian and Reed, 2008;
Fremstad and Boteach, 2015), have implications for how best to support
families. Between 1960 and 2014, the percentage of children under age 18
who lived with two married parents (biological, nonbiological, or adoptive)
decreased from approximately 85 percent to 64 percent. In 1960, 8 percent
of children lived in households headed by single mothers; by 2014, that
figure had tripled to about 24 percent (Child Trends Databank, 2015b;
U.S. Census Bureau, 2016). Meanwhile, the proportions of children living
with only their fathers or with neither parent (with either relatives or non-
relatives) have remained relatively steady since the mid-1980s, at about
4 percent (see Figure 1-2). Black children are significantly more likely to
live in households headed by single mothers and also are more likely to live
in households where neither parent is present. In 2014, 34 percent of black

INTRODUCTION 27
FIGURE 1-2 Living arrangements of children under age 18 in the United States, 1960-2015.
SOURCE: U.S. Census Bureau (2016).
children lived with two parents, compared with 58 percent of Hispanic chil-
dren, 75 percent of white children, and 85 percent of Asian children (Child
Trends Databank, 2015b).
From 1996 to 2015, the number of cohabiting couples with children
rose from 1.2 million to 3.3 million (Child Trends Databank, 2015b).
Moreover, data from the National Health Interview Survey show that in
2013, 30,000 children under age 18 had married same-sex parents and
170,000 had unmarried same-sex parents, and between 1.1 and 2.0 million
were being raised by a parent who identified as lesbian, gay, or bisexual but
was not part of a couple (Gates, 2014).
More families than in years past rely on kinship care (full-time care of
children by family members other than parents or other adults with whom
children have a family-like relationship). When parents are unable to care
for their children because of illness, military deployment, incarceration,
child abuse, or other reasons, kinship care can help cultivate familial and
community bonds, as well as provide children with a sense of stability
and belonging (Annie E. Casey Foundation, 2012; Winokur et al., 2014).
It is estimated that the number of children in kinship care grew six times
the rate of the number of children in the general population over the past
decade (Annie E. Casey Foundation, 2012). In 2014, 7 percent of children
lived in households headed by grandparents, as compared with 3 percent
in 1970 (Child Trends Databank, 2015b), and as of 2012, about 10 per-
cent of American children lived in a household where a grandparent was
present (Ellis and Simmons, 2014). Black children are twice as likely as the
overall population of children to live in kinship arrangements, with about
20 percent of black children spending time in kinship care at some point

during their childhood (Annie E. Casey Foundation, 2012). Beyond kinship

care, about 400,000 U.S. children under age 18 are in foster care with about
one-quarter of these children living with relatives (Child Trends Databank,
2015c). Of the total number of children in foster care, 7 percent are under
age 1, 33 percent are ages 1-5, and 23 percent are ages 6-10 (Child Trends
Databank, 2015c). Other information about the structure of American
families is more difficult to come by. For example, there is a lack of data
with which to assess trends in the number of children who are raised by
extended family members through informal arrangements as opposed to
through the foster care system.
As noted earlier, fathers, including biological fathers and other male
caregivers, have historically been underrepresented in parenting research
despite their essential role in the development of young children. Young
children with involved and nurturing fathers develop better linguistic and
cognitive skills and capacities, including academic readiness, and are more
emotionally secure and have better social connections with peers as they
get older (Cabrera and Tamis-LeMonda, 2013; Harris and Marmer, 1996;
Lamb, 2004; Pruett, 2000; Rosenberg and Wilcox, 2006; Yeung et al.,
2000). Conversely, children with disengaged fathers have been found to
be more likely to develop behavioral problems (Amato and Rivera, 1999;
Ramchandani et al., 2013). With both societal shifts in gender roles and
increased attention to fathers involvement in childrearing in recent years,
fathers have assumed greater roles in the daily activities associated with
raising young children, such as preparing and eating meals with them,
reading to and playing and talking with them, and helping them with
homework (Bianchi et al., 2007; Cabrera et al., 2011; Jones and Mosher,
2013; Livingston and Parker, 2011). In two-parent families, 16 percent of
fathers were stay-at-home parents in 2012, compared with 10 percent in
1989; 21 percent of these fathers stayed home specifically to care for their
home or family, up from 5 percent in 1989 (Livingston, 2014). At the same
time, however, fewer fathers now live with their biological children because
of increases in nonmarital childbearing (U.S. Census Bureau, 2015).
In addition, as alluded to earlier, parents of young children face trans-
formative changes in technology that can have a strong impact on parenting
and family life (Collier, 2014). Research conducted by the Pew Internet and
American Life Project shows that, relative to other household configura-
tions, married parents with children under age 18 use the Internet and cell
phones, own computers, and adopt broadband at higher rates (Duggan and
Lenhart, 2015). Other types of households, however, such as single-parent
and unmarried multiadult households, also show high usage of technology,
particularly text messaging and social media (Smith, 2015). Research by
the Pew Research Center (2014) shows that many parents25 percent in

INTRODUCTION 29
one survey (Duggan et al., 2015)view social media as a useful source of

parenting information.
At the same time, however, parents also are saturated with information
and faced with the difficulty of distinguishing valid information from fal-
lacies and myths about raising children (Aubrun and Grady, 2003; Center
on Media and Human Development, 2014; Dworkin et al., 2013; Future of
Children, 2008). Given the number and magnitude of innovations in media
and communications technologies, parents may struggle with understanding
the optimal use of technology in the lives of their children.
Despite engagement with Internet resources, parents still report turning
to family, friends, and physicians more often than to online sources such
as Websites, blogs, and social network sites for parenting advice (Center
on Media and Human Development, 2014). Although many reports allude
to the potentially harmful effects of media and technology, parents gener-
ally do not report having many concerns or family conflicts regarding their
childrens media use. On the other hand, studies have confirmed parents
fears about an association between childrens exposure to violence in media
and increased anxiety (Funk, 2005), desensitization to violence (Engelhardt
et al., 2011), and aggression (Willoughby et al., 2012). And although the
relationship between media use and childhood obesity is challenging to dis-
entangle, studies have found that children who spend more time with media
are more likely to be overweight than children who do not (see Chapter 2)
(Bickham et al., 2013; Institute of Medicine, 2011; Kaiser Family Founda-
tion, 2004).
The benefits of the information age have included reduced barriers to
knowledge for both socially advantaged and disadvantaged groups. Yet
despite rapidly decreasing costs of many technologies (e.g., smartphones,
tablets, and computers), parents of lower socioeconomic position and from
racial and ethnic minority groups are less likely to have access to and
take advantage of these resources (Center on Media and Human Develop-
ment, 2014; File and Ryan, 2014; Institute of Medicine, 2006; Perrin and
Duggan, 2015; Smith, 2015; Viswanath et al., 2012). A digital divide also
exists between single-parent and two-parent households, as the cost of a
computer and monthly Internet service can be more of a financial burden
for the former families, which on average have lower household incomes
(Allen and Rainie, 2002; Dworkin et al., 2013).
STUDY APPROACH
The committees approach to its charge consisted of a review of the
evidence in the scientific literature and several other information-gathering
activities.

Evidence Review
The committee conducted an extensive review of the scientific literature
pertaining to the questions raised in its statement of task (Box 1-2). It did
not undertake a full review of all parenting-related studies because it was
tasked with providing a targeted report that would direct stakeholders to
best practices and succinctly capture the state of the science. The commit-
tees literature review entailed English-language searches of databases in-
cluding, but not limited to, the Cochrane Database of Systematic Reviews,
Medline, the Education Resources Information Center (ERIC), PsycINFO,
Scopus, and Web of Science. Additional literature and other resources
were identified by committee members and project staff using traditional
academic research methods and online searches. The committee focused its
review on research published in peer-reviewed journals and books (includ-
ing individual studies, review articles, and meta-analyses), as well as reports
issued by government agencies and other organizations. The committees
review was concentrated primarily, although not entirely, on research con-
ducted in the United States, occasionally drawing on research from other
Western countries (e.g., Germany and Australia), and rarely on research
from other countries.
In reviewing the literature and formulating its conclusions and rec-
ommendations, the committee considered several, sometimes competing,
dimensions of empirical work: internal validity, external validity, practical
significance, and issues of implementation, such as scale-up with fidelity
(Duncan et al., 2007; McCartney and Rosenthal, 2000; Rosenthal and
Rosnow, 2007).
With regard to internal validity, the committee viewed random-
assignment experiments as the primary model for establishing cause-
and-effect relationships between variables with manipulable causes (e.g.,
Rosenthal and Rosnow, 2007; Shadish et al., 2001). Given the relatively lim-
ited body of evidence from experimental studies in the parenting literature,
however, the committee also considered findings from quasi-experimental
studies (including those using regression discontinuity, instrumental vari-
ables, and difference-in-difference techniques based on natural experiments)
(Duncan et al., 2007; Foster, 2010; McCartney et al., 2006) and from ob-
servational studies, a method that can be used to test logical propositions
inherent to causal inference, rule out potential sources of bias, and assess
the sensitivity of results to assumptions regarding study design and mea-
surement. These include longitudinal studies and limited cross-sectional
studies. Although quasi- and nonexperimental studies may fail to meet
the gold standard of randomized controlled trials for causal inference,
studies with a variety of internal validity strengths and weaknesses can col-
lectively provide useful evidence on causal influences (Duncan et al., 2014).

INTRODUCTION 31
When there are different sources of evidence, often with some differences in
estimates of the strength of the evidence, the committee used its collective
experience to integrate the information and draw reasoned conclusions.
With regard to external validity, the committee attempted to take into
account the extent to which findings can be generalized across population
groups and situations. This entailed considering the demographic, socio-
economic, and other characteristics of study participants; whether variables
were assessed in the real-world contexts in which parents and children live
(e.g., in the home, school, community); whether study findings build the
knowledge base with regard to both efficacy (i.e., internal validity in highly
controlled settings) and effectiveness (i.e., positive net treatment effects in
ecologically valid settings); and issues of cultural competence (Bracht and
Glass, 1968; Bronfenbrenner, 2009; Cook and Campbell, 1979; Harrison
and List, 2004; Lerner et al., 2000; Rosenthal and Rosnow, 2007; Whaley
and Davis, 2007). However, the research literature is limited in the ex-
tent to which generalizations across population groups and situations are
examined.
With regard to practical significance, the committee considered the
magnitude of likely causal impacts within both an empirical context (i.e.,
measurement, design, and method) and an economic context (i.e., benefits
relative to costs), and with attention to the salience of outcomes (e.g.,
how important an outcome is for promoting child well-being) (Duncan
et al., 2007; McCartney and Rosenthal, 2000). As discussed elsewhere in
this report, however, the committee found limited economic evidence with
which to draw conclusions about investing in interventions at scale or to
weigh the costs and benefits of interventions. (See the discussion of other
information-gathering activities below.) Also with respect to practical signif-
icance, the committee considered the manipulability of the variables under
consideration in real-world contexts, given that the practical significance of
study results depend on whether the variables examined are represented or
experienced commonly or uncommonly among particular families (Fabes
et al., 2000).
Finally, the committee took into account issues of implementation, such
as whether interventions can be brought to and sustained at scale (Durlak
and DuPre, 2008; Halle et al., 2013). Experts in the field of implementa-
tion science emphasize not only the evidence behind programs but also
the fundamental roles of scale-up, dissemination planning, and program
monitoring and evaluation. Scale-up in turn requires attending to the abil-
ity to implement adaptive program practices in response to heterogeneous,
real-world contexts, while also ensuring fidelity for the potent levers of
change or prevention (Franks and Schroeder, 2013). Thus, the committee
relied on both evidence on scale-up, dissemination, and sustainability from
empirically based programs and practices that have been implemented and

evaluated, and more general principles of implementation science, includ-

ing considerations of capacity and readiness for scale-up and sustainability
at the macro (e.g., current national politics) and micro (e.g., community
resources) levels.
The review of the evidence conducted for this study, especially pertain-
ing to strategies that work at the universal, targeted, and intensive levels
to strengthen parenting capacity (questions 2 and 3 from the committees
statement of task [Box 1-2]), also entailed searches of several databases that,
applying principles similar to those described above, assess the strength of
the evidence for parenting-related programs and practices: the National
Registry of Evidence-Based Programs and Practices (NREPP), supported by
SAMHSA; the California Evidence-Based Clearinghouse for Child W elfare
(CEBC), which is funded by the state of California; and Blueprints for
Healthy Youth Development, which has multiple funding sources. Although
each of these databases is unique with respect to its history, sponsors, and
objectives (NREPP covers mental health and substance abuse interventions,
CEBC is focused on evidence relevant to child welfare, and Blueprints
describes programs designed to promote the health and well-being of chil-
dren), all are recognized nationally and internationally and undergo a rigor-
ous review process.
The basic principles of evaluation and classification and the processes
for classification of evidence-based practices are common across NREPP,
CEBC, and Blueprints. Each has two top categoriesoptimal and promis-
ingfor programs and practices (see Appendix B; see also Burkhardt et al.,
2015; Means et al., 2015; Mihalic and Elliot, 2015; Soydan et al., 2010).
Given the relatively modest investment in research on programs for parents
and young children, however, the array of programs that are highly rated
remains modest. For this reason, the committee considered as programs
with the most robust evidence not only those included in the top two cat-
egories of Blueprints and CEBC but also those with an average rating of
3 or higher in NREPP. The committees literature searches also captured
well-supported programs that are excluded from these databases (e.g., be-
cause they are recent and/or have not been submitted for review) but have
sound theoretical underpinnings and rely on well-recognized intervention
and implementation mechanisms.
Other reputable information sources used in producing specific portions
of this report were What Works for Health (within the County Health Rank-
ings and Roadmaps Program, a joint effort of the Robert Wood Johnson
Foundation and the University of Wisconsin); the What Works Clearing-
house of the U.S. Department of Educations Institute of Education Services;
and HHSs Home Visiting Evidence of Effectiveness (HomVEE) review.
In addition, the committee chose to consider findings from research
using methodological approaches that are emerging as a source of innova-
tion and improvement. These approaches are gaining momentum in parent-

INTRODUCTION 33
ing research and are being developed and funded by the federal government
and private philanthropy. Examples are breakthrough series collaborative
approaches, such as the Home Visiting Collaborative Innovation and Im-
provement Network to Reduce Infant Mortality, and designs such as facto-
rial experiments that have been used to address topics relevant to this study.
Other Information-Gathering Activities

The committee held two open public information-gathering sessions
to hear from researchers, practitioners, parents, and other stakeholders on
topics germane to this study and to supplement the expertise of the com-
mittee members (see Appendix A for the agendas of these open sessions).
Material from these open sessions is referenced in this report where relevant.
As noted above, the committees task included making recommenda-
tions related to promoting the wide-scale adoption of effective strategies for
supporting parents and the salient knowledge, attitudes, and practices. Cost
is an important consideration for the implementation of parenting pro-
grams at scale. Therefore, the committee commissioned a paper reviewing
the available economic evidence for investing in parenting programs at scale
to inform its deliberations on this portion of its charge. Findings and ex-
cerpts from this paper are integrated throughout Chapters 3 through 6. The
committee also commissioned a second paper summarizing evidence-based
strategies used by health care systems and providers to help parents acquire
and sustain knowledge, attitudes, and practices that promote healthy child
development. The committee drew heavily on this paper in developing sec-
tions of the report on universal/preventive and targeted interventions for
parents in health care settings. Lastly, a commissioned paper on evidence-
based strategies to support parents of children with mental illness formed
the basis for a report section on this population.4
In addition, the committee conducted two sets of group and indi-
vidual semistructured interviews with parents participating in family sup-
port programs at community-based organizations in Omaha, Nebraska,
and Washington, D.C. Parents provided feedback on the strengths they
bring to parenting, challenges they face, how services for parents can be
improved, and ways they prefer to receive parenting information, among
other topics. Excerpts from these interviews are presented throughout this
report as Parent Voices to provide real-world examples of parents ex-
periences and to supplement the discussion of particular concepts and the
committees findings.
4The papers commissioned by the committee are in the public access file for the study and
can be requested at https://www8.nationalacademies.org/cp/ManageRequest.aspx?key=49669

[October 2016].

TERMINOLOGY AND STUDY PARAMETERS

As specified in the statement of task for this study (Box 1-2), the term
parents refers in this report to those individuals who are the primary
caregivers of young children in the home. Therefore, the committee re-
viewed studies that involved not only biolofical and adoptive parents but
also relative/kinship providers (e.g., grandparents), stepparents, foster par-
ents, and other types of caregivers, although research is sparse on unique
issues related to nontraditional caregivers. The terms knowledge, atti-
tudes, and practices and the relationships among them were discussed
earlier in this chapter, and further detail can be found in Chapter 2).
The committee recognized that to a certain degree, ideas about what
is considered effective parenting vary across cultures and ecological condi-
tions, including economies, social structures, religious beliefs, and moral
values (Cushman, 1995). To address this variation, and in accordance with
its charge, the committee examined research on how core parenting knowl-
edge, attitudes, and practices differ by specific characteristics of children,
parents, and contexts. However, because the research on parenting has
traditionally underrepresented several populations (e.g., caregivers other
than mothers), the evidence on which the committee could draw to make
these comparisons was limited.
The committee interpreted evidence-based/informed strategies very
broadly as ranging from teaching a specific parenting skill, to manualized
parenting programs, to policies that may affect parenting. The term inter-
ventions is generally used in this report to refer to all types of strategies,
while more specific terms (e.g., program, well-child care) are used
to refer to particular types or sets of interventions. Also, recognizing that
nearly every facet of society has a role to play in supporting parents and en-
suring that children realize their full potential, the committee reviewed not
only strategies designed expressly for parents (e.g., parenting skills train-
ing) but also, though to a lesser degree, programs and policies not designed
specifically for parents that may nevertheless affect an individuals capacity
to parent (e.g., food assistance and housing programs, health care policies).
As noted earlier in this chapter, this report was informed by a life-
course perspective on parenting, given evidence from neuroscience and a
range of related research that the early years are a critical period in shaping
how individuals fare throughout their lives. The committee also aimed to
take a strengths/assets-based approach (e.g., to identify strategies that build
upon the existing assets of parents), although the extent to which this ap-
proach could be applied was limited by the paucity of research examining
parenting from this perspective.

INTRODUCTION 35
GUIDING PRINCIPLES
A number of principles guided this study. First, following the ideas of
Dunst and Espe-Sherwindt (2016), the distinction between two types
of family-centered practicesrelational and participatoryinformed the
committees thinking. Relational practices are those focused primarily on
intervening with families using compassion, active and reflective listen-
ing, empathy, and other techniques. Participatory practices are those that
actively engage families in decision making and aim to improve families
capabilities. In addition, family-centered practices focused on the context
of successful parenting are a key third form of support for parenting. A
premise of the committee is that many interventions with the most trou-
bled families and children will require all these types of servicesoften
delivered concurrently over a lengthy period of time.
Second, many programs are designed to serve families at particular risk
for problems related to cognitive and social-emotional development, health,
and well-being. Early Head Start and Head Start, for example, are means
tested and designed for low-income families most of whom are known to
face not just one risk factor (low income) but also others that often cluster
together (e.g., living in dangerous neighborhoods, exposure to trauma,
social isolation, unfamiliarity with the dominant culture or language).

Special populations addressed in this report typically are at very high risk
because of this exposure to multiple risk factors. Research has shown that
children in such families have the poorest outcomes, in some instances
reaching a level of toxic stress that seriously impairs their developmental
functioning (Shonkoff and Garner, 2012). Of course, in addition to charac-
terizing developmental risk, it is essential to understand the corresponding
adaptive processes and protective factors, as it is the balance of risk and
protective factors that determines outcomes. In many ways, supporting
parents is one way to attempt to change that balance.
From an intervention point of view, several principles are central. First,
intervention strategies need to be designed to have measurable effects over
time and to be sustainable. Second, it is necessary to focus on the needs of
individual families and to tailor interventions to achieve desired outcomes.
The importance of personalized approaches is widely acknowledged in
medicine, education, and other areas. An observation perhaps best illus-
trated in the section on parents of children with developmental disabilities
in Chapter 5, although the committee believes this approach applies to
many of the programs described in this report. A corresponding core prin-
ciple of intervention is viewing parents as equal partners, experts in what
both they and their children need. It is important as well that multiple kinds
of services for families be integrated and coordinated. As illustrated earlier

in Box 1-1, families may be receiving interventions from multiple sources

delivered in different places, making coordination all the more important.
A useful framework for thinking about interventions is described in
the National Research Council and Institute of Medicine (2009) report
Preventing Mental, Emotional, and Behavioral Disorders among Young
People. Prevention interventions encompass mental health promotion: uni-
versal prevention, defined as interventions that are valuable for all children;
selected prevention, aimed at populations at high risk (such as children
whose parents have mental illness); and indicated prevention, focused on
children already manifesting symptoms. Treatment interventions include
case identification, standard treatment for known disorders, accordance of
long-term treatment with the goal of reduction in relapse or occurrence,
and aftercare and rehabilitation (National Research Council and Institute
of Medicine, 2009).
The committee recognizes that engaging and retaining children and
families in parenting interventions are critical challenges. A key to pro-
moting such engagement may be cultural relevance. Families representing
Americas diverse array of cultures, languages, and experiences are likely
to derive the greatest benefit from interventions designed and implemented
to allow for flexibility.
Finally, the question of widespread implementation and dissemination
of parenting interventions is critically important. Given the cost of testing
evidence-based parenting programs, the development of additional pro-
grams needs to be built on the work that has been done before. Collectively,
interventions also are more likely to achieve a significant level of impact if
they incorporate some of the elements of prior interventions. In any case,
a focus on the principles of implementation and dissemination clearly is
needed. As is discussed in this report, the committee calls for more study
and experience with respect to taking programs to scale.
REPORT ORGANIZATION
This report is divided into eight chapters. Chapter 2 examines desired
outcomes for children and reviews the existing research on parenting knowl-
edge, attitudes, and practices that support positive parent-child interactions
and child outcomes. Based on the available research, this chapter identifies
a set of core knowledge, attitudes, and practices. Chapter 3 provides a brief
overview of some of the major federally funded programs and policies that
support parents in the United States. Chapters 4 and 5 describe evidence-
based and evidence-informed strategies for supporting parents and enabling
the identified knowledge, attitudes, and practices, including universal and
widely used interventions (Chapter 4) and interventions targeted to parents
of children with special needs and parents who themselves face adversities

INTRODUCTION 37
(Chapter 5). Chapter 6 reviews elements of effective programs for strength-

ening parenting capacity and parents participation and retention in effec-
tive programs and systems. Chapter 7 describes a national framework for
supporting parents of young children. Finally, Chapter 8 presents the com-
mittees conclusions and recommendations for promoting the wide-scale
adoption of effective intervention strategies and parenting practices linked
to healthy child outcomes, as well as areas for future research.
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Parenting Knowledge,
Attitudes, and Practices
This chapter responds to the first part of the committees chargeto

identify core parenting knowledge, attitudes, and practices that are asso
ciated with positive parent-child interactions and the healthy develop-
ment of children ages birth to 8. The chapter also describes findings from
research regarding how core parenting knowledge, attitudes, and practices
may differ by specific characteristics of children and parents, as well as
by context. The chapter begins by defining desired outcomes for children
that appear frequently in the research literature and inform efforts by
agencies at the federal, state, and local levels to promote child health and
well-being. It then reviews the knowledge, attitudes, and practices identi-
fied in the literature as corethose most strongly associated with healthy
child d evelopmentdrawing primarily on correlational and experimental
studies. This is followed by brief discussion of the family system as a key
source of additional determinants of parenting. The chapter concludes with
a summary. The core knowledge, attitudes, and practices identified in this
chapter serve as a foundation, along with contextual factors that affect
parenting, for the committees review of the effectiveness of strategies for
strengthening parenting capacity in subsequent chapters of this report.
DESIRED OUTCOMES FOR CHILDREN

To determine the salient features of core parenting knowledge, atti
tudes, and practices, the committee first identified desired outcomes for
children. Identifying these outcomes grounds the discussion of core parent-
ing knowledge, attitudes, and practices and helps researchers, practitioners,
45

and policy makers establish priorities for investment, develop policies that
provide optimal conditions for success, advocate for the adoption and im-
plementation of appropriate evidence-based interventions, and utilize data
to assess and improve the effectiveness of specific policies and programs.
Child outcomes are interconnected within and across diverse domains
of development. They result from and are enhanced by early positive and
supportive interactions with parents and other caregivers. These early inter
actions can have a long-lasting ripple effect on development across the life
course, whereby the function of one domain of development influences
another domain over time. In the words of Masten and Cicchetti (2010, p.
492), effectiveness in one domain of competence in one period of life be-
comes the scaffold on which later competence in newly emerging domains
develops . . . competence begets competence. From the literature, the com-
mittee identified the following four outcomes as fundamental to childrens
well-being. While the committee focused on young children (ages 0-8), these
outcomes are important for children of all ages.
Physical Health and Safety

Children need to be cared for in a way that promotes their ability to
thrive and ensures their survival and protection from injury and physical
and sexual maltreatment. While such safety needs are important for all
children, they are especially critical for young children, who typically lack
the individual resources required to avoid dangers (National Research
Council and Institute of Medicine, 2000). Rather, young children rely on
parents and other primary caregivers, inside and outside the home, to act
on their behalf to protect their safety and healthy development (Institute
of Medicine and National Research Council, 2015). At the most basic
level, children must receive the care, as reflected in a number of emotional
and physiological protections, necessary to meet normative standards for
growth and physical development, such as guidelines for healthy weight and
receipt of recommended vaccinations (Institute of Medicine and National
Research Council, 2015). Physical health and safety are fundamental for
achieving all of the other outcomes described below.
Emotional and Behavioral Competence

Children need care that promotes positive emotional health and well-
being and that supports their overall mental health, including a positive
sense of self, as well as the ability to cope with stressful situations, temper
emotional arousal, overcome fears, and accept disappointments and frus-
trations. Parents and other caregivers are essential resources for children in
managing emotional arousal, coping, and managing behavior. They serve

PARENTING KNOWLEDGE, ATTITUDES, AND PRACTICES 47
in this role by providing positive affirmations, conveying love and respect

and engendering a sense of security. Provision of support by parents helps
minimize the risk of internalizing behaviors, such as those associated with
anxiety and depression, which can impair childrens adjustment and ability
to function well at home, at school, and in the community (Osofsky and
Fitzgerald, 2000). Such symptoms as extreme fearfulness, helplessness,
hopelessness, apathy, depression, and withdrawal are indicators of emo-
tional difficulty that have been observed among very young children who
experience inadequate parental care (Osofsky and Fitzgerald, 2000).
Social Competence
Children who possess basic social competence are able to develop and
maintain positive relationships with peers and adults (Semrud-Clikeman,
2007). Social competence, which is intertwined with other areas of develop-
ment (e.g., cognitive, physical, emotional, and linguistic), also may include
childrens ability to get along with and respect others, such as those of a dif-
ferent race or ethnicity, religion, sexual orientation, or economic background
(Institute of Medicine and National Research Council, 2015). Basic social
skills include a range of prosocial behaviors, such as empathy and concern
for the feelings of others, cooperation, sharing, and perspective taking, all
of which are positively associated with childrens success both in school and
in nonacademic settings and can be fostered by parents and other caregivers
(Durlak et al., 2011; Fantuzzo et al., 2007). These skills are associated with
childrens future success across a wide range of contexts in adulthood (e.g.,
school, work, family life) (Elias, 2006; Fantuzzo et al., 2007).
Cognitive Competence
Cognitive competence encompasses the skills and capacities needed at
each age and stage of development to succeed in school and in the world
at large. Childrens cognitive competence is defined by skills in language
and communication, as well as reading, writing, mathematics, and problem
solving. Children benefit from stimulating, challenging, and supportive
environments in which to develop these skills, which serve as a foundation
for healthy self-regulatory practices and modes of persistence required for
academic success (Gottfried, 2013).
PARENTING KNOWLEDGE, ATTITUDES, AND PRACTICES

The child outcomes described above provide the context for consider-
ing the range of parenting knowledge, attitudes, and practices and identify-
ing those that research supports as core. As noted in Chapter 1, the term

knowledge for the purposes of this report refers to facts, information,

and skills gained through experience or education and understanding of
an issue or phenomenon. Attitudes refers to viewpoints, perspectives,
reactions, or settled ways of thinking about aspects of parenting or child
development, including parents roles and responsibilities. Attitudes may be
related to cultural beliefs founded in common experience. And practices
refers to parenting behaviors or approaches to childrearing that can shape
how a child develops. Generally speaking, knowledge relates to cognition,
attitudes relate to motivation, and practices relate to ways of engaging or
behavior, but all three may emanate from a common source.
These three components are reciprocal and intertwined theoretically,
empirically, and bidirectionally, informing one another. For example, prac-
tices are related to knowledge and attitudes, and often involve the applica-
tion of knowledge. According to behavior modification theory (Ajzen and
Fishbein, 1980; Fishbein et al., 2001), a persons attitude often determines
whether he or she will use knowledge and transform it into practice. In
short, if one does not believe in or value knowledge, one is less likely to act
upon it. What parents learn through the practice of parenting can also be a
source of knowledge and can shape parents attitudes. Parenting attitudes
are influenced as well by parenting self-efficacy, which has been broadly
defined as the level of parents self-belief about their ability to succeed in
the parenting role (Jones and Prinz, 2005).
Parenting knowledge, attitudes, and practices are shaped not only by
each other but also by a number of contextual factors, including childrens
characteristics (e.g., gender, temperament); parents own experiences (e.g.,
those from their own childhood) and circumstances; expectations learned
from others, such as family, friends, and other social networks; and cultural
systems. Of particular relevance to this study, the contextual factors that
influence parenting knowledge, attitudes, and practices also include the sup-
ports available within the larger community and provided by institutions,
as well as by policies that affect the nature and availability of supportive
services.
In response to the study charge (Box 1-2 in Chapter 1), this chapter
presents the evidence on core parenting knowledge, attitudes, and practices
separately. However, it should be noted that in the research literature, the dis-
tinctions among these concepts, especially knowledge and attitudes, are not
well-delineated and that the applications of these concepts to parenting often
are equally informed by professional wisdom and historical observation.
Parenting Knowledge
Parenting is multidimensional. To respond to the varied needs of their
children, parents must develop both depth and breadth of knowledge, rang-

ing from being aware of developmental milestones and norms that help in
keeping children safe and healthy to understanding the role of professionals
(e.g., educators, child care workers, health care providers, social workers)
and social systems (e.g., institutions, laws, policies) that interact with fami-
lies and support parenting. This section describes these areas of knowledge,
as well as others, identified by the available empirical evidence as support-
ing core parenting practices and child outcomes. It is worth noting that the
research base regarding the association between parental knowledge and
child outcomes is much smaller than that on parenting practices and child
outcomes (Winter et al., 2012). Where data exist, they are based largely on
correlational rather than experimental studies.
Knowledge of Child Development
Parent Voices
[Some parents recognized the need for education related to providing care
for young children.]
I am a new parent and even though I have a bachelors degree from India,
I do not have a particular education in child care. Just because I have a
degree, it does not mean it is a degree on how to take care of a child.
Father from Omaha, Nebraska
The importance of parents knowledge of child development is a pri-

mary theme of many efforts to support parenting. Evidence-based rec-
ommendations issued by the American Psychological Association Task
Force on Evidence-Based Practice with Children and Adolescents (2008),
the Centers for Disease Control and Prevention (CDC) (2015b), and the
World Health Organization (WHO) (2009) emphasize the need for policy
and program initiatives to promote parenting knowledge. As they suggest,
to optimize childrens development, parents need a basic understanding
of infant and child developmental milestones and norms and the types of
parenting practices that promote childrens achievement of these milestones
(Belcher et al., 2007; Benasich and Brooks-Gunn, 1996, p. 1187; Bond and
Burns, 2006; Bornstein and Cote, 2004; Hess et al., 2004; Huang et al.,
2005; Larsen and Juhasz, 1985; Mercy and Saul, 2009).
A robust body of correlational research demonstrates tremendous vari-
ation in parents knowledge about childrearing. Several of these studies
suggest that parents with higher levels of education tend to know more
about child developmental milestones and processes (Bornstein et al., 2010;

onrad et al., 1992; Hess et al., 2004; Huang et al., 2005), as well as effec-
C
tive parenting strategies (Morawska et al., 2009). This greater knowledge
may reflect differential access to accurate information, differences in par-
ents trust in the information or information source, and parents comfort
with their own abilities, among other factors. For example, research shows
that parents who do not teach math in the home tend to have less knowl-
edge about elementary math, doubt their competence, or value math less
than other skills (Blevins-Knabe et al., 2000; Cannon and Ginsburg, 2008;
Vukovic and Lesaux, 2013). However, parents knowledge and willingness
to increase their knowledge may change; thus, they can acquire develop-
mental knowledge that can help them employ effective parenting practices.
Parent Voices
[Some parents recognized the need for comprehensive parenting education.]

I always prefer education for the parents, from the beginning to the end.
From pregnancy, some dont know when to go to the doctor, and after
birth, when to go to the hospital or the doctor. So we need education from
the beginning to the end.
Mother from Omaha, Nebraska
The focus on parental knowledge as a point of intervention is im-

portant because parents knowledge of child development is related to
their practices and behaviors (Okagaki and Bingham, 2005). For example,
mothers who have a strong body of knowledge of child development have
been found to interact with their children more positively compared with
mothers with less knowledge (Bornstein and Bradley, 2012; Huang et al.,
2005). Parents who understand child development also are less likely to
have age-inappropriate expectations for their child, which affects the use
of appropriate discipline and the nature and quality of parent-child interac-
tions (Goodnow, 1988; Huang et al., 2005).
Support for the importance of parenting knowledge to parenting prac-
tices is found in multiple sources and is applicable to a range of cognitive
and social-emotional behaviors and practices. Several correlational studies
show that mothers with high knowledge of child development are more
likely to provide books and learning materials tailored to childrens interests
and age and engage in more reading, talking, and storytelling relative to
mothers with less knowledge (Curenton and Justice, 2004; Gardner-Neblett
et al., 2012; Grusec, 2011). Fathers understanding of their young childrens
development in language and literacy is associated with being better pre-

pared to support their children (Cabrera et al., 2014). And parents who do
not know that learning begins at birth are less likely to engage in practices
that promote learning during infancy (e.g., reading to infants) or appreciate
the importance of exposing infants and young children to hearing words
and using language. For example, mothers who assume that very young
children are not attentive have been found to be less likely to respond to
their childrens attempts to engage and interact with them (Putnam et al.,
2002).
Stronger evidence of the role of knowledge of child development in sup-
porting parenting outcomes comes from intervention research. Randomized
controlled trial interventions have found that parents of young children
showed increases in knowledge about childrens development and prac-
tices pertaining to early childhood care and feeding (Alkon et al., 2014;
Yousafzai et al., 2015).
Some studies have found a direct association between parental knowl-
edge and child outcomes, including reduced behavioral challenges and im-
provements on measures of cognitive and motor performance (Benasich and
Brooks-Gunn, 1996; Dichtelmiller et al., 1992; Hunt and P araskevopoulos,
1980; Rowe et al., 2015). In an analysis of data from a prospective cohort
study that controlled for potential confounders, children of mothers with
greater knowledge of child development at 12 months were less likely to
have behavior problems and scored higher on child IQ tests at 36 months
relative to children of mothers with less developmental knowledge (Benasich
and Brooks-Gunn, 1996). This and other observational studies also show
that parental knowledge is associated with improved parenting and qual-
ity of the home environment, which, in turn, is associated with childrens
outcomes (Benasich and Brooks-Gunn, 1996; Parks and Smeriglio, 1986;
Winter et al., 2012), in addition to being contingent on parental attitudes
and competence (Conrad et al., 1992; Hess et al., 2004; Murphy et al.,
2015).
Experimental studies of parent education interventions support these
associational findings. In an experimental study of parent education for
first-time fathers, fathers, along with home visitors, reviewed examples of
parental sensitivity and responsiveness from videos of themselves playing
with their children (Magill-Evans et al., 2007). These fathers showed a
significant increase in parenting competence and skills in fostering their
childrens cognitive growth as well as sensitivity to infant cues 2 months
after the program, compared with fathers in the control group, who dis-
cussed age-appropriate toys with the home visitor (Magill-Evans et al.,
2007). A nother experimental study examined a 13-week population-level
behavioral parenting program and found intervention effects on parenting
knowledge for mothers and, among the highest-risk families, increased in-
volvement in childrens early learning and improved behavior management

practices. Lower rates of conduct problems for boys at high risk of problem
behavior also were found (Dawson-McClure et al., 2015).
Knowledge of Parenting Practices

Parents knowledge of how to meet their childrens basic physical (e.g.,
hunger) and emotional (e.g., wanting to be held or soothed) needs, as well
as of how to read infants cues and signals, can improve the synchronicity
between parent and child, ensuring proper child growth and development.
Specifically, parenting knowledge about proper nutrition, safe sleep envi-
ronments, how to sooth a crying baby, and how to show love and affection
is critical for young childrens optimal development (Bowlby, 2008; Chung-
Park, 2012; Regalado and Halfon, 2001; Zarnowiecki et al., 2011).
For many parents, for example, infant crying is a great challenge during
the first months of life. Parents who cannot calm their crying babies suffer
from sleep deprivation, have self-doubt, may stop breastfeeding earlier, and
may experience more conflict and discord with their partners and children
(Boukydis and Lester, 1985; Karp, 2008). Correlational research indicates
that improvement in parental knowledge about normal infant crying is asso
ciated with reductions in unnecessary medical emergency room visits for
infants (Barr et al., 2015). That knowledge leads to changes in behavior is
further supported in systematic reviews by Bryanton and colleagues (2013)
of randomized controlled trials and Middlemiss and colleagues (2015) of
studies with various design types, with both groups reporting that increases in
mothers knowledge about infant behavior is associated with positive changes
in the home environment, as well as improvements in infant sleep time.
Specific knowledge about health and safetyincluding knowledge
about how to access health care, protect children from physical harm (e.g.,
the importance of wearing a seat belt or a helmet), and promote good hy-
giene and nutritionis a key parenting competency. Experimental studies
show, for example, a positive link between parents knowledge of nutrition
and both childrens intake of nutritious foods and reduced calorie and
sodium intake (Campbell et al., 2013; Katz et al., 2011). In a randomized
controlled trial, Campbell and colleagues (2013) found that children whose
parents received knowledge, skills, and social support related to infant feed-
ing, diet, physical activity, and television viewing consumed fewer sweet
snacks and spent fewer minutes daily viewing television relative to children
whose parents were in the control group (Campbell et al., 2013). Also
associated with childrens intake of nutritious foods is parents modeling of
good eating habits and nutritional practices (Mazarello Paes et al., 2015).
In addition, although limited in scope, correlational evidence shows that
parents with knowledge about immunization are more likely to understand
its purpose and comply with the timetable for vaccinations (Smailbegovic et

al., 2003); that parents with more knowledge about effective injury preven-
tion practices are more likely to create safer home environments for their
children and reduce unintentional injuries (Corrarino, 2013; Dowswell et
al., 1996; Middlemiss et al., 2015; Morrongiello and Kiriakou, 2004);
and that parents with knowledge about asthma are more likely to use an
asthma management plan (Bryant-Stephens and Li, 2004; DeWalt et al.,
2007; Harrington et al., 2015). Other studies have found that parents with
more information about the purpose of vaccinations had greater knowledge
of immunization than parents in the control group (Hofstetter et al., 2015;
Jackson et al., 2011), and parents with more knowledge about sun safety
provided sunscreen and protective clothing for their children, who presented
with fewer sunburns (Crane et al., 2012).
Still, knowledge alone may not be sufficient in some cases. For example,
knowing about the importance of using car seats does not always translate
into good car seat practices (Yanchar et al., 2012, 2015), and knowledge
about the advantages of vaccines may not result in parents choosing to vac-
cinate their children. Some findings suggest that using multiple modes of
delivery is important to advancing parents knowledge. In an experimental
study, for example, Dunn and colleagues (1998) found that parents who
received educational information about child vaccinations via videotape as
well as in written form showed greater gains in understanding about vac-
cinations than parents who received the information in written form alone.
The evidence linking parental knowledge about the specific ways in
which parents can help children develop cognitive and academic skills,
including skills in math, is limited. However, the available correlational
data show that parents who know about how children develop language
are more likely to have children with emergent literacy skills (e.g., letter
sound awareness) relative to parents who do not (Ladd et al., 2011).
Several studies over the past 20 years have described parents increasing
knowledge and use of approaches for supporting childrens literacy (Clark,
2007; N ational Research Council, 1998; Snchal and LeFevre, 2002).
Much of this work has focused on book reading and parent-child engage-
ment around reading (Hindman et al., 2008; Mol et al., 2008; Morrow et
al., 1990). As early as the 1960s, Durkin (1966) and others referred to the
important role of the home literacy environment and parents beliefs about
reading in childrens early literacy development.
Knowledge of Supports, Services, and Systems

Little is known about parents knowledge of various supportssuch as
educators, social workers, health care providers, and extended familyand
the relationship between their conceptions of the roles of these supports
and their use of them.

To take an example, parents knowledge about child care and their

school decision-making processes are informed in a variety of ways through
these different supports. In their literature review of child care decision
making, Forry and colleagues (2013) found that many low-income parents
learn about their child care options through their social networks rather
than through professionals or referral agencies. While many parents say
they highly value quality, their choices also may reflect a range of other
factors that are valued. Parents tend to make child care decisions based on
structural (teacher education and training) and process (activities, parent-
provider communication) features, although their choices also vary by fam-
ily income, education, and work schedules. Sosinsky and Kim (2013), for
example, found that higher maternal education and income and being white
were associated with the likelihood of parents choosing higher-quality child
care programs that were associated with better child outcomes. Based on a
survey of parents of children in a large public school system, Goldring and
Phillips (2008) found that parents involvement, not satisfaction with their
childs school, was associated with school decision making. It should be
noted that while parents may know what constitutes high-quality child care
and education, structural (availability of quality programs and schools),
individual (work, income, belief), and child (temperament, age) factors
also influence these decision-making processes (Meyers and Jordan, 2006;
Shlay, 2010).
Taking another example, limited studies have looked at parental aware-
ness of services for children with special needs. A study that utilized a
survey and qualitative interviews with parents of children with autism in-
dicated that parents autism spectrum disorder service knowledge partially
mediates the relationship between socioeconomic status and use of services
for their children (Pickard and Ingersoll, 2015).
Parenting Attitudes
Although considerable discussion has focused on attitudes and beliefs
broadly, less research attention has been paid to the effects of parenting
attitudes on parents interactions with young children or on parenting prac-
tices. Few causal analyses are available to test whether parenting attitudes
actually affect parenting practices, positive parent-child interaction, and
child development. Even less research exists on fathers attitudes about
parenting. Given this limited evidence base, the committee drew primarily
on correlational and qualitative studies in examining parenting attitudes.
Parents attitudes toward parenting are a product of their knowl-
edge of parenting and the values and goals (or expectations) they have
for their childrens development, which in turn are informed by cultural,
social, and societal images, as well as parents experiences and their overall

v alues and goals (Cabrera et al., 2000; Cheah and Chirkov, 2008; Iruka
et al., 2015; Okagaki and Bingham, 2005; Rogoff, 2003; Rosenthal and
Roer-Strier, 2006; Whiting and Whiting, 1975). People in the United States
hold several universal, or near universal, beliefs about the types of parental
behaviors that promote or impair child development. For example, there is
general agreement that striking a child in a manner that can cause severe
injury, engaging in sexual activity with a child, and failing to provide ade
quate food for and supervision of young children (such as leaving toddlers
unattended) pose threats to childrens health and safety and are unaccept-
able. At the same time, some studies identify differences in parents goals
for child development, which may influence attitudes regarding the roles of
parents and have implications for efforts to promote particular parenting
practices.
While there is variability within demographic groups in parenting
attitudes and practices, some research shows differences in attitudes and
practices among subpopulations. For example, qualitative research pro-
vides some evidence of variation by culture in parents goals for their
childrens socialization. In one interview study, mothers who were first-
generation immigrants to the United States from Central America empha-
sized long-term socialization goals related to proper demeanor for their
children, while European American mothers emphasized self-maximization
(Leyendecker et al., 2002). In another interview study, Anglo American
mothers stressed the importance of their young children developing a bal-
ance between autonomy and relatedness, whereas Puerto Rican mothers
focused on appropriate levels of relatedness, including courtesy and re-
spectful attentiveness (Harwood et al., 1997). Other ethnographic and
qualitative research shows that parents from different cultural groups
select cultural values and norms from their country of origin as well as
from their host country, and that their goal is for their children to adapt
and succeed in the United States (Rogoff, 2003).
Similarly, whereas the larger U.S. society has historically viewed indi
vidual freedom as an important value, some communities place more em-
phasis on interdependence (Elmore and Gaylord-Harden, 2013; Sarche
and Spicer, 2008). The importance of intergenerational connections (e.g.,
extended family members serving as primary caregivers for young chil-
dren) also varies among and within cultural communities (Bertera and
Crewe, 2013; Mutchler et al., 2007). The values and traditions of cultural
communities may be expressed as differences in parents views regarding
gender roles, in parents goals for children, and in their attitudes related to
childrearing.

Parent Voices
[One parent described differences between men and women in parenting

roles.]
Mothers play the main role as parents in [certain cultures]. Culturally
men arent that involved. The dad is the outer worker; the mother is the
inner worker. If you are talking about the mom, they are the ones who
care about the kids. They arent typically working outside the home. But
now, in the United States, the mothers are working outside the home.
Although slowly changing, attitudes about the roles of men and women
in the raising of young children often differ between men and women and
among various communities in the United States. Longitudinal research on
mothers attitudes toward fathers involvement in childrearing has made ref-
erence to the gatekeeping role of mothers of children with nonresidential
fathers (Fagan and Barnett, 2003; Schoppe-Sullivan et al., 2008). Research
has shown that fathers of young children participate in child caregiving
activities in increasing numbers (Cabrera et al., 2011), but has not exam-
ined the specific attitudes that fathers bring to particular parenting behav-
iors across the life span. Parents values and goals related to childrearing,
both overall and for specific demographic groups, also may shift from one
generation to the next in the United States based on changing norms and
viewpoints within social networks and cultural communities, as well as par-
ents knowledge of and access to new research and information provided by
educators, health care providers, and others who work with families.
Relatively little research has been conducted on parents attitudes
toward specific parenting-related practices. Much of the extant research
focuses on practices related to promoting childrens physical health and
safety. Studies of varying designs indicate that parental attitudes and beliefs
about the need for and safety of vaccination influence vaccination practices
(Mergler et al., 2013; Salath and Bonhoeffer, 2008; Vannice et al., 2011;
Yaqub et al., 2014). Maternal attitudes and beliefs about breastfeeding
(e.g., views about breastfeeding in public, the belief that it will be uncom-
fortable) are associated with initiation and continuation of breastfeeding
and appear to factor into differences in breastfeeding rates and practices
observed across cultural and other demographic groups in cross-sectional
survey and qualitative research (Vaaler et al., 2010; Wojcicki et al., 2010).
Other studies have found differences among parents (e.g., those living in
rural versus urban areas) in attitudes about the importance of monitoring

childrens activities and whereabouts (Armistead et al., 2002; Jones et al.,

2003) and parents beliefs about young childrens literacy development
(Lynch et al., 2006).
Parental involvement in childrens education has been linked to aca-
demic readiness (Fan and Chen, 2001). However, parents differ in their
attitudes about the role of parents in childrens learning and education
(Hammer et al., 2007). Some see parents as having a central role, while
others view the school as the primary facilitator of childrens education and
see parents as having less of a role (Hammer et al., 2007). These attitudinal
differences may be related to cultural expectations or parents own educa-
tion or comfort with teaching their children certain skills. Some parents, for
example, may have lower involvement in their childrens education because
of insecurity about their own skills and past negative experiences in school
(Lareau, 1989; Lawrence-Lightfoot, 2003). And as discussed above, some
parents view math skills as less important for their children relative to other
types of skills and therefore are less likely to teach them in the home.
Parents within and across different communities vary in their opinions
and practices with respect to the role and significance of discipline. Some
of the parenting literature notes that some parents use control to discipline
children, while others aim to correct but not to control children (Nieman
and Shea, 2004). In a small cross-cultural ethnographic study, Mosier and
Rogoff (2003) found that some parents regard rules and punishment as
inappropriate for infants and toddlers. The approach valued by these par-
ents to help children understand what is expected of them is to cooperate
with them, perhaps distracting them but not forcing their compliance. In
contrast, many middle-class U.S. parents display a preference for apply-
ing the same rules to infants and toddlers that older children are expected
to follow, although with some lenience (Mosier and Rogoff, 2003). And
ethnographic research provides some evidence of differences in African
American and E uropean American mothers beliefs about spoiling and in-
fant intentionality (whether infants can intentionally misbehave) related to
the use of physical punishment with young children (Burchinal et al., 2010).
Parents attitudes not only toward parenting but also toward providers
in societal agenciessuch as educators, social service personnel, health
care providers, and policewhich can be shaped by a variety of factors,
including discrimination, are important determinants of parents access to
and ability to obtain support. Studies show a relationship between parents
distrust of agencies and their likelihood of rejecting participation in an
intervention. For example, in systematic reviews of studies of various types,
parents who distrust the medical community and government health agen-
cies are less likely to have their children vaccinated (Brown et al., 2010;
Mills et al., 2005). Racial and ethnic minority parents whose attitudes
about appropriate remedies for young children vary from those of the West-

ern medical establishment often distrust and avoid treatment by Western

medical practitioners (Hannan, 2015). While not specific to parents, studies
using various methodologies show that individuals who have experienced
racial and other forms of discrimination, both within and outside of health
care settings, are less likely to utilize various health services or to engage
in other health-promoting behaviors (Gonzales et al., 2013; Institute of
Medicine, 2003; Pascoe and Smart Richman, 2009; Shavers et al., 2012). In
a survey study, African American parents racism awareness was negatively
associated with involvement in activities at their childrens school (McKay
et al., 2003). Longitudinal studies, mostly involving families with older
children, indicate that, like other sources of stress, parents experience of
discrimination can have a detrimental effect on parenting and the quality
of the parent-child relationship (Murray et al., 2001; Sanders-Phillips et al.,
2009). Adverse outcomes for youth associated with their own experience
of discrimination may be weakened by more nurturing/involved parenting
(Brody et al., 2006; Gibbons et al., 2010; Simons et al., 2006).
As noted earlier, attitudes are shaped in part by parenting self-
efficacya parents perceived ability to influence the development of his
or her child. Parenting self-efficacy has been found to influence parenting
competence (including engagement in some parenting practices) as well as
child functioning (Jones and Prinz, 2005). Studies show associations be-
tween maternal self-efficacy and childrens self-regulation, social, and cogni-
tive skills (Murry and Brody, 1999; Swick and Hassell, 1990). Self-efficacy
also may apply to parents confidence in their capacity to carry out specific
parenting practices. For example, parents who reported a sense of efficacy
in influencing their elementary school-age childrens school outcomes were
more likely to help their children with school activities at home (Anderson
and Minke, 2007). A multimethod study of African American families
found that maternal self-efficacy was related to childrens regulatory skills
through its association with competence-promoting parenting practices,
which included family routines, quality of mother-child interactions based
on observer ratings, and teachers reports of mothers involvement with
their childrens schools (Brody et al., 1999). Henshaw and colleagues
(2015) found in a longitudinal study that higher breastfeeding self-efficacy
predicted exclusive breastfeeding at 6 months postpartum, as well as better
emotional adjustment of mothers in the weeks after giving birth.
Parenting Practices
Parenting practices have been studied extensively, with some research
showing strong associations between certain practices and positive child
outcomes. This section describes parenting practices that research indicates
are central to helping children achieve basic outcomes in the areas discussed

at the beginning of the chapter: physical health and safety, emotional

and behavioral competence, social competence, and cognitive competence.
While these outcomes are used as a partial organizing framework for this
section, several specific practicescontingent responsiveness of parents,
organization of the home environment and the importance of routines, and
behavioral discipline practicesthat have been found to influence child
well-being in more than one of these four outcome areas are discussed
separately.
Practices to Promote Physical Health and Safety

Parents influence the health and safety of their children in many ways.
However, the difficulty of using random assignment designs to examine par-
enting practices that promote childrens health and safety has resulted in a
largely observational literature. This section reviews the available evidence
on a range of practices in which parents engage to ensure the health and
safety of their children. It begins with breastfeedinga subject about which
there has historically been considerable discussion in light of generational
shifts and commercial practices that have affected children in poor families.
Breastfeeding Breastfeeding has myriad well-established short- and long-

term benefits for both babies and mothers. Breast milk bolsters babies
immunity to infectious disease, regulates healthy bacteria in the intestines,
and overall is the best source of nutrients to help babies grow and develop.
Breastfeeding also supports bonding between mothers and their babies. Ac-
cording to a meta-analysis by the WHO (Horta and Victora, 2013), breast-
feeding is associated with a small increase in performance on intelligence
tests in children and adolescents, reduced risk for the development of type
2 diabetes and overweight/obesity later in life, and a potential decreased
risk for the development of cardiovascular disease. Breastfeeding may ben-
efit mothers health as well by lowering risk for postpartum depression,
certain cancers, and chronic diseases such as diabetes (U.S. Department of
Health and Human Services, 2011). Current guidelines from the American
Academy of Pediatrics (2012) and the WHO (2011) recommend mothers
breastfeed exclusively until infants are 6 months old. Thereafter and until
the child is either age 1 year (American Academy of Pediatrics, 2012) or 2
years (World Health Organization, 2011), it is recommended that children
continue to be breastfed while slowly being introduced to other foods.
According to 2011 data from the CDC (2015a), about 80 percent of
babies born in the United States are breastfed (including fed breast milk) for
some duration, and about 50 percent and 27 percent are breastfed (to any
extent with or without the addition of complementary liquids or solids) at

6 and 12 months, respectively. Forty percent and 19 percent are exclusively

breastfed through 3 and 6 months, respectively.
Mothers in the United States often cite a number of reasons for not
initiating or continuing breastfeeding, including lack of knowledge about
how to breastfeed, difficulty or pain during breastfeeding, embarrassment,
perceived inconvenience, and return to work (Hurley et al., 2008; Ogbuanu
et al., 2009; U.S. Department of Health and Human Services, 2011). Low-
income women with less education are less likely than women of higher
socioeconomic status to breastfeed (Heck et al., 2006). Some research with
immigrant mothers shows that rates of breastfeeding decrease with each
generation in the United States, possibly because of differences in accep-
tance of bottle feeding here as compared with other countries (e.g., Sussner
et al., 2008).
Nutrition and physical activity Parents play an important role in shaping

their young childrens nutrition and physical activity levels (Institute of
Medicine, 2011; Sussner et al., 2006). Among toddlers and p reschool-age
children, parents feeding practices are associated with their childrens
ability to regulate food intake, which can affect weight status (Faith et al.,
2004; Farrow et al., 2015). Parents modeling of healthful eating habits for
their children and offering of healthful foods, particularly during toddler
hood, when children are often reluctant to try new foods, may result in
children being more apt to like and eat such foods (Hill, 2002; Natale et
al., 2014; Sussner et al., 2006). The extant observational research gener-
ally shows that childrens dietary intake (particularly fruit and vegetable
consumption) is associated with food options available in the home and
at school, and that parents are important role models for their childrens
dietary behaviors (Cullen et al., 2003; Pearson et al., 2009; Wolnicka et
al., 2015). Conversely, the presence of less nutritious food and beverage
items in the home may increase childrens risk of becoming overweight.
For example, Dennison and colleagues (1997) and Welsh and colleagues
(2005) found positive associations between overweight in children and their
consumption of sugar-sweetened beverages. On the other hand, there are
some indications that overly strict diets may increase childrens preferences
for high-fat, energy-dense foods, perhaps causing an imbalance in childrens
self-regulation of hunger and satiety and increasing the risk that they will
become overweight (Birch and Fisher, 1998; Farrow et al., 2015).
A few cross-sectional and longitudinal studies, coupled with conven-
tional wisdom, suggest that eating dinner together as a family is associated
with increased consumption of fruits, vegetables, and whole grains and
reduced consumption of fats and soda (Gillman et al., 2000), as well as
with reduced risk for overweight and obesity (Gable et al., 2007; Taveras

et al., 2005). However, these studies involved primarily older children and
adolescents.
Physical activity is a complement to good nutrition. Even in young chil-
dren, physical activity is essential for proper energy balance and prevention
of childhood obesity (Institute of Medicine, 2011; Kohl and Hobbs, 1998).
It also supports normal physical growth. Parents may encourage activity in
young children through play (e.g., free play with toys or playing on a play-
ground) or age-appropriate sports. Children who spend more time outdoors
may be more active (e.g., Institute of Medicine, 2011; Sallis et al., 1993)
and also have more opportunity to explore their community and interact
with other children. For many parents living in high-crime neighborhoods,
however, most of whom are racial and ethnic minorities, the importance of
safety overrides the significance of physical activity. In some neighborhoods,
safety issues and lack of access to parks and other places for safe recreation
make it difficult for families to spend time outdoors, leading parents to
keep their children at home (Dias and Whitaker, 2013; Gable et al., 2007;
Powell et al., 2003).
Although more of the research on screen time and sedentary behavior
has focused on adolescents than on young children, several cross-sectional
and longitudinal studies on younger children show an association between
television viewing and overweight and inactivity (Ariza et al., 2004; Carson
et al., 2016; Dennison et al., 2002; DuRant et al., 1994; Gable et al., 2007;
Tremblay et al., 2011). An analysis of data on 8,000 children participating
in a longitudinal cohort study showed that those who watched more televi-
sion during kindergarten and first grade were significantly more likely to
be clinically overweight by the spring semester of third grade (Gable et al.,
2007). Although television, computers, and other screen media often are
used for educational purposes with young children, these findings suggest
that balancing screen time with other activities may be one way parents can
promote their childrens overall health. As with diet, childrens sedentary
behavior can be influenced by parents own behaviors. For example, De
Lepeleere and colleagues (2015) found an association between parents
screen time and that of their children ages 6-12 in a cross-sectional study.
Vaccination Parents protect their own and other children from potentially
serious diseases by making sure they receive recommended vaccines. Among
children born in a given year in the United States, childhood vaccination is
estimated to prevent about 42,000 deaths and 20 million cases of disease
(Zhou et al., 2014). In 2013, 82 percent of children ages 19-35 months
received combined-series vaccines (for diphtheria, tetanus, and pertussis
[DTP]; polio; measles, mumps, and rubella [MMR]; and Haemophilus
influenzae type b [Hib]), up from 69 percent in 1994 (Child Trends Data
bank, 2015b). Vaccination rates are lower among low-income children;

71 percent of children ages 19-35 months living below the poverty level
received the combined-series vaccines listed above in 2014 (Child Trends
Databank, 2015b). Although much of the media coverage on this subject
has focused on middle-income parents averse to having their children vac-
cinated, it is in fact poverty that is thought to account for much of the
disparity in vaccination rates by race and ethnicity (Hill et al., 2015). As
discussed earlier in this chapter, parental practices around vaccination may
be influenced by parents knowledge and interpretation of information on
and their attitudes about vaccination.
Preconception and prenatal care The steps women take with their health
care providers before becoming pregnant can promote healthy pregnancy
and birth outcomes for both mothers and babies. These include initiat-
ing certain supplements (e.g., folic acid, which reduces the risk of birth
defects), quitting smoking, attaining healthy weight for women who are
obese, and treating preexisting physical and mental health conditions (Aune
et al., 2014; Gold and Marcus, 2008; Institute of Medicine and National
Research Council, 2009).
During pregnancy, receipt of recommended prenatal care can help par-
ents reduce the risk of pregnancy complications and poor birth outcomes
by promoting healthy behaviors (e.g., smoking cessation, adequate rest and
nutrition), as well as identifying and managing any complications that do
arise. Prior to the birth of a child, health care providers also can educate
parents on the importance of breastfeeding, infant injury and illness preven-
tion, and other practices.
Infants born to mothers who do not receive prenatal care or who do
not receive it until late in their pregnancy are more likely than those born
to mothers who receive such care early in pregnancy to be born premature
and at a low birth weight and are more likely to die. Since the 1970s, there
has been a decline in the number of women in the United States receiving
late or no prenatal care, with the majority of pregnant women now re-
ceiving recommended prenatal care (Child Trends Databank, 2015a). Yet
disparities among subgroups persist. In 2014, American Indian and Alaska
Native (11% of births), black (10% of births), and Hispanic (8% of births)
women were more than twice as likely as white mothers (4% of births) to
receive late or no prenatal care (Child Trends Databank, 2015a). The
proportion of women receiving timely prenatal care increases with age: in
2014, 25 percent of births to females under age 15 and 10 percent of births
to females ages 15-19 were to mothers receiving late or no prenatal care,
compared with 7.8 percent for females ages 20-24 and 5.6 percent for those
ages 25-29 (Child Trends Databank, 2015a). Women whose pregnancies
are unintended also are less likely to receive timely prenatal care. Despite
the importance of timely and quality prenatal care, moreover, many parents

experience barriers to receiving such care, including poor access and rural
residence, limited knowledge of its importance, and mental illness (Heaman
et al., 2014).
Injury preventionUnintentional injuries are the leading cause of death

among children ages 1-9 (Centers for Disease Control and Prevention,
2015c) and a leading cause of disability for both younger and older children
in the United States. In addition to motor vehicle-related injuries, children
sustain unintentional injuries (due, for example, to suffocation, falls, poi-
soning, and drowning) in the home environment. About 1,700 children
under age 9 in the United States die each year from injuries in the home
(Mack et al., 2013).
Parents can protect their children from injury through various mea-
sures, such as ensuring proper use of automobile passenger restraints,
insisting that children wear helmets while bike riding and playing sports,
and creating a safe home environment (e.g., keeping medicines and clean-
ing products out of childrens reach, installing safety gates to keep children
from falling down stairs). Yet the limited available research on parents use
of safety measures suggests there is room for improvement in some areas.
For instance, appropriate use of child restraint systems is known to reduce
the risk of child motor vehicle-related injuries and deaths (Arbogast et al.,
2009; Durbin, 2011); nonetheless, data show that many children ride in
automobiles without appropriate restraints (Greenspan et al., 2010; Lee et
al., 2015; Macy et al., 2014). Likewise, using data from a national survey
conducted during 2001-2003, Dellinger and Kresnow (2010) show that less
than one-half of children ages 5-14 always wore bicycle helmets while rid-
ing, and 29 percent never did so. More recent data on parents home safety
practices and on helmet usage among young children are lacking.
Evidence that families home safety practices affect child safety comes
from intervention research. A large meta-analysis of randomized and non-
randomized controlled trials of home safety education interventions for
families (Kendrick et al., 2013) showed that the education was generally
effective in increasing the proportion of families that stored medicines and
cleaning products out of reach and that had fitted stair gates, covers on
unused electrical sockets, safe hot tap water temperatures, functional smoke
alarms, and a fire escape system. There was also some evidence for reduced
injury rates among children. As discussed in Chapter 4, helping parents re-
duce hazards in the home is a component of some home visiting programs.
Parents also protect their childrens safety by monitoring their where-
abouts and activities to prevent them from both physical and psychologi-
cal harm. The type of supervision may vary based on a childs needs and
age as well as parents values and economic circumstances. For all young
children, monitoring for the purposes of preventing exposure to hazards is

an important practice. As children grow older, knowing their friends and

where the children are when they are not at home or in school also becomes
important. As noted previously, research suggests the importance of moni-
toring screen time to childrens well-being. And monitoring of childrens
Internet usage may prevent them from being exposed to online predators
(Finkelhor et al., 2000).
Practices to Promote Emotional and

Behavioral Competence and Social Competence
Fundamental to childrens positive development is the opportunity
to grow up in an environment that responds to their emotional needs
(Bretherton, 1985) and that enables them to develop skills needed to cope
with basic anxieties, fears, and environmental challenges. Parents ability
to foster a sense of belonging and self-worth in their children is vital to the
childrens early development. In much the same way, parents contribute
to childrens emerging social competence by teaching them skillssuch as
self-control, cooperation, and taking the perspective of othersthat pre-
pare them to develop and maintain positive relationships with peers and
adults. Parents can promote the learning and acquisition of social skills by
establishing strong relationships with their children. The importance of
early parent-child interactions for childrens social competence is embed-
ded in many theoretical frameworks, such as attachment (Ainsworth and
Bowlby, 1991), family system theories (Cox and Paley, 1997), and eco-
cultural theories (Weisner, 2002). Parents socialize their children to adopt
culturally appropriate values and behaviors that enable them to be socially
competent and act as members of a social group.
Research suggests that children who are socially competent are inde-
pendent rather than suggestible, responsible rather than irresponsible, co-
operative instead of resistive, purposeful rather than aimless, friendly rather
than hostile, and self-controlled rather than impulsive (Landy and Osofsky,
2009). In short, the socially competent child exhibits social skills (e.g., has
positive interactions with others, expresses emotions effectively), is able to
establish peer relationships (e.g., being accepted by other children), and has
certain individual attributes (e.g., shows capacity to empathize, has coping
skills). Parents help children develop these social skills through parenting
practices that include fostering and modeling positive relationships and pro-
viding enriching and stimulating experiences and opportunities for children
to exercise these skills (Landy and Osofsky, 2009). Parents also help their
children acquire these skills by having them participate in routine activi-
ties (e.g., chores, taking care of siblings) and family rituals (e.g., going to
church) (Weisner, 2002). These activities are shared with and initiated by
parents, siblings, and other kin; unfold within the home; and are structured

by cultural and linguistic practices, expectations, and behaviors (Rogoff,

2003; Weisner, 2002). In this context, young children interact with their
mothers, fathers, siblings, and grandparents who teach them implicitly or
explicitly to acquire appropriate social behaviors, adapt to expected norms,
and learn linguistic conventions and cognitive skills (Sameroff and Fiese,
2000).
Another important aspect of parent-supported social development per-
tains to parents aiding their children in acquiring executive function skills
needed to adapt to changing needs of the environment and regulate their
impulses and responses to distressing situations (Blair and Raver, 2012;
Malin et al., 2014; Thompson, 1994). Evidence, primarily from correla-
tional research, suggests that parents who help their children regulate the
difficulty of tasks and who model mature performance during joint partici-
pation in activities are likely to have socially competent children (Eisenberg
et al., 1998). Parents also facilitate their childrens development of friend-
ships by engaging in positive social interaction with them and by creating
opportunities for them to be social with peers (McCollum and Ostrosky,
2008). In one correlational study, children whose parents initiated peer
contacts had more playmates and more consistent play companions in
their preschool peer networks (Ladd et al., 2002). Research also shows
that children who have increased opportunities for playing or interacting
with children from diverse backgrounds are likely to develop less preju-
dice and more empathy toward others (Bernstein et al., 2000; Perkins and
Mebert, 2005; Pettigrew and Tropp, 2000).
Findings from experimental studies on parent training provide evidence
of the types of parental practices that are associated with child emotional
and behavioral health (i.e., fewer internalizing and externalizing prob-
lems) and social competence (i.e., relationship building skills, moral disposi-
tions, and prosocial behaviors such as altruism). In one study for example,
parent training designed to decrease the use of harsh discipline and increase
supportive parenting reduced mother-reported child behavior problems in
children ages 3-9 (Bjrknes and Manger, 2013). In another randomized
study, mothers who received parent training to improve their empathy
toward their children became less permissive with their 2- to 3-year-olds,
who became less aggressive (Christopher et al., 2013).
These relationships have been found to hold in experimental studies
involving diverse samples. Brotman and colleagues (2005) found that a
program designed to reduce parents use of negative parenting and increase
their provision of stimulation for child learning increased social competence
with peers in young African American and Latino children who had a sib-
ling who had been involved in the juvenile justice system. In a European
study, Berkovits and colleagues (2010) studied ethnically diverse parents
participating in an abbreviated parent skills training delivered in pediatric

primary care aimed at encouraging childrens prosocial behavior. The find-

ings show significant increases in effective parenting strategies and in par-
ents beliefs about personal controls, as well as declines in child behavior
problems. Improvements in child behavior as a consequence of parent
training have been found not only for programs emphasizing better and
more consistent discipline and contingency management, but also for those
providing training that led to parents greater emotional support for their
children (McCarty et al., 2005). In addition, Stormshak and colleagues
(2000) found that punitive interactions between parents and children were
associated with higher rates of child disruptive behavior problems, and that
low levels of warm involvement were characteristic of parents of children
who showed oppositional behaviors.
Internalizing disorders in young children include depression (with-
drawal, persistent sadness) and anxiety (Tandon et al., 2009). They may
occur simultaneously with and/or independently of externalizing disor-
ders (e.g., noncompliance, aggression, coercive behaviors directed at the
environment and others) (Dishion and Snyder, 2016). Studies focusing
exclusively on the causes of internalizing disorders in young children are
relatively limited. However, the results of the available studies lead to
similar conclusions about the relationships among training, changes in
parenting practices, and child internalizing problems. First, there is evidence
that parental behaviors matter for child emotional functioning. Specifically,
parents sense of personal control and behaviors such as autonomy granting
are inversely related to child anxiety in cross-sectional research (McLeod et
al., 2007). Similarly, in another nonexperimental study, Duncombe and col-
leagues (2012) show that inconsistent discipline, parents negative emotion,
and mental health are related to child problems with emotion regulation.
Second, there is evidence that parent training interventions can modify
the parenting practices that matter. Third, some parent training interven-
tions have positive effects on childrens emotional functioning. In a review
of randomized controlled studies of the effects of group-based parenting
programs on behavioral and emotional adjustment, Barlow and colleagues
(2010) found significant effects of the programs on parent-reported out-
comes of children under age 4. Herbert and colleagues (2013) conducted
a randomized clinical trial of parent training and emotion socialization
for hyperactive preschool children in which the target outcome was emo-
tion regulation. Not only did the intervention group mothers report lower
hyperactivity, inattention, and emotional lability in their children, but also
changes in childrens functioning were correlated with more positive and
less negative parenting and with less verbosity, greater support, and use of
emotion socialization practices on the part of mothers.
With respect to social competence, a number of studies point to a
relationship with parenting practices and suggest that parent training may

have an impact on both parenting practices related to and childrens devel-

opment of social competence. An experimental evaluation of the Incred-
ible Years Program (discussed further in Chapter 5), for instance, found
that parent training contributed to improved parenting practices, defined
as lower negative parenting and increased parental stimulation for learn-
ing (Brotman et al., 2005), which, in turn, are related to childrens social
competence. Gagnon and colleagues (2014) found that preschool children
with a combination of reactive temperament and authoritarian parents
demonstrated low social competence (high levels of disruptive play and low
levels of interactive play). In a community trial by Havighurst and col-
leagues (2010), training focused on helping parents tune in to their own
and their childrens emotions resulted in significant improvement in the
parents emotion awareness and regulation, as well as the practice of emo-
tion coping. The intervention decreased emotionally dismissive beliefs and
behaviors among parents, who also used emotion labels and discussed the
causes and consequences of emotions with their children more often than
was the case prior to the training. The program improved parental beliefs
and relationships with their children, and these improvements were related
to reductions in child behavior problems (Havighurst et al., 2010).
Practices to Stimulate Cognitive Development

As explained in the National Research Council (2000) report How
People Learn: Brain, Mind, Experience, and School, individuals learn
by actively encountering events, objects, actions, and concepts in their
environments. For an individual to become an expert in any particular
knowledge or skill area, he or she must have substantial experience in that
area which is usually guided (Dweck and Leggett, 2000; National Research
Council, 2000). As childrens first teachers, parents play an important role
in their cognitive development, including their acquisition of such compe-
tencies as language, literacy, and numerical/math skills that are related to
future success in school and society more generally. Enriching and stimulat-
ing sets of experiences for children can help develop these skills.
Evidence of the potential importance of parenting for language devel
opment is found across studies of parent talk. This research offers compel-
ling correlational evidence that providing children with labels (e.g., for
objects, numbers, and letters) to promote and reinforce knowledge, re-
sponding contingently to their speech, eliciting and sustaining conversation
with them, and simply talking to them more often are related to vocabulary
development (Hart and Risley, 1995; Hirsh-Pasek et al., 2015; Hoff, 2003).
In addition to the frequency of talking with children, research is beginning
to show that the quality of language used by parents when interacting with
their children may matter for childrens vocabulary development. Studies

using various types of designs have shown that children whose fathers are
more educated and use complex and diverse language when interacting with
them develop stronger vocabulary skills relative to other children (Malin et
al., 2012; Pancsofar and Vernon-Feagans, 2006; Rowe et al., 2004).
Language development studies have found that providing an instruc-
tional platform in a childs early language experience, such as offering a
social context for communication and asking more what, where, and
why questions, is associated with language acquisition (Baumwell et al.,
1997; Bruner, 1983; Leech et al., 2013). Similar findings are provided by
experimental research on dialogic reading, in which adults engage children
in discussion about the reading material rather than simply reading to
them (Mol et al., 2008; Whitehurst et al., 1988). A meta-analytic review
of 16 interventions by Mol and colleagues (2008) showed that, relative to
reading as usual, dialogic reading interventions, especially use of expressive
language, were more effective at increasing childrens vocabulary. The ef-
fect was stronger for children ages 2-3 and more modest for those ages 4-5
and those at risk for language and literacy impairment (Mol et al., 2008).
Frequency of shared book reading by mothers and fathers is linked
to young childrens acquisition of skills and knowledge that affect their
later success in reading, writing, and other areas (Baker, 2014; Duursma
et al., 2008; Malin et al., 2014). Studies demonstrate that through shared
book reading, young children learn, among other skills, to recognize letters
and words and develop understanding that print is a visual representa-
tion of spoken language, develop phonological awareness (the ability to
manipulate the sounds of spoken language), begin to understand syntax
and grammar, and learn concepts and story structures (Duursma et al.,
2008; Malin et al., 2014). Shared literacy activities such as book reading
also expose children to new words and words they may not encounter in
spoken language, stimulating vocabulary development beyond what might
be obtained through toy-play or other parent-child interactions (Isbell et
al., 2004; Ninio, 1983; Whitehurst et al., 1988). Regular book reading also
may play a role in establishing routines for children and shaping wake and
sleep patterns, as well as provide them with knowledge about relationships
and coping that can be applied in the real world (Duursma et al., 2008).
Children of low socioeconomic status and minority children frequently
have smaller vocabularies relative to children of higher socioeconomic status
and white children, and these differences increase over time (Markman and
Brooks-Gunn, 2005). Some experts have theorized that this differential
arises from variations in speech cultures of families, which are linked
to socioeconomic status and race/ethnicity. The middle- and upper-class
(primarily white) speech culture is associated with more and more varied
language and more conversation, which contributes to bigger vocabularies
and improved school readiness among children in these homes (Hart and

Risley, 1999). Little research has focused on whether reducing these varia-
tions would help close the racial/ethnic gap in school readiness, however
(Markman and Brooks-Gunn, 2005). Relative to their middle- and upper-
class, mainly white, counterparts, low-income and immigrant parents are
less likely to report that they read to their children on a regular basis
and to have books and other learning materials in the home (Markman and
Brooks-Gunn, 2005). Besides culture, this difference may be due to such
factors as access to books (including those in parents first language), par-
ents own reading and literacy skills, and erratic work schedules (which
could interfere with regular shared book reading before children go to bed,
for example).
As discussed in Chapter 4, limited experimental research suggests
that interventions designed to promote parents provision of stimulating
learning experiences support childrens cognitive development, primarily
on measures of language and literacy (Chang et al., 2015; Garcia et al.,
2015; Mendelsohn et al., 2005; Roberts and Kaiser, 2011). In one study,
for example, interactions between high-risk parents and their children
over developmentally stimulating, age-appropriate learning material (e.g.,
a book or a toy), followed by review and discussion between parents and
child development specialists, were found to improve childrens cognitive
and language skills at 21 months compared with a control group, and also
reduced parental stress (Mendelsohn et al., 2005).
Early numeracy and math skills also are building blocks for young
childrens academic achievement (Claessens and Engel, 2013). To instill
early math skills in young children, parents sometimes employ such strate-
gies as playing with blocks, puzzles, and legos; assisting with measuring
ingredients for recipes; solving riddles and number games; and playing
with fake money (Benigno and Ellis, 2008; Hensen, 2005). Such experi-
ences may facilitate childrens math-related competencies, but compared
with the research on strategies to foster childrens language development,
the evidence base on how parenting practices promote math skills in young
children is small.
A growing literature identifies general aspects of home-based parental
involvement in childrens early learningsuch as parents expectations
and goals for their children, parent-child communication, and support for
learningthat appear to be associated with greater academic achievement,
including in math (Fan and Chen, 2001; Galindo and Sonnenschein, 2015;
Ginsburg et al., 2010; Jeynes, 2003, 2005). More work is needed, however,
to distill specific actions parents can take to promote math-related skills
in their young children. At the same time, as noted earlier, some parents
appear to be reluctant to engage their children in math learningsome
because they lack knowledge about early math and may engage in few
math-related activities in the home relative to activities related to language,

and some because they view math skills as less important than other skills
for their children (Blevins-Knabe et al., 2000; Cannon and Ginsburg, 2008;
Vukovic and Lesaux, 2013). Given the demonstrated importance of early
math skills for future academic achievement and the persistent gap in math
knowledge related to socioeconomic status (Galindo and Sonnenschein,
2015), additional research is needed to elucidate how parents can and do
promote young childrens math skills and how they can better be supported
in providing their children with these skills.
Finally, there is some evidence for differences across demographic
groups in the United States with respect to parents use of practices to pro-
mote childrens cognitive development. Barbarin and Jean-Baptiste (2013),
for example, found that poor and African American parents employed
dialogic practices less often than nonpoor and European American parents
in a study that utilized in-home interviews and structured observations of
parent-child interactions.
Contingent Responsiveness of Parents

Broadly defined, contingent responsiveness denotes an adults behavior
that occurs immediately after and in response to a childs behavior and is
related to the childs focus of attention (Roth, 1987). Dunst and colleagues
(1990) argue that every time two or more people are together, there is a
communicative exchange in which the behavior (nonverbal or verbal) af-
fects the other person, is interpreted, and is responded to with a discernible
outcome (p. 1). Such communication exchanges between parents and their
children are considered foundational for building healthy relationships be-
tween parents and children, as well as between parents (Cabrera et al., 2014).
Within the multiple relationships and systems that surround parents
and children, the quality of the relationship they share is vital for the well-
being of both (Bronfenbrenner and Morris, 1998). The science is clear on
the importance of positive parent-child relationships for children. Emotion-
ally responsive parenting, whereby parents respond in a timely and appro-
priate way to childrens needs, is a major element of healthy relationships,
and is correlated with positive developmental outcomes for children that
include emotional security, social facility, symbolic competence, verbal
ability, and intellectual achievement (Ainsworth et al., 1974). The majority
of children who are loved and cared for from birth and develop healthy
and reciprocally nurturing relationships with their caregivers grow up to
be happy and well adjusted (Armstrong and Morris, 2000; Bakermans-
Kranenburg et al., 2003). Conversely, children who grow up in neglectful or
abusive relationships with parents who are overly intrusive and controlling
are at high risk for a variety of adverse health and behavioral outcomes
(Barber, 2002; Egeland et al., 1993).

The development of health-promoting relationships between parents

and their children is rooted in evolutionary pressures that lead children to
be born wired to interact with their social environment in ways that will en-
sure their survival and promote their eventual development (Bowlby, 2008).
Through reaching out, babbling, facial expressions, and gestures, very young
children signal to caregivers when they are ready to engage with them.
Caregivers may respond by producing similar vocalizations and gestures
to signal back to infants that they have heard and understood (Masataka,
1993). Cabrera and colleagues (2007) found that children of fathers who
react to their behavior in a sensitive way by following their cues, responding,
and engaging them are more linguistically and socially competent relative to
children of fathers who do not react in these ways (Cabrera et al., 2007).
This serve and return interaction between caregivers and chil-
dren, which continues throughout childhood, is fundamental for growth-
promoting relationships (Institute of Medicine and National Research
Council, 2015; National Research Council and Institute of Medicine,
2000). A consistent give and take with responsive caregivers provides
the child with tailored experiences that are enriching and stimulating;
forms an emotional connection between caregiver and child; builds on the
childs interests and capacities; helps the child develop a sense of self; and
stimulates the childs intellectual, social, physical, and emotional and behav-
ioral growth (Institute of Medicine and National Research Council, 2015;
National Research Council and Institute of Medicine, 2000). This give and
take is particularly important for language development. It is believed that
through this process, the child learns that she or he is loved and will love
others in return, and that she or he is accepted and cared for and will also
eventually accept and care for others.
For infants, social expectations and a sense of self-efficacy in initiat-
ing social interactions are influenced by their early interactions with their
caregivers. McQuaid and colleagues (2009) found that mothers contin-
gent smiles (i.e., those in response to infant smiles) in an initial interactive
study phase predicted infant social bids when mothers were still-faced in a
subsequent study phase, a finding consistent with results of earlier research
(Bigelow, 1998). The adults response to the childs overtures for interac-
tion needs to be contingent on the childs behaviors. Infants spontaneous
vocalizations are characterized by pauses that enable caregivers to respond
vocally. Children who have experience with turn taking are able to vocalize
back to the caregiver in a synchronized manner (Masataka, 1993). Young
childrens social and emotional development is influenced by the degree to
which primary caregivers engage them in this kind of growth-promoting
interaction (Cassidy, 2002).
As described in Chapter 1, securely attached infants develop basic trust
in their caregivers and seek the caregivers comfort and love when alarmed

because they expect to receive protection and emotional support. Infants

who trust their caregivers to respond to their needs in a sensitive and timely
manner are able to explore and learn freely because they can return to their
safe base if they encounter unfamiliar things and events (Bowlby, 2008;
Cassidy, 2002). In the face of the demands of daily life, with parents being
unable to offer individualized responsiveness and synchronized, attuned
interactions all of the time, sensitive caregiving makes it possible to manage
and repair disruptions that inevitably occur in day-to-day parenting.
High-quality serve and return parenting skills do not always develop
spontaneously, especially during infancy and toddlerhood, before children
have learned to speak. Some research indicates that lower-income families
are at higher risk for not engaging in these types of interactions with their
children (Paterson, 2011), but there is variability within and across eco-
nomic and cultural groups (Cabrera et al., 2006). Differences among racial/
ethnic groups in mothers interactive behaviors with their young children
have also been noted (e.g., Brooks et al., 2013; Cho et al., 2007). In a study
of mothers of premature infants, for example, American Indian mothers
relative to African American mothers looked and gestured more with their
infants based on observer ratings (Brooks et al., 2013). Such differences
may be related to variation in sociocultural norms or to other factors.
Parents who experience such stressors as low income, conflict with partners
or other adults, depression, and household chaos face more challenges to
engaging in emotionally responsive parenting because of the emotional toll
these stressors can exact (Conger and Donnellan, 2007; Markman and
Brooks-Gunn, 2005; McLoyd, 1998). Building the capacities of all care-
givers to form responsive and nurturing relationships with their children is
crucial to promoting child well-being.
As detailed in Chapters 4 and 5, experimental studies largely confirm
evidence from correlational studies showing that sensitive parenting and
attachment security are related to childrens social-emotional development
(Van Der Voort et al., 2014). One international study found that an inter-
vention focused on responsive stimulation could promote positive care-
giving behaviors among impoverished families (Yousafzai et al., 2015).
Another study found that home visiting for parents of preterm infants that
entailed promotion of more sensitive and responsive parenting skills mod-
estly improved parent-infant interactions (Goyal et al., 2013).
These and other interventions that successfully promote positive par-
ent-child interactions, secure attachment, and healthy child development
have been developed for parents of both infants (Armstrong and Morris,
2000) and preschoolers (Bagner and Eyberg, 2007). Some research shows
that such an intervention provided first in infancy, followed by a second
dose during the toddler/preschool years, is most effective at improving
maternal behaviors and child outcomes (Landry et al., 2008). However,

the success of preventive interventions in improving the quality of parent-

infant attachment, a parents relationship with her or his child, and the
resulting child mental and physical outcomes depends upon the quality of
the intervention (Chaffin et al., 2004), the number of sessions (a moderate
number may be better than either more or less) (Moss et al., 2011), and
the degree to which other parts of the parent-child system (e.g., separation
due to parental incarceration or other reasons) are considered (Barr et
al., 2011). Although much of the literature has focused on non-Hispanic
white and black families, and mainly on mothers, preventive interventions
with successful maternal and child outcomes have also been developed for
Hispanic and Asian families (Ho et al., 2012; McCabe and Yeh, 2009) and
can be designed to include fathers (Barr et al., 2011).
Organization of the Home Environment and the Importance of Routines

Observational research suggests that childrens development is en-
hanced by parents use of predictable and orderly routines. Family routines,
such as those related to feeding, sleeping, and learning, help structure chil-
drens environment and create order and stability that, in turn, help children
develop self-regulatory skills by teaching them that events are predictable
and there are rewards for waiting (Evans et al., 2005; Hughes and Ensor,
2009; Martin et al., 2012). Conversely, an unpredictable environment may
undermine childrens confidence in their ability to influence their environ-
ment and predict consequences, which may in turn result in childrens hav-
ing difficulty with regulating their behavior according to situational needs
(Deater-Deckard et al., 2009; Evans and English, 2002).
Although family routines vary widely across time and populations,
studies have associated such routines with childrens developmental out-
comes (Fiese et al., 2002; Spagnola and Fiese, 2007). It is particularly
difficult, however, to infer causal effects of routines on child outcomes in
correlational studies because of the many contextual factors (e.g., parental
depression or substance abuse, erratic work schedules) or factors related
to economic strain (e.g., homelessness, poverty) that may make keeping
routines difficult and at the same time adversely affect child development
in other ways.
Several literatures have developed around routines thought to promote
particular developmental targets. For example, Mindell and colleagues
(2009) describe results from a randomized controlled trial in which m others
instructed in a specific bedtime routine reported reductions in sleep prob-
lems for their infants and toddlers (see also Staples et al., 2015, for a
recent nonexperimental analysis of bedtime routines and sleep outcomes).
De Castilho and colleagues (2013) found in a systematic review of random-
ized controlled trials consistent associations between childrens oral health

and elements of their family environment such as parents toothbrushing

habits. And in a nationally representative cross-sectional study, A nderson
and Whitaker (2010) report strong associations between exposure to vari-
ous household routines, such as eating meals as a family, obtaining ad-
equate sleep, and limiting screen time, and risk for obesity in preschool-age
children. As discussed above, a growing body of literature also reports
associations between more general aspects of childrens healthy develop-
ment, such as social competence, and the organization and predictability
of a broader set of day-to-day experiences in the home (see Evans and
Wachs, 2010).
In some cases, however, routines are difficult to establish because of
demands on parents, such as the nonstandard work schedules some parents
are forced to keep. Reviewing the cross-sectional and longitudinal literature
on nonstandard work schedules, for example, Li and colleagues (2014)
found that 21 of the 23 studies reviewed reported associations between
nonstandard work schedules and adverse child developmental outcomes.
They found that while parents working nonstandard schedules, particularly
those who work night or evening shifts, may be afforded more parent-child
time during the day, such schedules can lead to fatigue and stress, with
detrimental effects on the parents physical and psychological capacity to
provide quality parenting.
Other research has looked at the impacts on children of living in home
environments that are marked by high levels of chaos, or instability and
disorganization (Evans and Wachs, 2010; Vernon-Feagans et al., 2012).
A few studies have found a relationship between measures of household
instability and disorganization and risk of adverse cognitive, social, and
behavioral outcomes in young children. In a longitudinal study, for ex-
ample, Vernon-Feagans and colleagues (2012) found that a higher level
of household disorganization in early childhood (e.g., household density,
messiness, neighborhood and household noise) was predictive of poorer
performance on measures of receptive and expressive vocabulary at age
3. This finding held after taking into account a wide range of variables
known to influence childrens language development. Household instabil-
ity (e.g., number of people moving in and out of the household, changes
in residence and care providers) was not predictive of adverse language
outcomes (Vernon-Feagans et al., 2012). In another longitudinal study,
a questionnaire was used to assess household chaos based on whether
parents had a regular morning routine, whether a television was usu-
ally on in the home, how calm the home atmosphere was, and the like
when children were in kindergarten. Parent-reported chaos accounted for
variations in child IQ and conduct problems in first grade beyond other
home environment predictors of these outcomes such as lower parental
education and poorer home literacy environment (Deater-Deckard et al.,

2009). In other studies, children rating their homes as more chaotic have
been found to earn lower grades (Hanscombe et al., 2011) and to show
more pronounced conduct and hyperactivity problems (Fiese and Winter,
2010; Hildyard and Wolfe, 2002; Jaffee et al., 2012; Repetti et al., 2002;
Sroufe et al., 2005).
Household chaos has strong negative associations with childrens abili-
ties to regulate attention and arousal (Evans and Wachs, 2010). Children
raised in chaotic environments may adapt to these contexts by shifting
their attention away from overstimulating and unpredictable stimuli, es-
sentially tuning out from their environment (Evans, 2006). In the short
term, this may be an adaptive solution to reduce overarousal. In the long
term, however, it may also lessen childrens exposure to important aspects
of socialization and, in turn, negatively affect their cognitive and social-
emotional development.
Emerging evidence suggests that the relationship between household
chaos and poorer child outcomes may involve other aspects of the home
environment, such as maternal sensitivity. In chaotic environments, for ex-
ample, longitudinal research shows that parents abilities to read, interpret,
and respond to their childrens needs accurately are compromised (Vernon-
Feagans et al., 2012). Furthermore, supportive and high-quality exchanges
between caregivers and young children, thought to support young childrens
abilities to maintain and volitionally control their attention, are fewer and
of lower quality in such environments (Conway and Stifter, 2012; Vernon-
Feagans et al., 2012). This association is likely to be of particular impor-
tance in infancy, when children lack the self-regulatory capacities to screen
out irrelevant stimuli without adult support (Conway and Stifter, 2012;
Posner and Rothbart, 2007).
Even ambient noise from the consistent din of a television playing in
the background is associated with toddlers having difficulty maintaining
sustained attention during typical playa building block for the volitional
aspects of executive attentional control (Blair et al., 2011; Posner and
Rothbart, 2007). Studies with older children and adults show that chronic
exposure to noise is related to poorer attention during visual and auditory
search tasks (see Evans, 2006; Evans and Lepore, 1993).
In addition, household chaos likely serves as a physiological stressor
that undermines higher-order executive processes. Theoretical and empirical
work indicates that direct physiological networks link the inner ear with
the myelinated vagus of the 10th cranial nervea key regulator of para
sympathetic stress response (Porges, 1995). Very high or very low frequen-
cies of auditory stimuli such as those present in ambient and unpredictable
noise directly trigger vagal responses indicative of parasympathetic stress
modulation (Porges et al., 2013). In the same way, novel unpredictable and
uncontrollable experiences can activate the hypothalamic-pituitary-adrenal

(HPA)1 axis (Dickerson and Kemeny, 2004). General levels of chaos play
a role in childrens autonomic nervous system and HPA axis functioning
(Blair et al., 2011; Evans and English, 2002) in ways that may negatively
affect executive functioning (Berry et al., 2012; Oei et al., 2006).
Highly chaotic environments also may affect childrens language and
early literacy development through similar mechanisms. Overstimulation,
which may overtax childrens attentional and executive systems, may chal-
lenge young childrens ability to encode, process, and interpret linguistic
information (Evans et al., 1999). The lack of order in such an environ-
ment also may impair childrens emerging executive functioning abilities
(see Schoemaker et al., 2013). Better executive functioning has been found
in longitudinal research to be strongly associated with larger receptive
vocabularies in early childhood (Blair and Razza, 2007; Hughes and Ensor,
2007), as well as with lower levels of externalizing behaviors (Hughes and
Ensor, 2011). Other longitudinal studies have found positive relationships
between family routines and childrens executive functioning skills during
the preschool years (e.g., Hughes and Ensor, 2009; Martin et al., 2012;
Raver et al., 2013).
Behavioral Discipline Practices

Parental guidance or discipline is an essential component of parenting.
When parents discipline their children, they are not simply punishing the
childrens bad behavior but aiming to support and nurture them for self-
control, self-direction, and their ability to care for others (Howard, 1996).
Effective discipline is thought to require a strong parent-child bond; an
approach for teaching and strengthening desired behaviors; and a strategy
for decreasing or eliminating undesired or ineffective behaviors (American
Academy of Pediatrics, 1998).
Effective discipline entails some of the parenting practices discussed
earlier. In childrens earliest years, for example, discipline includes parents
use of routines that not only teach children about the behaviors in which
people typically engage but also help them feel secure in their relationship
with their parent because they can anticipate those daily activities. As
infants become more mobile and begin to explore, parents need to create
safe environments for them. Beginning in early childhood and continuing
as children get older, positive child behavior may be facilitated through par-
ents clear communication of expectations, modeling of desired behaviors,
and positive reinforcement for positive behaviors (American Academy of
1The HPA axis regulates the release of cortisol, an important hormone associated with
psychological, physiological, and physical health functioning (Dickerson and Kemeny, 2004,
p. 355).

Pediatrics, 2006). Over time, children internalize the attitudes and expecta-
tions of their caregivers and learn to self-regulate their behavior.
Parents use of corporal punishment as a disciplinary measure is a
controversial topic in the United States. Broadly defined as parents inten-
tional use of physical force (e.g., spanking) to cause a child some level of
discomfort, corporal punishment is assumed to have as its goal correcting
childrens negative behavior. Many researchers and professionals who work
with children and families have argued against the use of physical punish-
ment by parents as well as in schools (American Psychological Association,
2016; Hendrix, 2013). Although illegal in several countries, in no U.S.
state is parents use of corporal punishment entirely prohibited, with some
variation in where states draw the line between corporal punishment and
physical abuse (Coleman et al., 2010; duRivage et al., 2015).
The state laws are consistent with the views of many Americans who
approve of the use of spanking, used by many parents as a disciplinary mea-
sure with their own children (Child Trends Databank, 2015a; M acKenzie
et al., 2013). In a 2014 nationally representative survey of attitudes about
spanking, 65 percent of women and 78 percent of men ages 18-65 agreed
that children sometimes need to be spanked (Child Trends Databank,
2015a). Among parents participating in the Fragile Families and Child
Well-Being Study, 57 percent of mothers and 40 percent of fathers reported
spanking their children at age 3, and 52 percent of mothers and 33 percent
of fathers reported doing so when their children were age 5 (MacKenzie
et al., 2013).
Although physical punishment often results in immediate cessation of
behavior that parents view as undesirable in young children, the longer-
term consequences for child outcomes are mixed, with research show-
ing a relationship with later behavioral problems. In a systematic review
of studies using randomized controlled, longitudinal, cross-sectional, and
other design types, Larzelere and Kuhn (2005) found that, compared with
other disciplinary strategies, physical punishment was either the primary
means of discipline or was severe was associated with less favorable child
outcomes. In particular, children who were spanked regularly were more
likely than children who were not to be aggressive as children as well as
during adulthood.
More recent analyses of data from large longitudinal studies conducted
in the United States show positive associations between corporal punish-
ment and adverse cognitive and behavioral outcomes in children (Berlin et
al., 2009; Bodovski and Youn, 2010; MacKenzie et al., 2013; Straus and
Paschall, 2009). Using data from two cohorts of young children (ages 2-4
and 5-9) in the National Longitudinal Survey of Youth, Straus and Paschall
(2009) found that children whose mothers reported at the beginning of the
study that they used corporal punishment performed worse on measures of

cognitive ability 4 years later relative to children whose mothers stated that
they did not use corporal punishment. In the Early Head Start National
Research and Evaluation Project, Berlin and colleagues (2009) found that
spanking at age 1 predicted aggressive behavior problems at age 2 and lower
developmental scores at age 3, but did not predict childhood aggression at
age 3 or development at age 2. The overall effects of spanking were not
large. In the Fragile Families and Child Well-Being Study, MacKenzie and
colleagues (2013) found that children whose mothers spanked them at age 5
relative to those whose mothers did not had higher levels of externalizing
behavior at age 9. High-frequency spanking by fathers when the children
were age 5 was also associated with lower child-receptive vocabulary at
age 9. These studies controlled for a number of factors besides parents use
of physical punishment (e.g., parents education, child birth weight) that in
other studies have been found to be associated with negative child outcomes.
Some have proposed that the circumstances in which physical discipline
takes place (e.g., whether it is accompanied by parental warmth) may influ-
ence the meaning of the discipline for the child as well as its effects on child
outcomes (Landsford et al., 2004). Using data from a large longitudinal
survey, McLoyd and Smith (2002) found that spanking was associated with
an increase in problem behaviors in African American, white, and Hispanic
children when mothers exhibited low levels of emotional support but not
when emotional support from mothers was high.
Time-out is a discipline strategy recommended by the American Acad-
emy of Pediatrics for children who are toddlers or older (American Academy
of Pediatrics, 2006), and along with redirection appears to be used in-
creasingly by parents instead of more direct verbal or physical punishment
(Barkin et al., 2007; LeCuyer et al., 2011). Yet for some parents, use of
time-out may not be optimal, and parents who consult the Internet for how
best to use this disciplinary technique may find the information to be incom-
plete and/or erroneous (Drayton et al., 2014). Research on best practices
for the use of time-out continues to emerge, generally pointing to relatively
short time-outs that are shortened further if the child responds rapidly to
the request to go into time-out and engages in appropriate behavior during
time-out (Donaldson et al., 2013), or may be lengthened if the child engages
in inappropriate behavior during time-out (Donaldson and Vollmer, 2011).
However, these studies are limited by very small sample sizes. States, seek-
ing to shape briefer and more effective uses of the technique and to avoid
prolonged seclusion, are just beginning to prescribe how time-out should be
administered in schools (Freeman and Sugai, 2013).

PARENTING WITHIN FAMILY SYSTEMS

As discussed in Chapter 1, while focusing on the parenting knowl-
edge, attitudes, and practices that can help children develop successfully,
the committee recognized that human development is too complicated,
nuanced, and dynamic to assert that childrens parents alone determine the
course and outcome of their ontogeny (Bornstein and Leventhal, 2015,
p. 107). Parenting knowledge, attitudes, and practices are embedded in
various ecologies that include family composition, social class, ethnicity,
and culture, all of which are related to how parents treat their children and
what they believe about their children as they grow, and all of which affect
child outcomes.
Family systems theory offers a useful perspective from which to view
parenting behavior, to understand what shapes it, and to explain its com-
plex relation to child outcomes. As a system, the family operates according
to an evolving set of implicit rules that establish routines, regulate behav-
ior, legitimate emotional support and expression, provide for communica-
tion, establish an organized power structure or hierarchy, and provide for
negotiating and problem solving so that family tasks can be carried out
effectively (Goldenberg and Goldenberg, 2013). Families as systems also
create a climate or internal environment with features that shape parenting
behavior and influence child outcomes. Family climates can be character-
ized along various dimensions, such as cohesive-conflictual, supportive-
dismissive, tightly or loosely controlled, orderly-chaotic, oriented toward
academic achievement or not, expressive of positive or negative emotions,
hierarchical-democratic, fostering autonomy versus dependence, promoting
stereotypical gender roles or not, and fostering strong ethnic and cultural
identity or not.
Roles are defined within the family system in ways that may influence
parenting. Family members may operate with a division of labor based on
their own personal resources, mental health, skills, and education, in which
one member specializes in and is responsible for one set of functions, such
as garnering economic resources needed by the family, and another takes
responsibility for educating the children. When these differences work well,
family members complement and compensate for one another in ways that
may soften the rough edges of one and make up for the inadequacies of
another.
As discussed in this chapter and throughout the report, children do best
when they develop sustaining and supportive relationships with parents.
Yet while attachment theory has been useful in understanding mainly how
mothers form relationships with children, it has been less useful at guiding
research with fathers (Grossmann et al., 2002), and relatively little re-
search has examined other relations of the family system and microsystems

where family members spend time (e.g., school, church, work). As systems,
however, families are interdependent with the broader world and thus are
susceptible to influences and inputs from their environments. Actions occur-
ring in one system can result in reactions in another. For example, children
who have not developed healthy relationships with their parents may have
difficulty developing positive relationships with teachers.
In short, family systems are influenced by the evolving cultural, political,
economic, and geographic conditions in which they are embedded. Members
of a cultural group share a common identity, heritage, and values, which also
reflect the broad economic and political circumstances in which they live. An
understanding of salient macrolevel societal shifts (e.g., rates of cohabita-
tion or divorce), along with microsystem influences (e.g., attachments with
multiple caregivers and shifts in attachment patterns across childhood into
adulthood) that are the subject of more recent research, can be helpful for
rethinking parenting processes, what influences them, and how they matter
for children. This rethinking in turn highlights the need to understand how
complex living systems function and how they reorganize to accommodate
changes in their environments (Wachs, 2000).
SUMMARY
The following key points emerged from the committees examination
of core parenting knowledge, attitudes, and practices:
Parental knowledge of child development is positively associated

with quality parent-child interactions and the likelihood of par-
ents engagement in practices that promote their childrens healthy
development. Research also indicates that parents with knowledge
of evidence-based parenting practices, especially those related to
promoting childrens physical health and safety, are more likely
than those without such knowledge to engage in those practices.
Although there is currently limited empirical evidence on how
parents knowledge of available services affects uptake of those ser-
vices, parenting, and child outcomes, parents with this knowledge
are likely better equipped to access services for their families.
As mediators of the relationship between knowledge and prac-
tice, parental attitudes about the roles of parents and others in
the raising of young children, as well as about specific practices
(e.g., breastfeeding, immunization), can contribute to some varia-
tion in practices and in the uptake of services among individuals
and subpopulations. The committee found that empirical studies
on parenting attitudes do not allow for the identification of core
parenting attitudes consistently associated with positive child out-

comes. However, the available evidence points to a need for taking

parents attitudes and beliefs into consideration in the design and
implementation of programs and services in order to improve their
reach.
The committee identified several parenting practices that are as-
sociated with improvements in the four domains introduced at the
beginning of this chapter (physical health and safety, emotional
and behavioral competence, social competence, and cognitive
competence):
contingent responsiveness (serve and return);

showing warmth and sensitivity;
routines and reduced household chaos;
shared book reading and talking to children;
practices related to promoting childrens health and safetyin
particular, receipt of prenatal care, breastfeeding, vaccination,
ensuring childrens adequate nutrition and physical activity,
monitoring, and household/vehicle safety; and
use of appropriate (less harsh) discipline.
Much of the existing research is focused on mothers. A lack of re-

search exists on how parenting knowledge, attitudes, and practices
may differ for fathers and other caregivers (e.g., grandparents).
Studies suggest some variation in parenting knowledge, attitudes,
and practices among racial/ethnic, cultural, and other demographic
groups, but more attention is needed to whether and how these
differences matter for child outcomes.
With regard to practices that promote childrens cognitive skills,
research to date has examined primarily the effect of parenting on
childrens language and literacy skills. Research on how parenting
affects other cognitive domains, such as math and problem-solving
skills, would deepen understanding of the relationship between
parenting and childrens cognitive development.
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Federal Policies and Investments

Supporting Parents and Children
in the United States
Many of the parenting competencies described in Chapter 2 are reflected

in federal policies and investments designed to improve the well-being of
children and support parents in their efforts to create safe, supportive, and
nurturing environments for their children. The U.S. government has a more
than 100-year history of investing in programs and services for families that
are designed to promote positive outcomes and reduce n egative circum-
stances for children (see Box 3-1 for an overview). The p arent- and child-
focused policies and programs funded with public dollars and administered
or augmented at the state and local levels by government agencies, busi-
nesses, community-based organizations, and foundations are aimed at pro-
moting a host of positive outcomes, including keeping children safe from
harm; making sure they do not go to bed hungry; and reducing disparities
in outcomes associated with parental characteristics, especially those related
to income, race/ethnicity, and place of birth. Each year billions of dollars
are spent on these policies and programs at the federal level.
This chapter is intended to serve as a bridge between the description
of core parenting knowledge, attitudes, and practices in Chapter 2 and the
review of available evidence on what works to support and enhance these
knowledge, attitudes, and practices in Chapters 4 and 5. The policies and
investments described suggest an implicit governmental goal of promoting
parenting knowledge, attitudes, and practices; facilitating the job of parent-
ing; and ensuring that children are well cared for. However, no explicit link
is evident between these policies and investments and a well-organized and
articulated effort to promote the knowledge, attitudes, and practices they
are designed to support. Likewise, the connection between the policies and
101

BOX 3-1
The Founding and Evolution of the Childrens Bureau:
The First Agency Focused Solely on Children and Families
To understand what some have termed the current U.S. nonsystem of

supports for children and families and the many agency budgets, policies, and
programs that exist in this area, it is useful to look back at the creation of the first
agency focused solely on meeting the needs of children and how its focus on sup-
porting parents began and changed over time. The restructuring that transferred
responsibility for the work originally conducted by the Childrens Bureau to other
agencies is also of interest and may be relevant when this report considers barriers
to and facilitators for the effectiveness of salient policies and programs. Below are
some highlights from the 113-year history of the Childrens Bureau.
1909The White House Conference on the Care of Dependent Children

focused on the needs of vulnerable children experiencing abandonment,
neglect, destitution, and routine institutionalization. Recommendations
included a call for a federal childrens bureau.
1912President Taft signed legislation establishing the Childrens Bureau
as part of the Department of Commerce and Labor, which then moved to
the new Department of Labor. Julia Lathrop was the Bureaus first leader.
The Bureau was charged with understanding and reporting on all matters
relevant to the welfare of children and child life. Early research topics
included infant mortality, child labor, juvenile delinquency, mothers pen-
sions, and illegitimacy.
1923The Bureau published Juvenile-Court Standards and Foster-Home
Care for Dependent Children. Support focused on keeping children with
families and preventing institutionalization. The Bureau also partnered
with Yale School of Medicine to study rickets and risks of ancillary health
problems.
1926The Bureau published Public Aid to Mothers of Dependent Chil-
dren, an overview of legislation and work that supported mothers.
1930The Third White House Conference on Children resulted in the
Childrens Charter, which included 19 points focused on the health, wel-
fare, protection, and educational needs of children.
1935Passage of the Social Security Act authorized the Bureau to ad-
minister maternal and child health services, medical care for children with
disabilities, and child welfare services.
1930sThe Fair Labor Standards Act, containing child labor require-
ments that the Bureau worked with the states to enforce, was passed.
1940sThe Fourth White House Conference on Children focused on the
principles, conditions, and services that contribute to all childrens well-
being, not just those in need or those with a disability. Of special interest
was the development of standards for daycare.
1946The Childrens Bureau moved to the Social Security Administra-
tion within the Federal Security Agency; responsibility for child labor
regulatory enforcement remained with the Department of Labor.

FEDERAL POLICIES AND INVESTMENTS 103
1950The White House Conference on Children and Youth focused on

the emotional well-being of children and resulted in creation of a hand-
book for parents on supporting healthy personality development.
1953The Federal Security Agency became the Department of Health,
Education, and Welfare (DHEW). A Research Program for the Childrens
Bureau, based on a review of previous research and input from experts,
was published.
Early 1960sThe Bureaus work emphasized the needs of children in
foster care and continued to focus on child health. Supports for foster
care for refugee children from Cuba were also a focus.
1965Head Start was created within the Childrens Bureau.
1968A federal Panel on Early Childhood was created to coordinate
programs and plan funding.
1969DHEW housed the Office of Child Development (OCD), which in
turn housed the Childrens Bureau, Head Start Bureau, and Bureau of
Program Development and Resources.
1970The White House Child Conference was organized around 16
areas of well-being, including comprehensive family-oriented child devel-
opment programs.
1974Passage of the Child Abuse Prevention and Treatment Act led
to increased reporting of child abuse and neglect, services for abused
children, and research.
1980Passage of the Adoption Assistance and Child Welfare Act ex-
panded the role of the Childrens Bureau related to accountability of the
federal and state child welfare systems by means of annual reporting
requirements to Congress and state audits.
1980sThe Bureaus work focused on improving adoption rates for
special-needs children, use of family-based services, and prevention.
Improvement in data quality was a priority, leading to the Adoption and
Foster Care Analysis and Reporting System and the National Child Abuse
and Neglect Data System.
1990sThe Bureau focused on high-quality child abuse and neglect
prevention, foster care, and adoption.
1997The Adoption and Safe Families Act, which codified the three
responsibilities of child welfaresafety, permanency, and well-being
was passed.
2000-2010National rates of children in foster care declined by 25 per-
cent. Investment continued in discretionary programs and research in
areas including crack and substance use among parents, support for
evidence-based home visiting, and abandoned infants.
2012The Bureau published Promoting Social and Emotional Well-Being
of Children and Youth Receiving Child Welfare Services, a research-
based framework and roadmap for child welfare agencies use of the
latest in research and practice in their work with children and families.
SOURCE: Administration for Children and Families (2016b).

investments and the evidence, taken as a whole, is tenuous and at times

incongruous. It is important to note that the policies and investments were
instituted and amended over many years, reflecting various political and
philosophical approaches, and often predate the evidence on what works
that is described in the next two chapters. The connections across and
among the knowledge, attitudes, and practices; federal policies and invest-
ments; and the evidence are relatively haphazard. As a result, the collection
of policies and investments designed to strengthen and support parenting
represents a piecemeal approach rather than a coherent system that has
interconnected and cohesive goals and is informed by current knowledge
about what works.
This chapter begins by describing examples of recent public health
successes in changing parenting knowledge, attitudes, and practices to
achieve better outcomes for children. Next, the chapter provides a brief
overview of the federal budget supporting parents and children to help the
reader understand the overall scale of the federal investment in promot-
ing positive outcomes for children and families. The chapter then turns to
a description of federal policies and investments supporting parents and
children, which include policies and investments that are universal or near-
universal and those that are more targeted. The latter category encom-
passes economic support for low-income families and children, investments
in child and parent education, support for parents of children with special
needs and parents facing adversity, and policies and programs focused on
family and parental leave. Note that the discussion here is intended as an
overview and does not include all federal policies and investments that sup-
port parents and children. The impacts on outcomes for families, including
parenting, for several but not all of the programs reviewed in this chapter
are discussed in Chapter 4. The chapter concludes with a summary.
PUBLIC HEALTH SUCCESSES

A central premise of this study is that, based on historical data, it is
possible to shift the knowledge, attitudes, and practices of parents, and the
nation, so as to create a safer and healthier environment for children. Three
major successes in the field of public health illustrate this point: child pas-
senger safety, the Safe to Sleep campaign, and reductions in smoking and
drinking during pregnancy. These initiatives have been successful, in part,
because their behavior change messages are relatively straightforward and
consistently reinforced and are presented to parents through multiple, in-
fluential media and trusted sources. In most cases, these positive messages
are coupled with societys changing norms and expectations regarding the
behavior of parents. These three examples demonstrate what can be ac-
complished when policy and practice are aligned across service systems and

provide some idea of what is possible in improving parenting behavior. They

are focused to a large extent, though not exclusively, on the parents of young
children, and all three have advantaged young children and their families in
notable ways. Taken together, these examples demonstrate how parenting
knowledge about what to do and why it matters for keeping children safe
and well can lead to changes in parenting practices within a relatively short
period of time based on the advice, recommendations, and encouragement
of trusted information sources, as well as the potential benefit of a penalty
for not complying (child passenger safety in particular). While not exhaus-
tive, they also illustrate how marrying evidence, policies, and financing and
supporting parents and families can lead to better outcomes for children.
Child Passenger Safety

Progress has been seen in child passenger safety, although motor vehicle
collisions remain a leading cause of death for young children (Centers for
Disease Control and Prevention, 2015a). Less than 40 years ago, children
were allowed to play unrestrained while riding in a car; today, multiple
efforts are focused on ensuring that all children have the right size of car
seat and are properly buckled up. Advocacy for child passenger safety by
families and community members, physicians, traffic safety experts, and
researchers has influenced state and federal policy makers, car manufac-
turers, and an entire industry with respect to making car seats for babies,
toddlers, and children. Among children ages 0-8, use of restraints increased
from 51 percent in 1999 to 80 percent in 2007 (Childrens Hospital of
Philadelphia, 2008). Parents face potential social pressure from family
members and friends to buckle up themselves and their children, and fines
are levied if they are stopped for a moving violation and found not to be
using proper restraints.
The Safe to Sleep Campaign

A second example of a major shift in parenting behavior accomplished
in less than a generation is what was originally launched as the Back to
Sleep public education campaign in 1995 and is now called Safe to Sleep.
This initiative, led by the Eunice Kennedy Shriver National Institute of
Child Health and Human Development, is designed to reduce the incidence
of sudden infant death syndrome (SIDS) by having all caregivers place chil-
dren to sleep on their backs rather than their bellies, remove all soft bedding
in sleeping areas, and ensure that sleeping spaces outside of the home (e.g.,
at child care, when traveling) are just as safe as those in the home. From
1990 to 2014, the rate of SIDS decreased from 130.3 to 38.7 deaths per
100,000 live births (Centers for Disease Control and Prevention, 2015b).

Reduced Smoking and Drinking during Pregnancy

Finally, prenatal care visits and an emphasis on the known toxic effects
of exposure to tobacco and alcohol on the developing fetus have led to dra-
matic decreases in the numbers of women who smoke and drink while preg-
nant in the past 25 years. Women are exposed to reminders not to smoke
and drink during prenatal visits with health care providers and through
signage in many restaurants and bars. Approximately 20 percent of women
reported smoking during pregnancy in 1989, compared with 8.5 percent in
2013, although rates remain much higher among Native Americans (Child
Trends, 2015). In surveys conducted before 2001, 20 percent of women
reported consuming alcohol during pregnancy (Bhuvaneswar et al., 2007);
in a Centers for Disease Control and Prevention analysis of Behavioral
Risk Factor Surveillance System data for 2006 to 2010, this percentage had
declined to 8 percent (Centers for Disease Control and Prevention, 2012).
FEDERAL BUDGET SUPPORTING PARENTS AND CHILDREN

As noted earlier, significant federal fiscal support is dedicated to chil-
dren and to helping their parents provide for their basic needs. This funding
and the selected policies and investments described in the sections below,
among others, are interrelated and form a platform upon which a national
framework for more robustly meeting the needs of parents and improving
outcomes for children could be organized, as described in Chapter 2.
It is important to note that this federal spending is augmented publicly
and privately in various ways by states and localities, private businesses,
organizations, and foundations.1 Therefore, none of the estimates provided
herein represents a full picture of national spending on children and fami-
lies. Estimates of the total amount of federal money spent on children and
families also vary based on the methodology used. The committee drew on
data from Kids Share (Isaacs et al., 2015), which describes the share of the
federal budget dedicated to children and to families with children through
age 18. To the committees knowledge, a review of the budget specifically
with respect to parenting does not exist, and the amount spent on improv-
ing parenting knowledge, attitudes, and practices cannot be isolated in the
federal budget.
In 2014, 10 percent of total federal expendituresamounting to $463
billionwas on children (see Figure 3-1) (Isaacs et al., 2015). Most spend-
ing on children in 2014 was for child-related tax provisions (e.g., the
1Three-fifths of the total public funding for children is provided by state and local govern-
ments, the bulk of which is spent on public schools. In 2011, for example, 62 percent of the
total funds spent on children ($12,770 per child) was from state and local sources (Isaacs et
al., 2015).

FIGURE 3-1 Share of federal budget outlays spent on children (ages 0-18), 2014.
SOURCE: Adapted from Isaacs et al. (2015).
Earned Income Tax Credit [EITC], the Child Tax Credit, the dependent
exemption), followed by health, nutrition, income security (e.g., Temporary
Assistance for Needy Families [TANF]), education, early education and
care, and social services and housing (see Figure 3-2 and Table 3-1).
FEDERAL POLICIES AND INVESTMENTS

SUPPORTING PARENTS AND CHILDREN
Some of the federal expenditures that provide families with direct
economic support or services to enable them to better meet the needs of
their children are universal, while others are tied to family income. Fed-
eral funding is also directed at a number of programs available to parents
seeking information and support in caring for their children. This section
highlights some of the programs that are discussed further in Chapter 4;
while this review is not exhaustive, it should serve to illustrate the scale of
these investments.

Percentage Share of Federal Expenditures on Children
Child-R
Related Tax Pro
ovisions
Health
Nutrion
N
Income Security
S
Ed
ducaon
Earrly Educaon and Care
Social Services
S
Housing
H
0 10 20 30 40 50
FIGURE 3-2 Percentage share of federal expenditures on children (ages 0-18) by program
type, 2014.
NOTES: Categories representing less than 1 percent of federal expenditures are not depicted.
The Child-Related Tax Provision estimate was calculated by adding estimates (from Table 3-1
below) for refundable portions of tax credits, tax expenditures, and the dependent exemp-
tion and dividing by total expenditures on children ($463 billion). Table 3-1 lists programs
included in these and each of the other categories shown on the figure.
SOURCE: Adapted from Isaacs et al. (2015).
Universal and Near-Universal Policies and Investments
Child-Related Tax Provisions

By far the largest portion of the budget that goes to helping families
with children is in the form of tax provisions that include (1) refundable
components of tax credits, such as the EITC, the Child Tax Credit, and a
set of other smaller credits (almost $76 billion in 2014) and (2) tax expen-
ditures, such as exclusions for employer-sponsored health insurance, the
nonrefundable portions of the EITC and the Child Tax Credit, and other
small expenditures ($71billion in 2014) (Isaacs et al., 2015).
Established by Congress in 1975, the EITC is currently the largest
poverty alleviation program for the nonelderly in the United States. In
2013, it is estimated to have lifted 6.2 million people, including 3.2 million
children, out of poverty (Center on Budget and Policy Priorities, 2015e).
EITC benefits are paid by the federal government, as well as 26 states and
the District of Columbia, which set their own EITCs as a percentage of the
federal credit (Center on Budget and Policy Priorities, 2015e). Benefits are

TABLE 3-1 Federal Expenditures on Children by Program, 2014 (in

billions of dollars)
2014
Health 92.6
Medicaid 77.6
Childrens Health Insurance Program (CHIP) 9.0
Vaccines for children 3.6
Other health 2.4
Nutrition 58.3
Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp 33.4
Program)
Child nutrition 19.4
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 5.5
Commodity Supplemental Food Program (CSFP) *
Income Security 52.6
Social Security 21.0
Temporary Assistance for Needy Families 12.2
Supplemental Security Income 11.3
Veterans disability compensation 3.9
Child support enforcement 3.4
Other income security 0.8
Education 41.8
Education for the Disadvantaged (Title I, part A) 15.8
Special education/Individuals with Disabilities Education Act 12.6
School improvement 4.4
Impact Aid 1.1
Dependents schools abroad 1.2
Innovation and improvement 1.2
State Fiscal Stabilization Fund 1.1
Other education 4.3
Early Education and Care 12.8
Head Start (including Early Head Start) 7.7
Child Care and Development Fund 5.1
continued

TABLE 3-1 Continued

2014
Social Services 9.3
Foster care 4.3
Adoption assistance 2.3
Other social services 2.7
Housing 9.3
Section 8 low-income housing assistance 7.3
Low-rent public housing 1.1
Other housing 1.0
Training 1.2
Refundable Portions of Tax Credits 75.9
Earned Income Tax Credit 53.6
Child Tax Credit 21.5
Other refundable tax credits 0.8
Tax Expenditures 71.3
Exclusion for employer-sponsored health insurance 33.8
Child Tax Credit (nonrefundable portion) 25.6
Dependent care credit 4.3
Earned Income Tax Credit (nonrefundable portion) 3.3
Other tax expenditures 4.4
Dependent Exemption 37.9
TOTAL EXPENDITURES ON CHILDREN 463.1
Outlays Subtotal 353.8
Tax Expenditures Subtotal (including tax expenditures and dependent exemption) 109.2
NOTES: * = Less than $50 million. Does not sum to 100 because of rounding.
SOURCE: Isaacs et al. (2015).
paid as a function of earned income and thus are intended to incentivize

employment (i.e., encourage individuals to leave welfare for work and
increase work hours). Despite the benefits of this credit, there is signifi-
cant underparticipation (about 21% nationally) (Internal Revenue Service,
2015b). While there are no data to explain this underparticipation, it may
be due, in part, to lack of awareness and clarity about the credit, eligibility
criteria, and how to apply. In 2014, federal expenditures for the refundable
portion of the EITC were 53.6 billion (Isaacs et al., 2015).

The EITC reduces the amount owed in federal taxes. If the credit
exceeds a workers income tax liability, the remainder is provided as a
refund (Center on Budget and Policy Priorities, 2015e). Eligibility and the
amount of the credit received depend on filing status, income, and number
of qualifying children (Internal Revenue Service, 2015a).2 In the 2015 tax
year, the credit ranged from a maximum of $503 for filers with no qualify-
ing children, to $3,359 for those with one qualifying child, to $6,242 for
those with three or more qualifying children (Internal Revenue Service,
2015a). Eligibility for the federal EITC has been expanded several times
(Marr et al., 2015).
The Child Tax Credit, enacted in 1997, helps offset the costs of rais-
ing children for working families with qualifying children up to age 16.
Like the EITC, the Child Tax Credit is designed to incentivize employ-
ment, increasing with earnings up to a certain level. Families receive a tax
refund that amounts to 15 percent of their earnings above $3,000, with a
maximum $1,000 refund per child (Center on Budget and Policy Priorities,
2015a). Whereas the EITC is aimed at low-income families, both low- and
middle-income families are eligible for the Child Tax Credit; for married
individuals filing jointly, phaseout begins at $110,000 (Internal Revenue
Service, 2015c). Also like the EITC, the Child Tax Credit has lifted many
families out of poverty. In 2013, it moved 3.1 million people and 1.7 mil-
lion children out of poverty and reduced poverty for another 13.7 million
people, including 6.8 million children (Center on Budget and Policy Priori-
ties, 2016). The Child Tax Credit is paid by the federal government and a
few states that have their own programs. In the early and late 2000s, the
federal program underwent expansions that vastly increased the number of
eligible families (Mattingly, 2009). Expenditures for the refundable portion
of the Child Tax Credit were $21.5 billion in 2014 (Isaacs et al., 2015).
Finally, the Child and Dependent Care Tax Credit refunds individuals
for 20 to 35 percent of the amount paid to someone to care for a qualifying
child under age 13 (or for a spouse or dependent who is unable to care for
him- or herself) so that filers can work or look for work (Internal Revenue
Service, 2015d). Allowable expenses are up to $3,000 for one child or other
dependent and $6,000 for two or more dependents. Families with lower
incomes qualify for higher refunds. It is estimated that 6.3 million returns
claimed the credit in 2013 (Tax Policy Center, 2015). How many of these
were for children is unclear.
2For individuals who were single or widowed in 2015, both earned income and adjusted
gross income limits to qualify for the credit were $39,131 for those with one child, $44,454
for those with two children, and $47,747 for those with three or more children. For married
couples filing jointly in 2015, income limits were $44,651 for one child, $49,974 for two
children, and $53,267 for three or more children (Internal Revenue Service, 2015a).

Support for Health Care

The second largest category of federal investments in children and
families focuses on helping parents access health care for their children
and themselves. Health care policies and programs can benefit the health
of children directly, as well as benefit the health and financial well-being of
parents, with potential spillover effects on their children.
The passage of the Patient Protection and Affordable Care Act (ACA)
of 2010 resulted in a number of policy changes that increase access to health
care and supportive services for parents. Among other enhancements, the
ACA expanded Medicaid and improved child coverage; increased access to
essential health benefits such as maternity and newborn care, pediatric ser-
vices, and mental health and substance abuse services; and allowed parents
to select a pediatrician for their child.
Medicaid ($77.6 billion in federal expenditures for children in 2014)
and the Childrens Health Insurance Program (CHIP) ($9 billion) play an
important role in child coverage, and as of fiscal year (FY) 2014 provided
insurance coverage for more than one in three (more than 43 million) U.S.
children (Burwell, 2016; Isaacs et al., 2015). CHIP gives states federal
aid to provide programs for children in families whose incomes exceed
Medicaid thresholds but are not high enough for them to afford private
health insurance. Among disadvantaged populations, Medicaid and CHIP
are principally responsible for increasing childrens health insurance cover-
age. The programs have had positive effects not only on coverage but also
on access to care and health status among participants (American Academy
of Pediatrics, 2014; Paradise, 2014). Previous state public health insurance
expansions for parents show that such expansions may lead to higher rates
of child participation in Medicaid (Dubay and Kenney, 2003).
The Maternal, Infant, and Early Childhood Home Visiting Program
(established in 2010 as part of the ACA and currently funded through
FY 2017) helps expectant and new at-risk parents prepare for and support
children from birth to kindergarten. The implementation of evidence-based
home visiting is a defining feature of this program. Health, social service,
and child development specialists make regularly scheduled visits to provide
hands-on guidance and referrals based on family needs. The program is
designed to help parents develop and refine the skills they need to promote
the well-being of children so they are physically and emotionally healthy
and ready to learn. In FY 2014, more than 115,000 parents and their chil-
dren received home visits through this program (Health Resources Services
Administration, 2015). Both congressionally mandated performance mea-
sures and a rigorous impact evaluation are used to determine the programs
effectiveness in enhancing parent-child outcomes and improving child out-
comes in the health and psychoeducational domains. Total funding from

2011 through 2015 was more than $1.5 billion (Health Resources Services
Administration, 2015). Home visiting also is provided nationally through
many other funding streams.
Economic Support for Lower-Income Families and Children
Nutrition Assistance Policies and Programs

Proper nutrition can help people reach and maintain a healthy weight,
reduce chronic disease risk, lower pregnancy-related risks, support fetal
development, and promote overall health. Conversely, food insecurity3
is associated with health issues, such as diabetes, heart disease, depres-
sion, and obesity, and can cause difficulty during pregnancy (Institute of
Medicine, 2011; Lee et al., 2012). In 2014, federal investment in nutrition-
related programs for children was $58.3 billion (Isaacs et al., 2015). Such
programs include the Supplemental Nutrition Assistance Program (SNAP),
the Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC), and the National School Breakfast and National School
Lunch Programs.
SNAP, formerly known as the Food Stamp Program, is the largest nutri-
tion program in the United States. Almost 60 percent of federal expenditures
on children for nutrition in 2014 ($33.4 billion) was for SNAP (Isaacs et al.,
2015). Administered by the U.S. Department of Agriculture, SNAP provides
nutrition assistance to low-income individuals and families, with eligibility
requirements that are less restrictive than those of other programs. In FY
2015, an average of 45 million people participated in SNAP each month,
with an average monthly per household benefit of approximately $258
(U.S. Department of Agriculture, 2016c). Most households receiving SNAP
(76% in 2014) include a child or an elderly or disabled individual (Gray
and Kochhar, 2015), and many are very poor (with incomes less than 59%
of the federal poverty level) (Food Research Action Center, 2015).
WIC, another long-standing program, is a federal grant program that
provides vouchers for the purchase of nutritious food, as well as nutrition
education, breastfeeding support, and referrals to social services and com-
munity supports for low-income women who are pregnant, postpartum,
and breastfeeding as well as their children up to age 5. In FY 2015, the
program served more than 8 million women, infants, and children, provid-
ing an average of $43.37 in monthly benefits per person (U.S. Department
3Food insecurity is defined as limited or uncertain availability of nutritionally adequate and
safe foods or limited or uncertain ability to acquire such foods in a socially acceptable way
(National Research Council, 2006; U.S. Department of Agriculture, 2015).

of Agriculture, 2016d). The 2014 expenditures totaled $5.5 billion (Isaacs

et al., 2015).
Federal programs promoting child nutrition also include the National
School Breakfast Program and the National School Lunch Program, both
of which are offered in schools as well as in residential child care institu-
tions. While meals are available to all children through both programs,
children from families meeting income requirements are eligible to receive
meals at low or no cost. In FY 2015, an average of 12 million and 20 mil-
lion children per month received reduced-price or free meals through
the National School Breakfast and National School Lunch Programs,
respectively (U.S. Department of Agriculture, 2016a, 2016b). After-school
snacks also are provided to children meeting income eligibility criteria
(U.S. Department of Agriculture, 2013). Additional school-based nutri-
tion programs include the Special Milk Program, the Fresh Fruit and
Vegetable Program, and the Summer Food Service Program. In addition
to ensuring childrens nutrition, these programs can be viewed as income
supports to parents and also as stress reducers because they reduce time
demands on parents.
Income Security Policies and Programs

Another large area of federal spending on children takes the form of
income security, totaling about $53 billion in 2014 (Isaacs et al., 2015). The
largest income support to help parents and caregivers raise children after
the death of a parent is Old Age and Survivors Insurance, part of Social
Security, which covers insured workers. While not traditionally regarded
as a program targeting children and their parents, it represents the largest
income support for families with children. Child-related expenditures in
2014 were $21 billion for Social Security benefits to survivors and depen-
dents (Isaacs et al., 2015).
TANF helps families achieve self-sufficiency through an assortment of
services, such as direct cash payments, child care, education, job training,
and transportation assistance. Block grants are provided to states, ter-
ritories, and tribes, which have some discretion in determining eligibility
criteria and services, so the program varies by location (Center on Budget
and Policy Priorities, 2015b). Created through the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996, which was designed
to increase labor market participation among individuals receiving public
assistance, TANF requires jurisdictions to impose work requirements for
participation, and assistance is reduced or eliminated for work-eligible indi-
viduals not meeting those requirements. In FY 2015, the average number of
families served by TANF monthly was 1.35 million; these families included
3.12 million total recipients, 2.37 million of whom were children (Office

of Family Assistance, 2015). Expenditures on children for TANF in 2014

totaled $12.2 billion (Isaacs et al., 2015).
The federal Child Support Enforcement Program aims to encourage
parental responsibility so that children receive financial, emotional, and
medical support from both parents, even when they live in separate house-
holds (Office of Child Support Enforcement, 2015a). The programs ser-
vices, which may include assistance in locating parents, establishing legal
paternity, enforcing support orders, increasing health care coverage for
children, and removing barriers to child support payment (e.g., providing
referrals for employment services, supporting healthy co-parenting), are
available through local child support offices to any family with children
in which one parent is not living in the same home as the children (First
Focus, 2015; Office of Child Support Enforcement, 2016). Either parent
may apply for services, as may grandparents or other custodians. Services
are automatically provided to all families participating in TANF that could
benefit. In FY 2014, the Child Support Enforcement Program served 16 mil-
lion children and collected nearly $32 billion in child support, 95 percent
of which went to families (Office of Child Support Enforcement, 2015b).
Federal expenditures for child support enforcement in 2014 totaled $3.4
billion (Isaacs et al., 2015).
Housing Policies and Programs

Housing programs support parents in meeting various objectives for
their childrenincluding their health; safety; and emotional, social, and
cognitive well-beingby offsetting a number of stressors. Across various
income groups, housing-related expenses (e.g., shelter, utilities, furniture)
accounted for the largest share of families expenditures on children in
2013, totaling 30-33 percent of all expenses in mother and father families
with two children (Lino, 2014).
Federal support helps millions of low-income households with children
afford housing in the United States (Center on Budget and Policy Priorities,
2015c). The funding flows mainly through programs in the U.S. Depart-
ment of Housing and Urban Development, including Tenant-Based Rental
Assistance, Project-Based Rental Assistance, and the Public Housing Oper-
ating Fund. Together, these funding streams contributed more than $9 bil-
lion to federal spending on children in 2015, representing nearly 80 percent
of all housing investments that impact children (Isaacs et al., 2015).
The Housing Choice Voucher Program (HCVP) (often referred to as
Section 8) helps more than 5 million people in low-income families access
affordable rental housing in the private market that meets health and safety
standards (Center on Budget and Policy Priorities, 2015d; U.S. Department
of Housing and Urban Development, 2016b), supporting families in creat-

ing safe households for their children. Seventy-five percent of the vouchers
distributed to new participants each year are provided to extremely low-
income households.4 Currently, children reside in 46 percent of households
that are HCVP recipients (Center on Budget and Policy Priorities, 2015d).
Family unification vouchers are provided to families participating in HCVP
that are at risk of having their children placed in out-of-home care because
of a lack of adequate housing and to those for whom reunification is de-
layed because of lack of adequate housing (U.S. Department of Housing
and Urban Development, 2016a).
Investments in Child and Parent Education

In terms of state and local funding as well as federal investments, edu-
cation is by far the largest form of societal investment in children in the
United States. In addition to direct expenditures on education, from early
childhood through college, the federal government provides or supports ac-
cess to child care for children through both tax credits and direct support.
While most child care and education expenditures are focused exclu-
sively on the care and education of children, the U.S. Department of Health
and Human Services (HHS) and the U.S. Department of Education fund
and administer a number of early childhood care and education programs
for children ages 0-8, many of which are focused on helping parents engage
in parenting practices associated with healthy child development. HHS
manages two large programsHead Start (including Early Head Start)
and the Child Care and Development Fund (CCDF). The U.S. Department
of Education manages more than 80 federally funded education programs,
including special education programs, benefiting children of all ages, from
infants to high school students preparing for college; from all states and
territories; and across all income groups. State and local funding for public
education for children ages 5-8 dwarfs federal funding for children in this
age range.
The Head Start Program was established in 1965 to support the school
readiness of low-income children ages 3-5 through the provision of pre-
school education and supportive services to families. Early Head Start,
which became a part of Head Start programming following the reautho-
rization of the Head Start Act in 1994, provides services for low-income
pregnant women and families of children ages 0-3 for the purpose of
supporting childrens healthy development and strengthening family and
community partnerships (U.S. Department of Health and Human Services,
2015). Delivered in about 1,700 community agencies located throughout
4Defined as household income not above 30 percent of the local median or the federal
poverty line, whichever is higher (Center on Budget and Policy Priorities, 2015d).

the United States (U.S. Department of Health and Human Services, 2015),
Head Start and Early Head Start represent scaled-up, means-tested, and
rigorously evaluated approaches to two-generation programs, which target
parents and children from the same family. In addition to education ser-
vices directed at children, they typically provide parenting education; self-
sufficiency services; and resources and referrals to community providers to
meet families needs in a range of areas, such as transportation, housing,
and health care. The government spent $7.7 billion on Head Start and Early
Head Start in 2014 (Isaacs et al., 2015). In the 2014-2015 program year,
almost 1.1 million children ages 0-5 and pregnant women were served by
the two programs (Office of Head Start, 2015).
CCDF makes funding available to states, tribes, and territories to help
qualifying low-income families obtain child care so that parents can work
or attend classes or training. The program works to improve the quality
of child care so that children will have positive and enriching experi-
ences. Nearly 1.5 million children receive a child care subsidy from the
program every month (Administration for Children and Families, 2015).
State Q uality Rating and Improvement Systems (QRIS), developed to help
states evaluate the quality of care and education programs for children,
are funded largely through CCDF and include incentives for child care
providers to improve the quality of their programs (Administration for
Children and Families, 2016a). Implementation of QRIS was encouraged by
their inclusion in the U.S. Department of Educations Race-to-the-Top Early
Learning Challenge grants, which also required QRIS validation studies.
Many of these efforts were joint HHS-Department of Education early care
and education initiatives with funding targeted to different parts of the
service delivery system that supports parents of young children. Programs
such as CCDF may positively impact parenting by providing parents access
to services that promote self-sufficiency and parenting practices associated
with healthy child development.
Preschool Development Grants support states in building or enhanc-
ing infrastructure for preschool programs to enable the delivery of high-
quality preschool services to children, as well as in expanding high-quality
preschool programs in targeted communities that can serve as models for
extending preschool to all 4-year-olds from low- and moderate-income
families. In 2015, 18 states were awarded $237 million for year 2 of this
grant program (U.S. Department of Education, 2015).
Support for Parents of Children with Special Needs

and Parents Facing Adversity
In addition to the policies and programs discussed above that are
directed at ensuring the well-being of children of all ages and that reach

a large number of families, particularly low-income families, investments

are made to support parents who face situational or personal challenges.
Although families may face singular challenges, such as intimate partner
violence, challenges often cluster together. Substance abuse, mental illness,
involvement with the child welfare system, financial hardship, and other
challenges can overlap in families, with profound consequences for the
development and well-being of young children. A variety of federal invest-
ments are designed to support parents who face such challenges. Many
families experiencing these challenges have access to and utilize the univer-
sal and widely used supports discussed above, but these, even along with
community and family supports, often are insufficient.
Some investments for such families are part of broader spending on
health and education, such as that for programs for children with mental,
behavioral, and developmental disabilities. The Individuals with Disabilities
Education Act (IDEA) Part C, Grants for Children and Families, for ex-
ample, assists states in providing early intervention services for young chil-
dren with disabilities and their families. IDEA Part C allocations in 2015
totaled $438.6 million (First Focus, 2015), and those funds are included in
the federal budget for education described above.
In the area of child welfare, there are investments in programs that
are aimed at preventing and addressing child maltreatment and that pro-
vide assistance to kinship and foster parents. In 2015, for instance, nearly
$445 million in mandatory funding was allocated for the Promoting Safe
and Stable Families Program, which, through state grants, aims to prevent
unnecessary separation of children from their families and promote child
permanency. In 2015, $99 million was allocated for assistance payments
to grandparents and other kinship caregivers with legal guardianship of
children (First Focus, 2015).
Family and Parental Leave Policies and Programs

Newborns and infants require substantial, focused, and responsive
care. Parents of newborns need time to bond with their child and adjust
to the demands of caring for an infant while also overseeing their childs
healthy development. In addition, parents need time to rest and recover
from pregnancy and childbirth. As described in Chapter 2, breastfeeding is
a critical nutritional issue for infants. Mothers who are breastfeeding need
to be available to their infants and toddlers or need time to pump breast
milk during the day when they are not with their baby. Also, children have
considerable preventive (e.g., routine well-child visits), acute, and chronic
health care needs to which parents need to attend. Nonetheless, current
state and federal policies regarding parental and family medical leave cover
some but not all parents and employers, and among those covered, the poli-

cies address some but not all of their needs. For some parents, taking time
off from work to care for a newborn or a sick child means losing income
or even risking their job.
Most parents of young children are in the labor force (Bureau of Labor
Statistics, 2016). To meet their childrens needs, employees in the United
States tend to rely on a mix of support that combines employer benefits (if
offered) with federal, state, and local leave laws and programs (Schuster et
al., 2011). The Pregnancy Discrimination Act of 1978 requires that employ-
ers provide women who have medical conditions associated with pregnancy
and childbirth the same leave as is provided to employees who are tempo-
rarily unable to work because of other medical conditions (e.g., a broken
leg or a heart attack) (U.S. Equal Employment Opportunity Commission,
2016). The act does not require employers to provide paid leave, but if
they provide paid leave or disability benefits for some medical conditions,
they must do so for conditions related to pregnancy and childbirth as well.
The Family and Medical Leave Act of 1993 (FMLA) provides up to
12 weeks a year of unpaid leave with job protection to eligible employees
for their own serious health conditions; for the birth of a child or to care
for the employees newly born, adopted, or foster child; or to care for a
family member (spouse, child, or parent) with a serious health condition.
Eligibility is restricted to those who work for employers with 50 or more
employees and have worked at least 1,250 hours for the same employer in
the past 12 months (U.S. Department of Labor, 2016). Although 60 per-
cent of employees meet all eligibility criteria for FMLA (U.S. Department
of Labor, 2015), many employees cannot afford to take unpaid leave (Han
and Waldfogel, 2003).
Finally, although not federal policy, some states currently have or are
considering paid parental leave policies. The implications of these policies
for parents and children, as well as for employers, the economy, and society,
are yet to be determined.
SUMMARY
Federal funding that supports parents and children in the United States
is distributed across the federal budget, and responsibility for administering
the funded programs resides with a range of agencies, including those at
the state and local levels. There is no easy way to map the evidence-based
parenting knowledge, attitudes, and practices identified in Chapter 2 to the
federal budget; however, a review of the budget and a general understand-
ing of the policy and funding structure provides an overview of the existing
framework for the programs reviewed in Chapters 4 and 5. Although many
children interface with specific programs, the committee notes that there is
no simple way to compute how many children receive services through mul-

tiple programs at the same time or what percentage of those serve young
children ages 0-8an important question for understanding the return on
investment in programs. What the existing funding streams and service de-
livery platforms do provide are settings and systems with the potential to be
linked more systematically to offer support for parenting knowledge, atti
tudes, and practices that is grounded in evidence-based programming and
practice (see Chapter 7). As noted in subsequent chapters, new approaches
to developing interventions are being tested. Understanding how federal
funding flows into programs directly and indirectly to support parents and
children informs the development and financing of a new framework for
providing this support.
The following key points emerged from the committees review of fed-
eral policies and investments supporting parents and children:
The United States has a long history of funding policies and pro-
grams with the goal of improving childrens outcomes and the
well-being of families and society. These policies and programs are
not limited to young children; however, young children and their
parents are within the larger populations served.
Large-scale policies and programs designed to change parenting
behavior in some areas have been effective in improving targeted
outcomes at the population level. However, support for parents
is not isolated in these policies and programs, and there is little
information about parents awareness of how various policies and
programs can support them in their parenting role.
The specific policy and program approaches reflected in the fed-
eral budget are a mix of child-related tax provisions, policies and
programs designed to promote well-being and positive outcomes
for all children and families, and policies and programs targeted
at providing a safety net for children and families facing adversity
and various risk factors.
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Universal/Preventive and
Widely Used Interventions
This chapter reviews the evidence on interventions for strengthening par-

enting capacity and supporting parents of young children, from the prenatal
period through age 8. The focus is on universal and widely used interventions
that touch large numbers of families and that are primarily preventive, such as
those delivered in health care settings; those delivered in connection with child
care, early education, and K-3 schooling; and public education approaches.1
These interventions and approaches generally emphasize providing parents
with knowledge and guidance about childrens development and successful
parenting practices; many also connect parents to a variety of needed support
services. Following this review, the chapter turns to a discussion of the use of
information and communication technologies to support parenting. The chap-
ter then examines the research evaluating the impact on parenting of income,
nutrition, health care, and housing support programs and parental and family
leave policies described in Chapter 3. The chapter concludes with a summary.
UNIVERSAL/PREVENTIVE INTERVENTIONS
Parents seek knowledge about how to raise their children from many
sources, including both formal programs and information they obtain on
1A useful framework for thinking about interventions is described in the National Research
Council and Institute of Medicine (2009) report Preventing Mental, Emotional, and Behav-
ioral Disorders among Young People. In the prevention area, this framework specifies mental
health promotion; universal interventions defined as those that are valuable for all children;
and selective interventions, which are targeted at populations at high risk.
125

their own. Numerous books, magazine articles, and Websites provide in-
formation about parenting. Whereas earlier generations may have relied on
books such as Benjamin Spocks 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 institu-
tions, and community organizations for guidance and support. All of these
sources contribute to parents knowledge, attitudes, and practices with re-
spect 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.
Well-Child Care2
Well-child care refers to preventive care visits for children that include
not only basic health care, vaccination, and developmental assessment but
also anticipatory guidance (counseling and education on a broad variety of
topics aimed at supporting parents) and identification of family concerns
that can serve as a barrier to good parenting. Conducted by pediatricians,
family physicians, and other primary care providers, well-child care is a
2Portions of this section are based on a paper commissioned for this study, authored by
umaini R. Coker, assistant professor of pediatrics at the David Geffen School of Medicine
T
and Mattel Childrens Hospital, and associate director of health services research at the Chil-
drens Discovery and Innovation Institute, University of California, Los Angeles. The paper
can be requested from the study public access file at https://www8.nationalacademies.org/cp/
ManageRequest.aspx?key=49669 [October 2016].

UNIVERSAL/PREVENTIVE AND WIDELY USED INTERVENTIONS 127
mainstay of families interaction with the health care system. In 2013,

92 percent of children under the age of 6 and covered by health insurance
had had a well-child visit in the past year (Child Trends Databank, 2014).
In the 0-8-year age range, the American Academy of Pediatrics (AAP) rec-
ommends a regular schedule of multiple well-child visits during the first 2
years and annual visits thereafter and specifies that each visit should include
a physical exam, anticipatory guidance, and developmental/behavioral as-
sessment (American Academy of Pediatrics and Bright Futures, 2016). Sev-
eral other organizations, including the U.S. Preventive Services Task Force
and the American Academy of Family Physicians have developed similar
well-child care recommendations (American Academy of Family Physicians,
2005; U.S. Preventive Services Task Force, 2015). Visits may be conducted
either individually or in a group format.
Anticipatory guidance is intended to help parents prepare for and deal
with issues and concernssuch as anticipated developmental steps and
situational crisesthey may encounter as their child grows. Guidelines
for anticipatory guidance encompass a broad variety of topics pertinent
to supporting evidence-based parenting knowledge and practices, ranging
from promoting childrens health and safety (e.g., guidance on helmet use,
gun safety, treatment and counseling on overweight and obesity, guidance
for parents on tobacco cessation), to appropriate discipline techniques, to
managing difficult child behavior (e.g., sibling rivalry, tantrums) (American
Academy of Pediatrics, 2000, 2002; Green and Palfrey, 2002). Multiple ran-
domized controlled studies have examined tools for enhancing anticipatory
guidance, such as telephone advice lines, supplemental parent education via
DVD, Websites, and waiting-room kiosks (Bergman et al., 2009; Christakis
et al., 2006; Kempe et al., 1999; Paradis et al., 2011; Sanghavi, 2005). Most
of these supplemental interventions have failed to show substantial benefits,
but efforts to improve safe sleep by means of video education modules and
nurse education for parents have shown promising results in uncontrolled
trials (Canter et al., 2015; Goodstein et al., 2015). (See also the section on
information and communication technologies later in this chapter.)
Unfortunately, many families do not receive all of the parenting support
and guidance that is recommended in well-child care guidelines. A shortage
of provider time to cover the full range of topics may be one of the most
important factors in the observed variation in the quality of well-child
care. Longer well-child visits have been associated with more anticipatory
guidance, more psychosocial risk assessment, and better ratings of family-
centeredness of care in survey research with parents (Halfon et al., 2011).
Yet the AAP has estimated that it would take a clinician 90 minutes to com-
plete just one visit if all of its guidelines were followed (American Academy
of Pediatrics, 2004). Given the time limitations for well-child visits (often
constrained to 15-30 minutes), there have been efforts to expand the scope

of visits by partnering families with nonphysician providers who can offer

education, guidance, and counseling services to augment the care provided
during formal visits, either within or outside of those visits (Farber, 2009;
Zuckerman et al., 2004). However, the qualified personnel needed to pro-
vide those services are lacking.
In general, although well-child visits, including anticipatory guidance,
likely support parenting and the achievement of evidence-based parenting
knowledge, attitudes, and practices (e.g., vaccination), and several interven-
tions have been designed to enhance the effectiveness of well-child care,
evaluation of these interventions is limited. In addition, there is a lack of
objective measures with which to evaluate effects of these interventions on
parenting behavior or to identify the optimal mode of delivery of well-child
care (OConnell et al., 2015).
Some models of care and enhanced anticipatory guidance have proven
successful, particularly by extending the resources provided during the
initial visit through regular contact and support. Healthy Steps for Young
Children is a model of care and enhanced anticipatory guidance in which
a pediatric health care provider and a child specialist with training in child
development (e.g., nurse, social worker) partner to provide well-child care.
The specialist spends extra time with the family after the physician visit,
offering home visits and connecting the family with telephone help lines,
parent support groups, and community resources (Zuckerman etal., 2004).
Most of the evaluations of Healthy Steps have focused on parenting out-
comes rather than child outcomes (Piotrowski et al., 2009). A systematic
review of experimental and quasi-experimental studies (Piotrowski et al.,
2009) found that this model provided parents with effective developmental
screening and anticipatory guidance (Caughy et al., 2003, 2004; Huebner et
al., 2004; Johnston et al., 2006; Kinzer et al., 2004; McLearn et al., 2004;
Minkovitz et al., 2003; Niederman et al., 2007). For example, parents
reported improved parenting practices with respect to discipline, safety,
and promotion of early reading (Minkovitz et al., 2003a). Other positive
outcomes from Healthy Steps include parents reporting greater knowledge
of infant development, better recognition of appropriate discipline, im-
proved compliance with immunization and well-child visit schedules, and
increased satisfaction with pediatric care (Johnston et al., 2006; Minkovitz
et al., 2003).
Another program, the Parent-focused Redesign for Encounters, New-
borns to Toddlers (PARENT) intervention (Coker et al., 2016), employs a
team-based approach to care in which a parent coach provides the bulk of
services at well-child visits and addresses specific needs faced by families in
low-income communities. An initial randomized evaluation of this model
among 251 parents found positive effects on parents receipt of anticipa-
tory guidance and health information, psychosocial assessment, and other

services. Parents participating in the intervention had significantly reduced

emergency department use (22% of control parents versus 10% of interven-
tion parents reported two or more emergency department visits in the past
12 months) (Coker et al., 2016).
Finally, a well-known program designed to support early literacy,
Reach Out and Read, provides caregivers of young children with free,
age-appropriate books and anticipatory guidance on the importance of
child literacy at each well-child care visit to promote caregiver-child read-
ing. As noted in a recent review, the existing evidence on this program
is limited by nonrandom designs, data collected by self-report, and high
participant dropout rates (Yeager Pelatti et al., 2014). That said, a recent
cross-sectional survey of eight Reach Out and Read sites found that care-
givers provided with at least four books read to their children more often
than those who received fewer books (Rikin et al., 2015). Other obser-
vational studies of the program also have found that it is associated with
improvement in the home literacy environment for children, particularly
for parents who might otherwise face obstacles in this regard, with parents
participating in the program being more likely to report having books in
the home and reading aloud to and looking at books with their children
(Needlman et al., 2005; Zuckerman, 2009). However, there have been no
studies of the reading scores of children whose caregivers participate in
Reach Out and Read.
Patient-Centered Medical Homes and Shared Decision Making

The patient-centered medical home is a relatively new model of care
in which primary care providers serve as the medical home for patients,
offering team-based and coordinated care to increase the receipt of pre-
ventive services and reduce the need for specialty or emergency room
care. Early findings from a review of randomized controlled trials and
longitudinal studies suggest that interventions based on this model have a
small positive impact on patient experiences with health care and a small
to moderate effect on the delivery of primary care services (Jackson et
al., 2013). Family-centered care recognizes a partnership among patients,
families, and health care professionals and encourages shared decision
making (Scholle et al., 2010), which can improve patients knowledge
about treatment options and risk perceptions and help them take a more
active role in decisions about their care (Stacey et al., 2014). In meta-
analyses of studies using various designs, shared decision-making inter-
ventions designed to engage pediatric patients, parents, or both in medical
decisions significantly reduced decisional conflict and improved parents
knowledge of their childrens health conditions and how to manage them
(Wyatt et al., 2015).

Universal Health Interventions for Parents

for Specific Parenting Behaviors
Many interventions for parents that occur within health care settings
support parents in engaging in empirically grounded parenting practices
outlined in Chapter 2 that promote the physical health of their children.
Examples of these practices include receiving preconception and prenatal
care, breastfeeding, complying with recommended immunization sched-
ules, limiting childrens screen time, helping children avoid overweight and
obesity, reducing childrens exposure to environmental tobacco smoke,
and educating caregivers on normal infant crying to reduce shaken baby
syndrome/abusive head trauma.
Preconception and Prenatal Interventions

Self-identification as a parent often begins long before the birth of a
baby. Pregnancy and the postpartum period serve as the transition period
for becoming a parent as both mothers and fathers anticipate changes in
their roles, prepare for the upcoming birth, and recall important aspects of
their own childhoods (Leon, 2009). Parental attachment starts to develop
during pregnancy, facilitated by fetal movement as well as biological and
hormonal changes in the mother. Feeling the baby move or seeing the fetus
on ultrasound has been shown to significantly increase feelings of attach-
ment, and there are even surveys for measuring maternal-fetal attachment
during pregnancy (Pisoni et al., 2014).
As a universal parenting intervention, family planning helps optimize
the timing of pregnancy and defer conception for individuals who do not
desire children or do not feel ready to have a child under their current
circumstances. More than one-half of pregnancies in the United States are
unintended. These pregnancies can have serious negative consequences for
parents as well as for children, including complications with pregnancy and
delivery; exposure to illicit substances in utero; low birth weight; and higher
risk of infant death, abuse, and developmental delays (Finer and Zolna,
2014; Institute of Medicine, 1995; Sawhill and Venator, 2015). Family plan-
ning can include efforts both to delay the onset of sexual activity among
young people and to increase access to and use of birth control among those
who are sexually active but do not currently desire pregnancy (Finer and
Zolna, 2014). Family planning can be particularly valuable for populations
at high risk for unintended pregnancy, including adolescents, individuals
who abuse substances, and parents with severe mental illness (Institute of
Medicine, 1995; Seeman, 2010; Strunk, 2008). A randomized intervention
in North Carolina enrolled adolescent mothers with their first child in the
Adolescent Parenting Program, which offers case management and peer

group meetings aimed at keeping adolescents in school and preventing a

rapid second pregnancy (Sangalang et al., 2006). Compared with usual care,
the program did not reduce time to second birth among participants as a
whole, but the time to next birth was significantly longer for 12- to 16-year-
olds participating in the program. (The Adolescent Parenting Program is
discussed further in Chapter 5.) In a longitudinal study, adolescent moth-
ers offered subdermal contraceptive implants immediately postpartum had
significant reductions in rapid repeat pregnancy compared with controls,
as most had retained the implant 1 year after delivery (Tocce et al., 2012).
Preconception and prenatal health visits are universal strategies for
optimizing maternal health and well-being prior to and during pregnancy
and promoting healthy child development. As discussed in Chapter 1, ex-
posures in the in utero environment can affect the developing fetus in ways
that shape health across the life span (Institute of Medicine and National
Research Council, 2009; Tsankova et al., 2007; van Ijzendoorn et al., 2011).
Prior to conception, people can initiate many health behaviors with strong
evidence for improving child birth and developmental outcomes. These
behaviors include folic acid supplementation to reduce neural tube defects
(De-Regil et al., 2010); weight loss for obese mothers to prevent stillbirth
and infant death (Aune etal., 2014); and cessation of tobacco use (discussed
further below) to reduce the risk for pregnancy complications, low birth
weight, and preterm delivery. Preconception and prenatal services also are
important for identifying and providing intervention for women with such
conditions as psychosocial stress (e.g., depression, anxiety, job strain), which
during pregnancy is associated with preterm birth and low birth weight
(Gold and Marcus, 2008; Loomans et al., 2013), and mental illness, which
can increase the risk of fetal death and behavioral and mental health prob-
lems in children (Lancaster et al., 2010; ODonnell et al., 2014).
After conception, universal parenting programs promote healthy preg-
nancy and delivery, often through education and counseling to increase
parents knowledge of child development and use of effective parenting
practices. For example, California tested a Kit for New Parents available
through prenatal care providers, delivery hospitals, home visits, and other
means that provides new and expecting parents with free pregnancy and
early childhood information. The kit led to a significant increase in parent
knowledge at 2-month follow-up (based on an assessment of sleep safety,
infant feeding and nutrition, early learning, accessing child care, low-cost
medical care for babies, and smoking cessation) compared with controls in
a quasi-experimental study (Neuhauser et al., 2007). Also, nearly half of
mothers who received the kit reported improved parenting practices, with
significant differences seen between participants and controls at 14-month
follow-up in frequency of reading to their children, steps taken to child-
proof their homes, taking children for routine medical visits, and use of

safer bottle-feeding practices. These gains were particularly strong for

Spanish-speaking mothers, suggesting that videos and written materials
may be useful for such interventions as they can be easily translated into
other languages (Neuhauser et al., 2007).
Childbirth classes for expecting parents are widely available. Some
medical and community centers also offer classes in newborn care, first
aid, breastfeeding, and infant sleep. However, such classes have not been
studied for their effects on promoting evidence-based knowledge, attitudes,
and practices.
The use of group visits for prenatal care has attracted strong interest
because of the potential for peer support. While group care appears to
result in high participant satisfaction, however, a recent Cochrane review
found only four eligible studies of group prenatal care and noted no differ-
ences in either maternal or infant birth or health outcomes (Catling et al.,
2015). Centering Pregnancy is a proprietary model for group prenatal care
(Mittal, 2011) that has been given a strong evidence rating by the Agency
for Healthcare Research and Quality (2015). Groups of 8 to 10 women
meet with a health care provider to discuss nutrition, stress management,
breastfeeding, and other issues. One large randomized controlled trial ex-
amined the impact of this model on key outcomes, including adequacy of
prenatal care and rates of preterm birth. Analysis of data from individuals
who enrolled and participated (N = 993) showed that those in the inter-
vention received better prenatal care, had fewer preterm births, were more
likely to initiate breastfeeding, and had better prenatal knowledge relative
to those receiving usual care (Ickovics et al., 2007). Sites using the model
have reported an enhanced capacity to serve nonpregnant patients, as the
group sessions free up resources previously used to provide individual visits
(Agency for Healthcare Research and Quality, 2015).
All of these programs address knowledge, attitudes, and practices
focused on improving childrens physical and mental health at birth and be-
yond. However, some researchers have asserted that the sources of dispari-
ties in birth outcomes (e.g., the increased risk for preterm birth and infant
mortality among African American women relative to other women) are
isolated not only to the 9 months of pregnancy but also arise from parents
own developmental trajectories (Lu and Halfon, 2003). This view implies
that support for parents may need to start with support for positive envi-
ronments, health behaviors, and opportunities focused on reducing risks for
women long before they actually conceive. As discussed further in Chap-
ter 5, some evidence indicates that school-based clinics that provide pre-
natal care for teenagers in the school setting increase the uptake of health
care and also encourage adolescents to stay in school. These programs have
been shown to reduce absenteeism and dropout rates, help in identifying
potential developmental delays among children born to teenagers, improve

birth weights, and encourage the use of contraception in correlational and

qualitative research (Griswold et al., 2013; Strunk, 2008).
Breastfeeding
A systematic review of 10 randomized controlled studies of primary
care-based educational interventions designed to improve breastfeeding
practices among low-income women found that such interventions are ef-
fective in encouraging mothers to initiate breastfeeding as well as to continue
breastfeeding 3 months postpartum. Successful programs often involved
ongoing brief follow-up sessions with health care providers (Ibanez et al.,
2012). In another review of randomized controlled studies conducted pri-
marily in the United States and other Western nations, breastfeeding inter-
ventions using lactation consultants and counselors who provide a ntenatal
education and postnatal support were found to be associated with increased
initiation of breastfeeding and increased exclusive breastfeeding rates (Patel
and Patel, 2015).
A lack of research exists on how to support breastfeeding effectively
among adolescent mothers in the United States, whose breastfeeding rates
are disproportionately low (Sipsma et al., 2013; Wambach et al., 2011). In
one randomized study (N = 289), predelivery and postnatal education and
counseling from lactation consultants who were registered nurses and peer
counselors significantly increased breastfeeding duration, but not initiation
or exclusive breastfeeding, in adolescent mothers (Wambach et al., 2011).
Complying with Recommended Immunization Schedules

Health care providers and educational interventions delivered in health
care settings play an important role in parents immunization practices
(Dunn et al., 1998; Hofstetter et al., 2015; Mergler et al., 2013; Vannice
et al., 2011; Wallace et al., 2014; Yaqub et al., 2014). Such simple tools as
patient reminders and health care providers talking to parents about vac-
cination are associated with higher rates of child immunization (Hofstetter
et al., 2015; Szilagyi et al., 2000). Experimental studies indicate that mod-
erately intensive interventions also are effective. In a cluster randomized
trial, parents recruited from primary health care centers who received an
information leaflet on the measles, mumps, rubella vaccine and/or partici-
pated in a parent meeting addressing immunization experienced a decrease
in decisional conflict regarding child immunization after receiving the inter
vention. Those who participated in the parent meeting were significantly
more likely to have a fully vaccinated child than those who only received
the information leaflet (Jackson et al., 2011). In another randomized trial,
Dunn and colleagues (1998) found that videotape was more effective than

written material in increasing parents knowledge about immunization, but

actual uptake of the practice was not measured. Little evidence exists on
how to reduce parental refusal of vaccination (Sadaf et al., 2013).
Limiting Screen Time

Newer health interventions have focused on helping parents limit young
childrens screen time, such as the time they spend watching television and
using computers and hand-held devices, including playing video games. As
discussed in Chapter 2, limiting young childrens screen time can reduce
sedentary behavior associated with increased risk for future overweight
(see also the discussion of overweight and obesity below) (Gable et al.,
2007; Lumeng et al., 2006). In randomized controlled trials, family-based
interventions designed to reduce screen time that include a parental com-
ponent of medium to high intensity have been the most effective, and these
programs appear to be most beneficial for preschool-age children (Marsh et
al., 2014). Brief primary care interventions also may be effective. In an ex-
perimental study involving English- and Spanish-speaking parents, parents
who watched a short video or received a handout on reducing childrens
exposure to television violence, compared with parents who received stan-
dard primary care, were more likely to report reductions in their childrens
media viewing habits and exposure to media violence 2 weeks postinter-
vention. Parents who watched the brief video were slightly less likely to
report a change in media viewing habits and slightly more likely to report
a reduction in exposure to media violence relative to parents who received
the handout (Aragon et al., 2013).
Helping Children Avoid Overweight and Obesity

The rapid increase in the percentage of children who are considered
overweight or obese in the United States (currently about 30%) has led
to efforts to address the issue through multiple settings, including primary
care (Taveras et al., 2011). Obesity in childhood often persists into adult-
hood and is related to a myriad of adverse health outcomes, including dia-
betes, hyperlipidemia, and hypertension, among others. Most health care
settings with interventions related to child obesity focus on children who
are already overweight or obese rather than on primary prevention. One
systematic review found that only 8 of 31 randomized controlled trials in
primary care demonstrated significant benefits with respect to child weight
(Seburg et al., 2015). The review also noted that all of the interventions
with positive outcomesparticularly those focused on young children
included a parent-targeted component. Newer research examining the role
of motivational interviewing for parents of overweight children in primary

care shows promising outcomes although this work is still in early develop-
ment (Resnicow et al., 2015).
Reducing Environmental Tobacco Exposure

One of the most extensively evaluated interventions is cessation of
tobacco for parents who smoke. In the United States, about 9 percent
of women overall self-report smoking during pregnancy, and rates are much
higher in some communities (Child Trends Databank, 2015). Tobacco use
during pregnancy is associated with prematurity, growth restriction, and
infant death. While the U.S. Preventive Services Task Force does not specifi-
cally target parents, it has issued Grade A recommendations that clinicians
ask all adults and all pregnant women about tobacco use and provide
counseling for smokers (U.S. Preventive Services Task Force, 2009). Many
tobacco cessation programs for parents also involve identifying smokers at
well-child exams, in the hospital during delivery, and during postpartum
care, although some of the longitudinal interventions take place in the home
setting or via telephone. While several programs targeted to parents of
young children focus on outpatient settings (Winickoff et al., 2003), there
has been growing interest in hospital interventions targeting caregivers who
smoke for cases in which children are hospitalized for tobacco-sensitive ill-
nesses, such as asthma, other respiratory diseases, or infection (Chan et al.,
2005; Ralston and Roohi, 2008).
A systematic review identified 13 experimental and quasi-experimental
studies on interventions designed to assist families of young children with
smoking reduction and cessation (Brown et al., 2015). Ten of these studies
were focused on reducing child exposure to environmental tobacco smoke,
and most of them found positive outcomes, such as use of household re-
strictions on smoking or less smoking. Approaches that focused on smok-
ing cessation and relapse prevention among parents were less successful.
However, the heterogeneity among the interventions reviewed prevented
the authors from drawing firm conclusions about essential components
associated with success (Brown et al., 2015). In a separate meta-analysis of
randomized controlled trials and controlled clinical trials of interventions
aimed at preventing childrens exposure to tobacco smoke delivered primar-
ily in the context of health care (including such components as provision of
educational materials, counseling, and telephone check-ins), a small but sta-
tistically significant benefit was noted based on parent self-report. Studies in
which child biomarkers were collected showed lower exposure to tobacco
smoke for those whose parents participated in the interventions, but these
findings were not significant (Rosen et al., 2014). Finally, a novel approach
to promoting cessation of tobacco use among parents through primary
care is a pilot program that includes electronic health record prompts for

exposure to tobacco smoke at well-child visits, as well as decision support,

education, and a referral to the state quit hotline (Sharifi et al., 2014).
Educating Caregivers on Normal Infant Crying

Typically delivered by health care professionals, the Period of PURPLE
Crying Program aims to educate caregivers about normal infant crying given
where the infant is in his or her development and thereby prevent shaken
baby syndrome/abusive head trauma. Caregivers learn that there is a unique
developmental phase beginning at age 2 weeks through age 3-4 months
during which infants may cry for hours despite efforts to soothe them, that
shaking a baby can be fatal, and that alternatives (such as walking away)
can be used instead (Barr, 2012; Reese et al., 2014). Even though this pro-
gram is currently classified as promising by the California Evidence-Based
Clearinghouse for Child Welfare, the concern about crying as a precursor
to abuse (especially abusive head trauma) is supported by evidence showing
that teaching parents about typical crying and how to respond effectively
is beneficial. In one study, the programs approach was associated with a
significant reduction in cases of infants ages 0-5 months who were brought
to the emergency department primarily because of crying (with no other
underlying medical condition) by 29.5 percent relative to before the program
was implemented (Barr et al., 2015). The Period of PURPLE Crying Program
has been or is in the process of being implemented in a number of health
care facilities throughout the United States (National Center on Shaken Baby
Syndrome, 2013).
Public Education Approaches

As noted in Chapter 3, public education has increased general aware-
ness of some positive parenting knowledge, attitudes, and practices among
parents and families. Some public education initiatives use media to dissem-
inate information relevant to promoting parenting knowledge, attitudes,
and practices to a broad audience. An example is the universal component
of the Triple P-Positive Parenting Program, referred to as Triple P level 1.
(The full Triple P system is described in Chapter 5.) Triple P level 1 uses
a coordinated media and communication strategy targeting all parents
and other members of the community to destigmatize parents seeking
and participating in parenting support programs, counter parent-blaming
messages in the media, and connect parents with supportive resources and
programs. Messages are delivered using newsletters, brochures, posters,
radio and televisions spots, and other media (Shapiro et al., 2015; Triple
P-Positive Parenting Program, 2016a). A number of controlled evaluations
have found that parents who participate in Triple P show improved quality

of parenting compared with controls (Hoath and Sanders, 2002; Sanders

et al., 2000; Turner and Sanders, 2006; Zubrick et al., 2005). To the com-
mittees knowledge, however, no studies have evaluated the specific effects
of Triple P level 1 in changing parenting-related knowledge, attitudes, or
practices at the individual or community level.
Other media efforts focused on parenting are organization driven.
ZERO TO THREE, for example, is a nonprofit organization founded by
experts in child development, health, and mental health that disseminates
evidence-based parenting information nationwide. Based on the premise
that childrens earliest years are a period of substantial growth during which
experiences can have lasting impacts, ZERO TO THREE has created a va-
riety of resources to educate parents about how to nurture children during
this important developmental stage. Tools include tip sheets, brochures,
podcasts, and videos on a range of parenting-related topics, such as what
parents should expect from their children given their age and steps parents
can take at each developmental stage to help their children acquire various
skills (e.g., language, communication, thinking, self-control); how to pro-
mote young childrens social-emotional development and school readiness;
and how to address challenging behaviors (ZERO TO THREE, 2015).
The Centers for Disease Control and Prevention also has developed a
number of parenting resources, including information on developmental
milestones and parenting tips in such areas as creating structure and rules
for children, using consequences, giving directions, and using time-out.
Videos and other tools are designed to help parents practice these skills
(Centers for Disease Control and Prevention, 2016).
Several public health education campaigns in clinics and hospitals have
proven successful. An example, reviewed in Chapter 3, is the Safe to Sleep
campaign (previously known as Back to Sleep), which was thought to have
played a significant role in reducing the incidence of sudden infant death
syndrome (SIDS) over the past two decades (U.S. Department of Health
and Human Services, 2015b). Much of the Safe to Sleep information is
provided in hospital settings prior to postpartum discharge and in outpa-
tient c linics. Similarly, use of media for wide dissemination of information
about h elmet safety, coupled with distribution of free and reduced-price
helmets, in the National Safe Kids campaign is believed to have increased
knowledge among parents about the importance of children wearing hel-
mets during bicycling and other wheeled sports and increased childrens
helmet use (Morris et al., 1994; Rouzier and Alto, 1995). Other examples
with documented success range from tobacco control, to seat belt use, to
reduced use of illicit drugs (Hornik, 2002).
The literature on successful public health campaigns identifies character-
istics conducive to success (Randolph and Viswanath, 2004). These include
maximizing exposure to targeted messages among the audience; using social

marketing tools to create the appropriate messages for distribution, drawing

on message effect theories (Storey et al., 2008); and creating associated
structural conditions, such as a supportive environment or opportunities to
support the audience in making the recommended changes. The reach of the
communication effort, as well as the campaigns intensity (e.g., how often
individuals are exposed to the message), duration, and messaging approach
and whether it is used in combination with other elements, also may influ-
ence the extent of its impact (Boles et al., 2014; Friend and Levy, 2002).
Likewise, certain factors can reduce the success of public health cam-
paigns. This is the case, for example, when individuals become confused or
they develop distrust as a result of competing messages advocating behav-
iors inconsistent with or contradictory to those being promoted by a cam-
paign (Carpenter et al., 2015; Nagler, 2014). Another characteristic of the
contemporary information environment that presents a significant challenge
to public health campaigns is the generation of a large body of information
and data on a range of topics and the dissemination of such information on
increasingly proliferating information delivery platforms (Viswanath et al.,
2012). Also posing a challenge are differences among social groups in the
generation, manipulation, and distribution of information at the group
level and differences in access to and ability to take advantage of informa-
tion at the individual level, a phenomenon characterized as communication
inequalities (Viswanath, 2006).
Despite these challenges, public health campaigns can be an effective
tool for reaching a large and heterogeneous population at a much lower
cost than many other forms of interventions. And information and com-
munication technologies make it possible to customize and tailor infor-
mation to the needs of the parents based on their background and social
circumstances. The use of information and communication technologies is
discussed further later in this chapter.
Instruction in Parenting for Adolescents in the General Population

Part of the committees task was to describe key periods of interven-
tion that are more effective in supporting parenting capacitybeginning
in high school or even earlier (see Box 1-2 in Chapter 1). The committee
interpreted this part of its task as including individuals of high school age
and younger in the general population who are not pregnant or parents.
(See Chapter 5 for a discussion of interventions for adolescent parents.)
However, scarce scientific evidence supports the premise that informing
individuals about the challenges of parenting during high school or earlier
will help lower pregnancy rates or improve future parenting among those
who do become parents. Evaluations of infant simulation programs, in-
cluding the well-known Baby Think it Over (BTIO: now marketed by

Realityworks as RealCare Baby), have not yet demonstrated a direct

relationship between participating in such programs and reduced pregnancy
rates or improved parenting.
Some evidence from longitudinal research does point to a prospec-
tive association between perceived benefits of childbearing and subsequent
pregnancy among young women wishing to avoid pregnancy (Rocca et al.,
2013). Additional longitudinal data show that positive attitudes toward
an adolescent birth may be predictive of a subsequent birth (Rosengard et
al., 2004). The converse also may be truethat adverse attitudes toward
adolescent parenting may be predictive of delayed childbearing, although
this has not been shown.
Some, but not unequivocal, evidence indicates that participating in
BTIO resulted in changes in adolescents perceptions with regard to the
costs and rewards of adolescent parenting. For example, Somers (2013)
used an experimental design and a 1-year follow-up with middle schoolers
from low-income families in an urban district to test BTIO. The program
instilled a more realistic perception of their lack of readiness among the
BTIO groups; however, none of the other expected outcomeschanges in
sexual behavior, contraceptive use, personal intentions to avoid teenage
pregnancy, sexual attitudes, and actual pregnancy rateswas seen. Some
of these effects could be due to the relatively low rate of sexual activity
even after 1 year.
Roberts and McCowan (2004) implemented a randomized controlled
trial of an intervention combining the New York State parenting curriculum
(which focused on reflection-based parenting skills with specific child care
competencies) and exposure to BTIO, with the control group experienc-
ing only the BTIO curriculum. Their findings, based on a sample of high
school students in a rural community, show that the infant simulator is an
effective tool for teaching child care skills in that the students more often
expressed their belief that parenting is a skill that takes time and patience to
learn, that teenagers cannot afford to raise a baby, that raising a child and
continuing ones education is difficult, and that teenagers should abstain
from sexual behaviors.
Herrman and colleagues (2011) concluded that 79 teens in a single-
group study using a pre- and post-test design showed no changes in percep-
tions following six weekly BTIO classes and a weekend infant simulator
experience. The committee agrees with their conclusion that until such a
time as a multiple site, large sample, randomized study with control groups
using a valid instrument to measure outcomes is conducted, the use of in-
fant stimulators will remain controversial (Herrman et al., 2011, p. 327).
It is possible that the use of infant simulators as part of a more comprehen-
sive pregnancy prevention program providing accurate information about
both abstinence and contraception could change attitudes about becoming

pregnant and encourage a reduction in unprotected sexual intercourse.

Many effective pregnancy prevention programs do include exercises aimed
at getting adolescents to consider the untoward impact on their lives if they
become parents. Programs such as BTIO could reinforce this message, al-
though this is not a known effect of the program. However, the committee
found no direct evidence as to whether teaching youth in the general popu-
lation about parenting has an impact on their future behavior as parents.
Couple Relationship Education

Over the past two decades, concerns about the state of family life in the
United States have led to the creation of many general programs designed
to strengthen couple relationships, prevent the emergence of conflict and
violence, and increase fathers positive involvement with their children. Gen-
erally characterized as couple relationship education (Cowan et al., 2010;
Panter-Brick et al., 2014), these programs have focused primarily on improv-
ing couples communication, although a very few, using clinically trained
staff, also focus on parenting. Couple relationship education programs ini-
tially were targeted to middle-class couples early in their marriage and not
already in marital or relationship distress. More recently, there have been
efforts to provide services for couples that are at risk by virtue of low income
but not otherwise identified as experiencing serious relationship difficulties.
Two relatively large-scale couple relationship education initiatives have
been funded and evaluated by the federal government. Building Strong
Families (Wood et al., 2014), which included three different couple rela-
tionship intervention approaches, was conducted across eight U.S. sites,
with 5,102 low-income, unmarried couples being randomly assigned to
intervention and control conditions. The couples were not identified as
having specific relationship difficulties. The Supporting Healthy Marriage
Program (Hsueh et al., 2012) was a randomized controlled trial involving
6,298 low-income married couples, expecting or with a child, at eight sites
assigned randomly either to one of four couples-group programs plus a
family support worker or to a no-treatment control condition. The results
for Building Strong Families appear to be limited, although there is some
evidence for a possible impact on conflict in low-income families. Self-
report and observational measures suggest that the Supporting Healthy
Marriage Program changed the way participants viewed their marriage, as
well as the extent to which they were able to implement the skills taught
by the program curricula (Cowan and Cowan, 2014).
A number of smaller programs have shown evidence of success (Cowan
and Cowan, 2014; Faircloth et al., 2011; Feinberg et al., 2010; Pinquart
and Teubert, 2010). One of these programs (Supporting Father Involve-
ment) works with parents about to have a child. A consistent body of

research finds that marital satisfaction often decreases following the birth
of a child, and marital conflict emerges or worsens. This program provides
a 16-week group course to either the couple or just the father. Randomized
controlled research involving several hundred families found reductions in
parenting stress; stability in couples relationship satisfaction; and stability
or reductions in childrens hyperactivity, social withdrawal, and psycho-
logical symptoms compared with families in a control group (Cowan and
Cowan, 2000). Reduction in parents violent problem solving was linked
to reductions in childrens aggression. In another randomized controlled
trial involving parents of children entering kindergarten, positive effects
were found on both mothers and fathers marital satisfaction and the chil-
drens adaptation (hyperactivity and aggression), according to their teachers
(Cowan et al., 2011).
WIDELY USED INTERVENTIONS

Beyond the health care system, the most widely used approaches to
strengthening and supporting parenting are home visiting programs; pro-
grams focused on helping parents provide cognitive stimulation in the home
through educational activities involving reading, language, and math; ef-
forts at providing parenting education in the context of classroom-based
ECE programs; and efforts to increase parent engagement in school set-
tings 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 qual-
ity of parent-child interactions; improving childrens 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 ses-
sions, 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 great-
est 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 visitors
aims generally include supporting parents in their parenting role, facilitat-
ing 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 o ccur 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 man-
dated (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 infra-

structure for implementation has grown (Daro, 2011; Daro and Benedetti,
2014). States, counties, and municipalities around the country have imple-
mented 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 ad-
dress include poor birth outcomes (low birth weight), child maltreatment,
and lack of school readiness. Historically, funding agencies and communi-
ties that developed home visiting programs or selected from existing pro-
grams 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 part-
ners, 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.
As depicted in Figure 4-1, home visiting programs aim to support sev-
eral evidence-based parenting knowledge, attitudes, and practices identified
in Chapter 2. Visits are designed to improve parents knowledge of chil-
drens development and how adults can support childrens 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 childs development and learning
may be unable to overcome that mind-set and engage fully in the home
visits. Home visitings primary pathway to the targeted long-term child
outcomes is through improvements in the parent-child emotional relation-
ship 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.

144

FIGURE 4-1 Illustrative prenatal and early childhood home visiting logic model.
NOTE: HIV = home visiting; KAPs = knowledge, attitudes, and practices.
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, at-
titudes, 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
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 evi-
dence 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 spe-
cific 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
areaschild health, child development and school readiness, and reduc-
tions 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 Educations What Works Clearinghouse), the HomVEE
project team identified seven national models that met the HHS evidence
3See http://homvee.acf.hhs.gov/ [August 2016].

4Itis important to note that requirements for territories and tribal entities were different
from those for the states given the available research evidenceno existing home visiting
models were originally found that had evidence of effectiveness for tribal populations. Thus,
HHS allowed grantees to choose from existing models but required them to conduct an
evaluation.

BOX 4-1
Nurse-Family Partnership (NFP)
NFP is designed to improve prenatal health and outcomes, child health

and development, and families economic self-sufficiency and/or maternal life-
course development for first-time, low-income mothers. The program consists of
one-on-one visits between trained registered nurses and mothers, beginning at
pregnancy and concluding when the child turns 2. Along with their professional
nursing experience, nurses use input from parents and principles of motivational
interviewing (discussed in Chapter 6) to meet program objectives.
NFP has strong evaluation results from randomized controlled trials con-
ducted in New York (Olds et al., 1997), Tennessee (Kitzman et al., 1997), and
Colorado (Olds et al., 2002). In all, 135 studies for NFP were released from 1979
to 2012, 31 of which were found to be eligible for review by HomVEE. Of these,
18 were rated high for outcomes in child health and development, maternal health,
and family economic self-sufficiency. Specific program effects have included
improved prenatal health, fewer childhood injuries, increased intervals between
births, improved school readiness, and higher rates of maternal employment.
SOURCE: Administration for Children and Families (2015b).
BOX 4-2
Parents as Teachers (PAT)
PAT serves families from pregnancy through kindergarten entry. Services

include one-on-one visits by parent educators, group hands-on learning activi-
ties, health and developmental screenings for children, and a resource network.
Programs offer families a minimum of 12 home visits annually and are required to
provide services for at least 2 years. The goals of PAT include increased parental
knowledge of child development, early detection of developmental and health-
related issues, prevention of child abuse and neglect, and improved school readi-
ness. Target populations and program duration are identified by program sites.
Between 1979 and 2011, 60 studies of PAT were conducted, 23 of which
were eligible for review through HomVEE (2 rated PAT high, and the rest rated
PAT moderate or low or overlapped with another study and were not rated). Evi-
dence showed small and inconsistent overall positive effects on parents knowl-
edge, attitudes, and behavior; no overall improvement in child development or
health; and significant improvement in cognitive, communication, social, and
self-help development for children in Spanish-speaking households. PAT services
have been found to provide the greatest benefit to those also receiving case
management services.
SOURCE: Administration for Children and Families (2015c).

BOX 4-3
Durham Connects
Durham Connects is a universal nurse home visiting program available to all

families in a defined service area that have newborns between 2 and 12 weeks
old. The goals of Durham Connects are to help families promote their childrens
health and well-being and reduce child abuse and neglect. Visits are conducted
by trained nurses who utilize a structured interview protocol to examine families
strengths and potential needs in domains associated with mother and infant well-
being and connect families to needed supportive services. Child weight and health
checks are also provided. Home visits may start 2-3 weeks after the childs birth.
Two additional follow-up home visits are available from the nurse home visitor or
through local social services employees.
Evaluations of Durham Connects have found favorable primary and second-
ary impacts on child health (e.g., reductions in child receipt of emergency care),
positive parenting practices, and use of community resources.
SOURCE: Administration for Children and Families (2015a).
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), F amily
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), Oklahomas 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 re-
5In order to meet HHS criteria for an evidence-based home visiting program, models must
have at least one high- or moderate-quality impact study with favorable, statistically signifi-
cant impacts for two or more outcomes, or at least two high- or moderate-quality impact
studies of the model using nonoverlapping participant samples with one or more favorable,
statistically significant impacts in the same domain. In either case, impacts must be found for
either the full sample or, if found for subgroups only, be replicated in the same domain in at
least two studies using nonoverlapping participant samples. For models meeting these criteria
based on randomized trials only, significant impacts must be sustained for at least 1 year after
participants were enrolled and must be reported in a peer-reviewed journal. Single-case studies
may be considered if at least five studies on the intervention meet the What Works Clearing-
houses pilot design standards, are conducted by three research teams without overlapping
authorship, and the combined number of cases is at least 20 (U.S. Department of Health and
Human Services, 2016).

viewed, and 4 more met the HHS criteria (Avellar et al., 2014): D
urham
Connects/Family Connects, Family Spirit, Maternal Early Childhood Sus-
tained 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.
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, at-
titudes, 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 programs 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
6Primary outcomes refer to those that were measured through direct observation or as-
sessment, administrative data, or self-report using a standardized instrument. Table 4-1 does
not include impacts on secondary outcomesthose self-reported by means other than a
standardized instrument.
7The papers commissioned by the committee are in the study public access file and can be
requested at https://www8.nationalacademies.org/cp/ManageRequest.aspx?key=49669 [Oc-

tober 2016].

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
Outcome
Family Child
Positive Economic Development Reductions
Parenting Self- Child and School in Child
Practices Sufficiency Health Readiness Maltreatment
Child FIRST Not Not Not 5/16 1/3
measured measured measured
Durham Not Not 6/9 Not Not
Connects/Family measured measured measured measured
Connects
Early Head Start- 3/28 Not Not 2/36 Not
Home Visiting measured measured measured
Early Intervention 0/9 Not 8/18 Not Not
Program for measured measured measured
Adolescent
Mothers
Early Start (New 3/3 Not 2/4 2/6 1/2
Zealand) measured
Family Check-Up 2/2 Not Not 3/14 Not
for Children measured measured measured
Family Spirit 0/5 Not Not 10/40 Not
measured measured measured
Health Access Not 2/3e 6/9 Not 1/1
Nurturing measured measured
Development
Services
Healthy Not Not 1/3 Not Not
Beginnings measured measured measured measured
Healthy Families 2/50 Not 0/9 9/43 1/34
America measured
Healthy Steps f 0/1 Not 2/2 0/2 Not
measured measured
Home Instruction 1/10 Not Not 3/20 Not
for Parents measured measured measured
of Preschool
Youngsters
Maternal Early 1/6 Not 0/3 Not Not
Childhood measured measured measured
Sustained Home-
Visiting Program
continued

TABLE 4-1Continued
Outcome
Family Child
Positive Economic Development Reductions
Parenting Self- Child and School in Child
Practices Sufficiency Health Readiness Maltreatment
Minding the Baby 0/2 Not 1/2 Not 0/1
measured measured
Nurse-Family 4/22 4/21a 4/30 5/59 7/25
Partnership
Oklahomas 2/7 Not Not Not Not
Community-Based measured measured measured measured
Family Resource
and Support
Program
Parents as 3/50b 1/1 0/1 7/66c 1/3
Teachers
Play and Learning 11/24d Not Not 1/16 Not
Strategies-Infant measured measured measured
SafeCare Not Not Not Not 1/6
Augmented measured measured measured measured
NOTE: The table shows the number of favorable outcomes relative to the total number of
outcomes. Footnotes indicate when the total number of outcomes includes an unfavorable or
ambiguous outcome(s). In accordance with www.homvee.acf.hhs.gov/models.aspx, descrip-
tions of the outcomes are as follows: (1) Favorable: a statistically significant impact on an
outcome measure in a direction that is beneficial for children and parents. An impact could be
statistically positive or negative, and is determined favorable based on the end result. (2) No
effect: findings for a program model that are not statistically significant. (3) Unfavorable or
ambiguous: a statistically significant impact on an outcome measure in a direction that may
indicate potential harm to children and/or parents. An impact could statistically be positive
or negative, and is determined unfavorable or ambiguous based on the end result. While
some outcomes are clearly unfavorable, for other outcomes it is not as clear which direction
is desirable. (4) Not measured: current research (meeting HomVEE standards for a high or
moderate rating) includes no measures in this domain.
aOne of the three outcomes were unfavorable or ambiguous.
bThis report focuses on Healthy Steps as implemented in the 1996 evaluation. HHS has
determined that home visiting is not the primary service delivery strategy and the model does
not meet current requirements for MIECHV program implementation
cOne of the 21 outcomes were unfavorable or ambiguous.
dFour of the 50 outcomes were unfavorable or ambiguous.
eOne of the 66 outcomes were unfavorable or ambiguous.
fOne of the 24 outcomes were unfavorable or ambiguous.
SOURCES: Adapted from www.homvee.acf.hhs.gov/models.aspx; Avellar et al. (2012, 2014,

2015); Paulsell et al. (2010).

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 num-
ber 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 activi-
ties that support child behavior and learning, showed changes in parent
warmth, encouragement of autonomy, and supports for childrens skills and
appropriate guidance, but no changes in the quality of behavior supporting
childrens 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-suffi-
ciency. The HomVEE review identified several studies in which participa-
tion in NFP was associated with reduced rates of subsequent childbearing
(Kitzman etal., 1997; Olds et al., 2002, 2004) and lowered use of some
forms of public assistance (Olds et al., 2010). In two impact studies, par-
ticipation 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). Tak-

ing 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 paperRest Routine and the MOM Programshowed
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 interven-
tion 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 prob-
lems 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 follow-
up [Eckenrode et al., 2010; Kitzman et al., 2010; Olds et al., 2004]). In the
commissioned paper, the University of California at Los Angeles F amily
Development Project is identified as improving child behavior but not cog-
nitive skills (Heinicke et al., 2001). Minding the Baby (Sadler et al., 2013)
also demonstrated evidence of efficacy but only for the childs 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 prob-
lems 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 maltreat-
ment. The program had effects on hospitalizations for accidents and inju-
ries 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
Womens 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 Admin-
istration (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 engage-
ment, and child development.
HV CoIIN uses the Institute for Healthcare Improvements Break-
through 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 implementa-
tion of improved programs (Arbour, 2015). The collaboratives 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 spe-
cific contexts, collect data on a number of indicators over time to demon-
strate 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 Im-
provement 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 leg-
islatively 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 im-
provement and sustainability in home visiting, and demonstrating the ef-
fectiveness 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 collaboratives 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).
Programs Promoting Parent Educational Activities

in the Early Home Learning Environment
As discussed in Chapter 2, in recent years there has been increased
attention to parent behaviors that are associated with childrens cognitive
development as well as social-emotional skills. Designing interventions that
generate large impacts on parent practices in promoting childrens cognitive
skills has proved difficult. Two large meta-analyses of randomized controlled
trials have included evaluations of parent skills training in relation to chil-
drens cognitive outcomes. One found that parent training in promoting
childrens cognitive, academic, and social skills was associated with smaller
effects relative to parent training programs that did not include those com-
ponents (Kaminski et al., 2008). The other found that interventions for
new and expecting at-riskparents that focus on the promotion of childrens
cognitive development (e.g., teaching parents how to use stimulating mate
rials) generate small to very small effects on various noncognitive childhood
outcomes, including parent-child relations (Pinquart and Teubert, 2010).

There is, however, some experimental research suggesting that interven-

tions designed to promote parents provision of stimulating learning experi-
ences do support childrens cognitive development, primarily on measures
of language and literacy. Intensive parent training in the home or a com-
munity setting provided by coaches who visit parents frequently (as often
as weekly) have been shown to increase responsive and developmentally
stimulating parenting and, in turn, childrens early achievement and posi-
tive social behavior. Evidence-based models of this approach include Play
and Learning Strategies (PALS) (Landry et al., 2006, 2008, 2012); My
Baby and Me (which used the PALS curriculum for responsive parenting
plus additional training on such topics as developmental milestones, health
and safety, and literacy) (Guttentag et al., 2014); Lets Play in Tandem (Ford
et al., 2009); the Head Start Research-based Developmentally Informed
Parent (REDI-P) Program (Bierman et al., 2015); and the Getting Ready
for School Program (Noble et al., 2012).
In PALS and My Baby and Me, parents of infants are coached during
90-minute in-home sessions on contingent responsiveness, joint engage-
ment, interactive communication, and emotional support for their children.
Multiple randomized trials of these programs have indicated increased
contingent responsiveness, verbal stimulation, and warmth from socially
disadvantaged mothers and, in turn, later improvements in childrens re-
ceptive and/or expressive language skills and complexity of play, as well
as more prosocial play with their mothers and fewer behavior problems
(Guttentag et al., 2014; Landry et al., 2006, 2008, 2012). It is worth not-
ing, however, that while My Baby and Me produced gains for mothers and
children when administered from 4 to 30 months of age, PALS administered
during the toddler years produced more positive outcomes for children than
it did during infancy alone or across both infancy and toddlerhood. Lets
Play in Tandem (Ford et al., 2009) and REDI-P have (Bierman et al., 2015)
demonstrated effectiveness in randomized controlled trials with respect to
parent engagement during the preschool years, at ages 3 and 4-5, respec-
tively. For Lets Play in Tandem, weekly home visits for 1 year were used to
train parents in how to engage children in activities designed to promote vo-
cabulary, emergent literacy, and numeracy skills, as well as self-regulation.
Although changes in parenting behaviors were not examined following
treatment, significant child-level effects included improved vocabulary, lit-
eracy, numeracy, and general academic skills, as well as inhibitory control
and social-behavioral skills. For REDI-P, parent training during home visits
was focused primarily on developing parenting skills directed at childrens
social-emotional, self-regulatory, and literacy outcomes, including how to
better engage in literacy-based play and learning activities that support
childrens learning skills and motivation. The intervention improved the
richness of parent-child conversations and interactive reading activities.

When the children entered kindergarten, significant differences between

treatment and control groups included better self-directed learning, literacy
skills, and academic performance for those whose parents had received the
trainings (Bierman et al., 2015).
Although generally less intensive than the other in-home and workshop
trainings discussed above, several dialogic reading interventions (Arnold et
al., 1994; Lonigan and Whitehurst, 1998; Whitehurst et al., 1988, 1994)
have been designed to increase parents engagement with their children
during storybook reading by training them to ask open-ended questions,
respond to and encourage childrens comments and interests, and teach
children vocabulary. Experimental evaluations of these interventions have
shown them to be effective for improving literacy or language outcomes
(e.g., expressive language skills), although these effects appear to be limited
to immediately after the end of the intervention and may be most pro-
nounced when complemented by similar interventions within child care/
preschool. Similarly, programs designed to tutor parents in reading effec-
tively with their children have demonstrated short-term but not long-term
improvements in childrens literacy (Mehran and White, 1988). Notably,
in these dialogic reading interventions, there is some evidence that video-
based instruction and modeling that is complemented by discussion with
parents is effective for training parents to better engage in their childrens
early learning (Arnold et al., 1994; Whitehurst et al., 1988).
There are several other programs with some evidence of impact. In one
randomized controlled study, interactions between high-risk parents and
their children over developmentally stimulating, age-appropriate learning
material (e.g., a book or a toy) followed by review and discussion between
parents and child development specialists, were found to improve childrens
cognitive and language skills at 21 months compared with a control group,
and also reduced parental stress (Mendelsohn et al., 2005). In another ex-
perimental study, children of mothers who watched a series of short films
on talking to children, using praise, using bath time to learn, and looking
at books and puzzles, among other topics, followed by discussion with
community health workers to encourage mothers to practice the activities
with their children, showed significant benefits on measures of cognitive
development predictive of academic achievement compared with controls
(Chang et al., 2015).
Language interventions for parents of children with developmental dis-
abilities and delays also have shown an impact. An 18-study meta-analysis
found that language interventions implemented by parents had a significant
and positive effect on the development of receptive and expressive language
skills in children ages 18-60 months with and without intellectual disabili-
ties (Roberts and Kaiser, 2011). In another randomized controlled study,
Parent-Child Interaction Therapy, which targets child behavior problems

through mothers use of child-directed play, improved language production

among children ages 20 to 70 months with and at risk of developmental
delays compared with a control group (Garcia et al., 2015).
In the Getting Ready for School intervention (Noble et al., 2012),
2-hour weekly workshops with parents over a 15-week period were used
to complement existing Head Start teacher-parent workshops for families of
children in randomly selected intervention classrooms. The complementary
workshops, led by a trained facilitator, focused on teaching parents how
to engage with their children at home in activities focused on literacy (e.g.,
helping their children learn the letters in their names), language (e.g., learn-
ing how to ask questions of their children), and math (e.g., helping their
children recognize and extend patterns). Although parenting behaviors were
not measured, compared with children in comparison classrooms, children
of parents in the intervention evidenced improved language and literacy as
well as applied problem and math concept scores.
There is also some evidence that aligning home learning contexts for
literacy with early elementary school literacy learning is valuable, at least
for increasing the frequency of literacy activities in the home of socially
disadvantaged children. The Family Literacy Program (Morrow and Young,
1997), for example, encouraged parents to create home centers for parent-
child literacy activities that paralleled 1st- to 3rd-grade classroom cen-
ters, while also encouraging reading daily, sharing stories, and writing
journals together. Parents were guided through monthly group meetings
and one-on-one mentorship. In an experimental study, according to par-
ents and children, in-home literacy activities increased in the intervention
group relative to controls, and teacher-rated literacy ability and interest
improved, although no improvements were evident on a standardized read-
ing assessment.
There is also evidence that transmedia interventionsfocused on media
content delivered across multiple platforms (e.g., videos, online games,
and apps)can be used to promote parent engagement in the home. From
2010 to 2015, the U.S. Department of Education supported the Ready to
Learn initiative, a series of descriptive and experimental studies on parent-
caregiver outcomes in supporting childrens cognitive (literacy and math)
engagement and social-emotional skills. A randomized controlled evalu-
ation study, Supporting Parent-Child Experiences with PEG+CAT Early
Math Concepts, conducted by SRI International, addressed the question
of how time spent viewing and playing with PBS KIDS educational, non
commercial media at home, in family settings, can foster positive outcomes
for children and parents/caregivers (Moorthy et al., 2014). Using videos,
online games, and tablet-based apps that allowed caregivers and children to
engage with PEG+CAT characters, parents and caregivers in the treatment
group reported a higher frequency of joint parent-child use of technology,

more joint gameplay, and more conversation connecting digital media and
daily life than did nontreatment parents and caregivers. In addition, the
study report indicates that children participating in the intervention ex-
hibited statistically significant improvements in the mathematics skill areas
of ordinal numbers, spatial relationships, and 3-D shapes compared with
children in the nontreatment group. Important study limitations, however,
included reliance on parent self-reports, selection bias, and inadequate as-
sessments targeted by the study experience.
Finally, it is worth noting recent findings indicating that information
about the importance of engaging in childrens learning may not be enough
to achieve meaningful behavioral changes among parents. In a randomized
field experiment of the Parent and Children Together Program (Mayer
et al., 2015)a 6-week intervention with English- and Spanish-speaking
parents of children enrolled in Head Start programsthree behavioral
tools were employed (text reminders, goal setting, and social rewards), and
parents were provided with information about the importance of reading to
children. Findings indicated large increases in usage of a reading app after
the 6-week intervention with increases due to the behavioral tools rather
than the increased information.
Parenting Education Delivered in the Context of

Classroom-Based Early Care and Education Programs
ECE programs provide full- or part-time classroom-based services (cen-
ter or family child care) for children from birth to age 5. They often include
parenting education and other services for families (sometimes starting pre-
natally) designed to improve the overall circumstances of families and pro-
mote parenting knowledge, attitudes, and practices that support childrens
cognitive and social-emotional development and success in school (Brooks-
Gunn et al., 2000; Chase-Lansdale and Brooks-Gunn, 2014; F antuzzo 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 poten-
tial for additive effects for the child and family. Childrens positive experi-
ences 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 com-

ponents 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 childrens 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 commit-
tee 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) parent-
ing education, including at least two home visits per year whereby teachers
give parents information about their childrens current classroom activities;
(2) group parenting support classes on topics of interest to parents; and
(3) opportunities to volunteer in the childs 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 lin-
guistic 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,
8In June 2015, a Notice of Proposed Rulemaking on Head Start Program Performance
Standards was issued, focused on the development of new targets for program participation
(Administration for Children and Families, 2015d).

but take-up rates for nutrition, income, housing, utilities, education and
job training assistance programs did not differ significantly between par-
ents 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 eval-
uation of parenting impacts in the National Head Start Impact Study.
Parenting-related measures included disciplinary practices, educational sup-
ports, 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 co-
hort 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
programs 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 sig-
nificant impacts on childrens 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 mea-
sures (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 out-
comes. Nonexperimental analyses could provide exploratory answers to
these types of questions.
Early Head Start center-based impacts on knowledge, attitudes, and prac-

tices 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 ap-
proaches, 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 find-
ings may have implications for the need for increased flexibility in pro-
gramming 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 childrens academic experiences. In
some cases, these targets are complemented by attempts to improve align-
ment 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 gen-
eral engagement in home learning activities, it led to increased frequency
of parent-child reading and improved childrens vocabulary in a quasi-
experimental study (Mendez, 2010).
The Kids in Transition to School (KITS) Program is a short-term, tar-
geted, 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 involve-
ment 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, Ohios Learning
and Earning Program, and the Teen Parent Demonstration) offered ado-
lescent mothers a wide range of services, including, in some cases, parent-
ing 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 im-
provements in the quality of their childrens home environments and early
literacy and behavior (Polit, 1989).
Evaluations of the other three programs were based on random as-
signment and showed a less positive set of impacts (Granger and C yrton,
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 Demon-
stration 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 evalua-
tions of New Chance and the Teen Parent Demonstration, but in neither
case did the program improve scores on the mental health measures em-
ployed. Moreover, mothers in the New Chance Demonstration experi-
mental group reported significantly more parenting stress relative to their
control counterparts.
Consistent with the view of child care as merely a support for the
mothers employment and education activities, none of these three pro-
grams affected any of the assessed dimensions of childrens school readi-

ness. 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 sup-
port infants and childrens cognitive, social-emotional, and physical devel
opment, as well as to enhance parents ability to support their childrens
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 programs 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 sup-
ported 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 CCDPs 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. Evalu-
ators 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 programs 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 C hicago
is a center-based early intervention program that offers comprehensive edu-
cational 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 objec-
9Calculated based on the Consumer Price Index (Crawford et al., 2016).

tives, 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
childrens 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 programs
effects, suggesting that the program components targeting parents played a
role in its success (Reynolds etal., 2004).
New in two-generation programming are so-called Two G eneration
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 A nnie
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 train-
ing 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 motiva-
tion. 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 childrens cognitive skills (language, literacy, and math)
and focus as well on childrens social-emotional development, given the
reciprocal nature of these skills. For example, Educare, based in 12 Educare
schools and on Head Starts parent involvement objectives, focuses on
receptive language, vocabulary, and early reading, and childrens 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 compar-
ing 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 func-

tion 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.
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 childrens 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 com-
munication and connections with other families and community members
(e.g., parent social networks).
Although the terminology used to describe parenting behaviors relative
to childrens 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 con-
nections 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 childrens 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 en-
able them to take advantage of these opportunities and resources (Dearing et
al., 2015; Henderson and Mapp, 2002). In the parent-engagement interven-
tion literature, programs generally take one of two approaches: (1) focus-
ing primarily on improving parents level and quality of engagement in the
home environment with regard to learning stimulation and behavior regula-
tion, or (2) focusing on connecting parents with their childrens 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

BOX 4-4
Parenting in Older-Model Early Care and Education Programs
It is difficult to draw lessons from older-model early care and education

(ECE) programs because children assigned to comparison groups faced much
different and typically worse conditions relative to those faced today. Family sizes
were much larger, parents education levels were much lower, and very few poor
children attended center-based preschool (Duncan and Magnuson, 2013). These
conditions combined to set a very low standard of care for low-income children for
programs developed in the 1960s, 1970s, and 1980s to improve upon. That said,
it is still useful to mention the knowledge, attitudes, and practices components
of the most prominent of these early programsthe High/Scope Perry Preschool
Study (Perry) and the Abecedarian Project.
Perry provided 1-2 years of part-day educational services plus weekly home
visits by teachers to 58 low-income, low-IQ African American children ages 3 and
4 in Ypsilanti, Michigan, during the 1960s. Meetings with groups of parents were
also organized (Weikart and Lambie, 1970). The home visits focused mainly on
instructional activities between the teacher and children, although the teachers
were encouraged to engage in informal conversation with the mothers about the
teaching materials brought to the home, childrearing practices, and the academic
needs of the children when they started school. Perrys evaluation included
teachers ratings of the degree of cooperation shown by mothers; predictions of
mothers future school relationship, which were collected in kindergarten through
3rd grade; and, when the children reached age 15, both their and their parents
reports of the quality of parenting. No treatment/control group differences were
found for any of these items (personal communication with Larry Schweinhart,
August 8, 2015).
The Abecedarian program served 57 low-income African American families
from Chapel Hill, North Carolina (Campbell and Ramey, 1994). Enrolling partici-
pants in the first year of life, the program was considerably more intensive than
Perry Preschool, providing center-based education and other services to children
8 hours a day, 5 days a week, 50 weeks a year, and generating costs totaling
about $80,000 per child (in 2014 dollars). Supportive social services were avail-
able to families facing problems with housing, food, transportation, and the like,
although these services also were made available to families in the control group,
making it impossible to assess program impacts on these social services. Unique
to the Abecedarian group were opportunities for parents to serve on the advisory
boards of the daycare center and participate in a series of voluntary programs
covering such topics as nutrition and behavior management (Burchinal et al.,
1997). Although Abecedarian boosted childrens IQs and academic skills and had
lasting effects on their educational attainment and health (Barnett and Masse,
2007), it had no impact on the parenting measures gathered in the study (personal
communication with Peg Burchinal, August 8, 2015).
In summary, these two best-known early ECE programs both included par-
enting components, and both generated child impacts well into adulthood. But for
neither program was there evidence of impact on parenting knowledge, attitudes,
and practices.

Growth-
promoting
Community
Teacher Affordances Parent
Knowledge Knowledge
& Attitudes & Attitudes
Social Capital
Family
Child
Attributions &
Motivation
Child Academic
Achievement &
Learning
Child Learning
Skills &
Strategies
Family
Engagement
in Education
FIGURE 4-2 Hypothesized benefits of parents engagement in childrens early education for
childrens achievement and school success.
SOURCE: Dearing et al. (2015).
contexts characterized by multipronged social and economic disadvantage

(Garca Coll et al., 1996; Huston and Bentley, 2009). More specifically,
theory on parents engagement in childrens early education has hypoth-
esized benefits for achievement and school success through three primary
mechanisms (see Figure 4-2).
First, collaboration among families, schools, and communities can help
build the capacity to stimulate and support childrens learning. This link-
age 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 childrens 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 chil-
drens schooling with developmentally appropriate levels of autonomy and

emotional support, they communicate positive beliefs about the childrens

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 childrens 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 etal., 2016), practice recommendations for inter-
ventions 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 childrens needs across the developmental spectrum), inten-
tional (focused on specific objectives), strengths-based (building on family
and child competencies and interests), and collaborative (structured around
mutualparent and teachergoals). In turn, interventions proving suc-
cessful in randomized experimental evaluations share such characteristics as
a strong emphasis on (1) frequent communication and sharing of informa-
tion 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).
Evidence-Based Programs for Promoting

Parent Engagement in Young Childrens Schooling
Much of the research on parents and childrens schooling has focused
on the association between parent involvement and childrens academic
outcomes. Studies have found that specific parent involvement behaviors,
such as participation in school activities and direct communication with
teachers, are linked to higher academic achievement in both reading and
mathematics (El Nokali et al., 2010; Fan and Chen, 2001; Fantuzzo et al.,
2004, 2013). Furthermore, parent involvement in the home, such as moni-
toring assigned homework and participating in learning activities, as well
as having conversations with their children about school, is linked to higher
reading and writing scores and report card grades. With some exceptions,
the research on the effects of fathers similar involvement has been sparse.
Many attempts have been made to improve parent engagement through
interventions in the home and through home-school connections. The focus

here is on interventions with socially disadvantaged children and families

targeting home-school connections between prekindergarten and 3rd grade
for which evidence of efficacy has been derived from randomized experi-
mental evaluations.
A family mathematics curriculum intervention (Starkey and Klein,
2000) used an approach similar to that of the Family Literacy Program for
improving parent engagement in childrens math learning. Specifically, Head
Start teachers trained parents in the use of math learning activities and
games designed to promote developmentally sequenced learning of number
concepts, arithmetic operations, logical reasoning, geometric concepts, and
patterns. One notable feature of this program was that Head Start teachers
were matched ethnically with parents. Families also were given learning
activities to use at home. Although parenting behaviors were not observed
in the home, this 4-month (eight classes) intervention resulted in improved
math performance among children in the treatment group compared with
the control condition.
In the Parent Corps Program, parent groupscofacilitated by pre-
school teachers and mental health professionals with expertise in behavior
managementare used to help parents establish structure and routines
for children, to teach positive parenting practices (e.g., use of positive
reinforcement and consistent consequences), and to provide opportunities
for facilitator-observed parent-child interactions. Parent Corps evaluators
note that a critical component of the intervention model is the numerous
opportunities to directly increase parentteacher communication. Parents
heard from teachers about their use of effective behavior management
practices at school and in turn shared ideas based on how their child
responded to the practices at home. Teachers heard parents perspectives
about daily struggles and the challenges of implementing these practices at
home (Brotman et al., 2011, p. 263). More effective parenting practices
in the treatment compared with the control groups were evident, including
parent reports of using more effective disciplinary practices, higher scores
on tests of knowledge of effective behavior management strategies, and
higher-quality parenting in researcher-observed parent-child interactions
(Brotman et al., 2011). The intervention also resulted in reduced behavior
problems among children.
Getting Ready is an evidence-supported intervention targeting parents
decision-making role at school (Sheridan et al., 2010). This program uses
structured interactions between early childhood teachers and parents dur-
ing home visits, parent-teacher conferences, and monthly family socializa-
tion activities that are designed to engage parents actively in learning and
behavior goal setting and decision making. Together, teachers and parents
identify learning opportunities at home and school and plan how educators
and parents can complement each others efforts to promote learning and

track childrens growth. Priorities include affirming parents competence,

increasing their access to information on child development, and reinforcing
positive parenting practices. Treatment effects have, in fact, been evident
for parental warmth and sensitivity, learning support, and autonomy sup-
port (Knoche et al., 2012). In one study involving children of mothers with
depression, children in the Getting Ready intervention experienced a sig-
nificantly greater decline in some problem behaviors (e.g., difficulty stand-
ing still, tendency to run around) relative to children in the control group.
However, no differences were observed for other learning-related behaviors
(Sheridan et al., 2014). In addition, the Getting Ready intervention has been
found to improve childrens language and literacy (Sheridan et al., 2011),
with some evidence that its effects on achievement are largest for children
at greatest risk for underachievement (e.g., those whose parents have less
than a high school education and those who did not speak English prior to
treatment [Sheridan et al., 2011]).
Applying a similar collaborative model focused exclusively on child
behavior, the Parent-Child Action Teams intervention uses a parent liaison
to create and guide partnerships among parents, teachers, and other school
professionals focused on assessing and monitoring childrens learning prog-
ress. In addition to parent-reported improvements in empowerment, inter-
vention children were found to have significant reductions in externalizing
and internalizing behavior problems compared with control children.
USE OF INFORMATION AND COMMUNICATION

TECHNOLOGIES TO SUPPORT PARENTING
Information and communication technologies can contribute to par-
enting in two ways: (1) socialization with respect to what parenting is and
means through the media, especially entertainment media, and (2) devel-
opment 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 com-
mon 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 im-

proving program reach. In 2013, approximately 84 percent of households
reported having a computer (with 78.5% having a desktop or laptop com-
puter and 63.6% having a handheld computer), and approximately 74 per-
cent of households reported Internet use (File and Ryan, 2014). According
to data from the Pew Internet and American Life Projects Networked
Families Survey, married parents with minor children living at home rela-
tive 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
technologyparticularly mobile phones and the Internetis 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 tech-
nologies 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),

TABLE 4-2 Computer and Internet Use among U.S. Households, 2013
Percentage of
Total Percentage of Households
Households Households with an
(in with a Internet
Household Characteristic thousands) Computer Subscription
Race and Hispanic Origin of Householder
White alone, non-Hispanic 80,699 85.4 77.4
Black alone, non-Hispanic 13,816 75.8 61.3
Asian alone, non-Hispanic 4,941 92.5 86.6
Hispanic (of any race) 14,209 79.7 66.7
Limited English-Speaking Household

Yes 111,084 84.7 75.5
No 5,207 63.9 51.4
Metropolitan Status
Metropolitan area 98,607 85.1 76.1
Nonmetropolitan area 17,684 76.5 64.8
Household Income
Less than $25,000 27,605 62.4 48.4
$25,000-$49,999 27,805 81.1 69.0
$50,000-$99,999 34,644 92.6 84.9
$100,000-$149,999 14,750 97.1 92.7
$150,000+ 11,487 98.1 94.9
Educational Attainment of Householder

Less than high school 12,855 56.0 43.8
High school graduate 28,277 73.9 62.9
Some college/associates degree 34,218 89.0 79.2
Bachelors degree or higher 36,349 95.5 90.1
SOURCE: Adapted from File and Ryan (2014).

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).
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 par-
ents and families.
Parent Voices
[One parent acknowledged that the Internet can be a platform for com-
munication of information to parents.]
Parents need education on how to find the right information on the
Internet. Only a few parents use Internet access to get information on
parenting, but most of them, they always rely on others.
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 O nline,
the Incredible Years), as well as programs developed at the outset for de-
livery 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 inter-
ventions 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 pro-
grams for which parent and child behavioral outcomes were reported
InfantNet, Internet-Parent Management Training, Parenting Wisely, and
Triple P Onlinemedium to large effect sizes were observed in the areas of
infant and parent positive behaviors, child behavioral problems (e.g., con-
duct, 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 pro-
grams 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 includ-
ing 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 inter-
vention, 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 adapta-
tion 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 pro-
gram, 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 collabo-
rators 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 Incred-
ible 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 dis-
semination 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 PTriple P Online and a self-help workbookno dif-
ferences 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 recur-
rence 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 ran-
domized 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 parent-
ing 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 haz-
ards. 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 evalu-
ated 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 effec-
tive 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 prac-
tice 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 com-
pleted a 1-month follow-up (N = 90) indicated that they would be less likely
than controls (N = 140) to overreact and respond harshly during disciplin-
ary interactions with their children and more likely to follow through with
promised consequences. These parents also reported a reduction in their
childrens 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 parent-
ing 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 emerg-
ing 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 emo-
tional measures, such as marital functioning, parenting stress, and de-
pression. 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 mothers sense of increased
connection to the outside world and eventually improving her well-being
(McDaniel etal., 2012).
In a quasi-experimental study involving 1,300 mothers of infants, inter
vention participants were provided with online interactive resources that
offered information and social support. These resources included an infor-
mation database, an online peer discussion forum, and an online answering
service staffed by nurses and midwives, covering such topics as how to re-
spond 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 inter-
vention 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 com-
plexity 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, childrens 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 cam-
paigns and office posters, helped extend parents interests to new areas,
while parents preferred verbal communication for brief and concrete mes-
sages. 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 communicat-
ing 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 col-
leagues (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 improve-
ment 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 com-
munication 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 availabil-
ity 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 mea-
sured 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 grow-
ing reliance on technology for information relevant to parenting. This may
be especially true for younger, including adolescent, parents, who are ac-
customed 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 interven-
tions are to have a positive effect on parenting practices, their developers
need to apply theories of behavior change (e.g., the theory of reasoned ac-
tion and the theory of planned behavior) that can inform influential mecha-
nisms 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 tech-
nologies is work on how entertainment media socialize young parents on
norms of parenting. While formal avenues of classes and structured cur-
ricula are important for developing and reinforcing certain norms about
parenting, entertainment media are also likely to have a significant influ-
ence. 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 facili-
tating better parenting.
The Earned Income Tax Credit and Child Tax Credit

As discussed in Chapter 3, the Earned Income Tax Credit (EITC),
which offsets the amount owed in taxes for low-income working families,
is one of the largest poverty alleviation programs for the nonelderly in the
United States (Center on Budget and Policy Priorities, 2016). The credit is
paid by the federal government, as well as by 26 states and the District of
Columbia, which set their own EITCs as a percentage of the federal credit

(Center on Budget and Policy Priorities, 2016). Federal benefits were as

high as $6,269 for families with three or more qualifying children in 2016
(Internal Revenue Service, 2016). Single mothers are the group most likely
to be eligible for the EITC. Noncustodial parents who qualify as childless
workers may claim the EITC, although payments under this category are
much smaller than those to custodial parents (Marr and Huang, 2015;
Marr et al., 2015). The Child Tax Credit, up to $1,000 per child, offsets
the costs of raising children for low- to moderate-income working families
(Center on Budget and Policy Priorities, 2016). The credit is paid by the
federal government and a few states that have their own programs.
A growing literature, none of it relying on random assignment, has
demonstrated associations between the generosity of EITC payments and
maternal work, stress, and health-related outcomes and behaviors; parent-
ing practices discussed in Chapter 2, such as receipt of prenatal care and
breastfeeding; and child well-being.
Consistent evidence suggests that tax credits improve employment-
related outcomes for most recipients. Analyses of the EITC expansions
that took place in the 1990s show that they contributed to significant in-
creases in work and wage growth among single mothers and female heads
of households compared with women who were otherwise similar but did
not receive the EITC (Blank, 1997; Herbst, 2010; Hotz and Scholz, 2003).
According to Meyer and Rosenbaum (2001), more than one-half of the
large increase in employment among single mothers that occurred during
the late 20th century can be attributed to the EITC expansions that took
place between 1984 and 1996.
Benefits such as the EITC that are designed to encourage parents to
work are not unambiguously beneficial for children and their parents, how-
ever, especially when they are provided to single low-income, parents who
are particularly likely to hold jobs that are stressful and require them to
work long hours or unusual shifts (Heinrich, 2014). While the income that
working parents earn may benefit themselves and their children in some
ways, the stress they bring home from work may undermine their parenting
practices and the atmosphere in the home (Duncan et al., 2001; Heinrich,
2014). Working parents who lack access to or cannot afford quality child
care may place their young children in lower-quality care or leave them
unsupervised or with older child siblings. If policies such as the EITC aimed
at increasing employment rates among parents are to be beneficial, these
kinds of problems need to be prevented (Heinrich, 2014).
A considerable body of research has explored how the EITC may influ-
ence adult recipients health and health-related behaviors although a 2013
review of many of these studies found that they carry a high risk of bias
from confounding and insufficient control of underlying time trends (Pega
et al., 2013). One of the stronger studies links expansions of the EITC to

data from the Behavioral Risk Factor Surveillance System and the National
Health and Nutrition Examination Survey (Evans and Garthwaite, 2010).
In particular, between 1993 and 1996, the generosity of the EITC increased
sharply, especially for mothers with two or more children. If income matters
for maternal stress and health, the authors argue, greater improvement
should be seen for children and mothers in two-child low-income families
than in single-child low-income families. Indeed, the study found that,
compared with mothers with one child, low-income mothers with two or
more children experienced larger reductions in risky biomarkers and self-
reported better mental health.
Additional studies have shown that the generosity of EITC payments is
associated with improvement in several health-related outcomes/behaviors,
including food security, smoking cessation, and efforts to lose weight.
The EITC also may improve working mothers access to health insurance
(Averett and Yang, 2012; Cebi and Woodbury, 2009). At the same time,
however, the generosity of EITC payments has been found to be associated
with detrimental effects on metabolic factors among women (Rehkopf et
al., 2014) and morbidity indictors such as weight gain (Schmeiser, 2009).
As for child outcomes, studies have found that EITC expansions in the
early 1990s contributed to improved academic achievement in the form of
higher test scores (especially in math) and higher high school/GED comple-
tion rates (Chetty et al., 2011; Dahl and Lochner, 2012; Maxfield, 2013).
The Maxfield (2013) study also found effects of higher EITC payments
on college enrollment by age 19 or 20. An analysis of reading and math
test scores among 2.5 million children in grades 3 to 8 in an urban school
district and corresponding tax record data for their families, spanning the
school years 1988-1989 through 2008-2009, found that additional income
from the EITC resulted in significant increases in students test scores; a
$1,000 increase in the tax credit raised students test scores by 6 percent
of a standard deviation (Chetty et al., 2011). Students with higher test
scores were more likely to attend college, have higher-paying jobs, and live
in better neighborhoods as adults and less likely to have a child during
adolescence. These findings led the authors to conclude that a substantial
portion of the cost of tax credits may be offset by earnings gained in the
longer term.
In addition, available evidence suggests an association between parents
receipt of the EITC and improved birth and perinatal outcomes. An analy-
sis by Arno and colleagues (2009) found that each 10 percent increase in
EITC penetration (within or across states) was associated with a 23.2 per
100,000 reduction in infant mortality (P = .013). However, it is unclear how
differences among states in poverty and unemployment rates, as well as in
welfare programs other than the EITC, may have influenced these findings
(Arno et al., 2009). Some research has found the size of EITC payments to

be associated with improvements in such indicators of perinatal health as

mothers utilization of prenatal and postnatal care, mothers use of tobacco
and alcohol during pregnancy, term birth, and birth weight (Baker, 2008;
Rehkopf et al., 2014).
Because the Child Tax Credit is newer than the EITC, it has not been
studied as extensively. The two credits share several features, however, so
the benefits for families may be similar as well. Like the EITC, the Child
Tax Credit alleviates poverty for working families by supplementing wages
and incentivizing work (Marr et al., 2015). In terms of child outcomes,
income support from the Child Tax Credit is associated with better aca-
demic achievement for elementary and middle-school students (Chetty et
al., 2011; Dahl and Lochner, 2012; Duncan et al., 2011).
Temporary Assistance for Needy Families (TANF)

TANF is an income support program created to help families achieve
self-sufficiency. The program provides block grants to states to be used for
an assortment of services, such as income support, child care, education,
job training, and transportation assistance, with services and eligibility
varying by state (Center on Budget and Policy Priorities, 2015b). Addi-
tionally, states are required to include work requirements for participants,
and assistance is reduced or stopped if an individual does not work. In
general, TANF recipients are less educated and poorer with more mental
and physical health problems relative to low-income nonrecipients, and
those with larger families are impacted more than those with small families
(Hildebrandt and Stevens, 2009; Muenning et al., 2015)
When TANF was created, the economy was strong, and during the first
year of the program, 73 percent of funds went to cash assistance (Hahn
et al., 2012). Over time, cash assistance has decreased, and states have
used the block grants for other purposes. Today, they spend approximately
25percent of TANF funds on basic assistance; 25 percent on child care and
connecting families to work; and about one-third on other types of services,
such as child welfare, emergency assistance, early education, teen pregnancy
prevention, and two-parent family formation and marriage support (Schott
et al., 2015).
Since TANF was initiated, few evaluations of the program have been
conducted, and only a few studies have used national or recent data (Acs
and Loprest, 2007; Bloom et al., 2011; Hildebrandt and Stevens, 2009).
States are not required to report whom they serve with TANF funds or
what outcomes are achieved. This lack of accountability and transparency
means that little is known about TANFs effectiveness. It has been found in
analyses of studies that included randomized controlled trials that TANF
has saved money for both individuals and government (Muennig et al.,

2015) and overall has increased employment and earnings among partici-
pants (Ziliak, 2015). However, there is currently no evidence that giving
states broad flexibility in use of the funds has improved outcomes for poor
families (Schott et al., 2015).
Health
It has been found that women with relatively smaller families who are
able to work have better health and longevity outcomes under TANF, while
those with disabilities or family obligations that prevent them from working
are better off under Aid to Families with Dependent Children (AFDC), and
in fact many of these women have enrolled in the Supplemental Security
Income Program instead of TANF (Muenning et al., 2015). Over the aver-
age TANF recipients working life, AFDC would cost about $28,000 more
than TANF, but it would increase life by an additional .44 year (Muenning
et al., 2015).
Work Participation
TANFs work incentives allow participants to work and receive as-
sistance. The work participation rate is the primary measure of state per-
formance for TANF. Hence, states can have an incentive not to help those
who may be difficult to employ since they often need extra assistance to
find work and stay employed (Hahn et al., 2012). Little evidence indicates
that TANF helps participants obtain better jobs than they could have found
on their own, and the jobs they find through TANF often do not help them
move on to better jobs thereafter (Lower-Basch, 2013). There has been
some evaluation of models aimed at helping those who are difficult to
employ. It has been found that state approaches to providing such service
vary. Random assignment studies have found some positive effects from
employment- and treatment-focused strategies. PRIDE in Philadelphia, for
example, increased employment, with impacts that lasted several years. At
the end of the program, however, most participants did not have jobs, and
80 percent still were receiving cash assistance; 2 years later, only 23 per-
cent of participants had a job (Bloom et al., 2011). Overall, employment-
focused interventions have had weak longer-term employment effects, while
treatment-focused interventions have increased service use but do not have
strong evidence for increasing employment (Bloom et al., 2011).
Education and Future Earnings

Encouraging TANF recipients participation in and completion of addi
tional education can help improve their families economic position. Many

states provide some basic education classes, vocational training, and post-
secondary education, which may be supplemented by other supports, such
as child care and tuition assistance. However, states also encourage TANF
recipients to work at the same time.
Studies evaluating TANFs education initiatives have found mixed re-
sults (Hamilton and Scrivener, 2012). Using random assignment research
designs, one evaluation found an increase in enrollment in education and
training, especially among single parents (Hamilton and Scrivener, 2012).
Even when enrollment has increased, however, the challenge has been
increasing the percentage of participants who complete the education or
training. Studies suggest that the following are beneficial: financial incen-
tives to encourage attendance, academic progress, acquisition of marketable
skills, community college exposure, job search aids, and student support
assistance (Hamilton and Scrivener, 2012). TANF recipients also often
face challenges to pursuing postsecondary education, particularly since
many recipients do not have a GED or high school diploma (Hamilton and
Scrivener, 2012).
Some argue that expanding TANFs educational support may make the
program less effective at helping recipients become employed (Greenberg et
al., 2009). In an analysis of results from 28 cost-benefit studies that used
random assignment evaluation, programs for GED completion and basic
education that recipients are required to take did not appear to increase
income (Greenberg et al., 2009). Unpaid work experience programs that are
mandatory after a period of unsuccessful job searching have shown limited
benefits (Greenberg et al., 2009).
Nutrition Assistance Programs

Many households today are food insecure. In 2014, an estimated
14 percent of households were food insecure at some point during the past
year (Coleman-Jensen et al., 2015); the proportion was 19.2 percent among
households with children under age 18. Nutrition assistance programs
reach millions of low-income families in the United States each year. Major
programs are the Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC), the Supplemental Nutrition Assistance Pro-
gram (SNAP), and the National School Breakfast and National School
Lunch Programs.
Special Supplemental Nutrition Program for

Women, Infants, and Children (WIC)
WIC helps parents obtain knowledge and adopt practices that promote
their own and their young childrens health by providing nutrition educa-

tion and vouchers for the purchase of healthy foods, breastfeeding support,
and health and social service referrals. The program reaches millions of
low-income pregnant, postpartum, and breastfeeding women and their
children under age 5 each year (U.S. Department of Agriculture, 2016d).
WIC nutrition education is provided in a manner that is easy for
participants to understand and that acknowledges the real-world interac-
tions among nutritional needs, living circumstances, and cultural prefer-
ences. Mothers meet with WIC staff either individually or in groups to
learn about the role of nutrition and physical activity in health, as well
as to discuss nutrition-related practices (e.g., how to read nutrition labels
and prepare healthy meals) (Carlson and Neuberger, 2015). Traditionally,
nutrition education has taken place in person at WIC offices, but online
education is available in many jurisdictions. Parents may use WIC vouchers
to purchase infant formula and baby food as well as fruits and vegetables,
whole grains, and other healthy foods. For breastfeeding mothers, counsel-
ing and educational materials, as well as peer support, are provided. To
promote breastfeeding, breastfeeding mothers are eligible for WIC benefits
for a longer period relative to nonbreastfeeding mothers, and those who
breastfeed exclusively have a broader selection of foods from which to
choose for voucher purchases. Referral services may include child immuni-
zations and health and dental care, as well as counseling for women who
smoke and abuse alcohol (Carlson and Neuberger, 2015).
Since WIC was initiated about 40 years ago, abundant research has
shown evidence of its effectiveness. WIC participation during pregnancy
is consistently associated with longer gestations and higher birth weights,
with effects tending to be greatest among children born to disadvantaged
mothers. Other outcomes include improved child nutrition (e.g., increased
vitamin and mineral intake, reduced consumption of fat and added sugars),
better infant feeding practices, and greater receipt of preventive and cura-
tive care (Carlson and Neuberger, 2015; Fox et al., 2004). Evidence also in-
dicates that updates to WIC-approved foods in 2007 to bring them more in
line with the latest nutrition science, made in response to recommendations
in the Institute of Medicine (2006) report WIC Food Packages: Time for
a Change enhanced the impact of WIC on the purchase and consumption
of healthy foods among families participating in the program (Carlson and
Neuberger, 2015). These changes included, among others, adding whole
grain and soy products; reducing milk, cheese, and juice allowances; and
giving states and other jurisdictions more flexibility to accommodate food
preferences of cultural groups.
Despite efforts to promote breastfeeding, mothers participating in WIC
have been found to be less likely to breastfeed than those not participating.
It is unclear whether this differential is related to the availability of formula
through WIC or other factors. Also in response to the 2006 Institute of

Medicine report, the U.S. Department of Agriculture took steps to encour-

age breastfeeding among mothers participating in WIC, such as no longer
routinely providing them with formula for the first month after birth and
providing a limited amount of formula in subsequent months to mothers
of partially breastfeeding infants. Whether these changes have had an im-
pact on breastfeeding rates among WIC participants is thus far unknown
(Carlson and Neuberger, 2015).
Research on the nonhealth benefits of WIC is limited. One recent study
that analyzed data from two nationally representative longitudinal surveys
showed that children whose mothers participated in WIC while pregnant
performed better than those of mothers not participating on measures of
cognitive skills at age 2. This finding persisted into childrens early school
years based on reading assessment (Jackson, 2015).
An evaluation of the Early Developmental Screening and Intervention
(EDSI) initiative among WIC participants in California illustrates how WIC
can support parents interactions with health care professionals. The initia-
tive used a health education class to teach parents about child development
and how to talk to their childs health care professional(s) about the childs
development. Before the class, 42 percent of parents reported by survey that
they had concerns about their childs development, learning, or behavior,
and only 26 percent of them had been asked about these concerns at their
childs last health care visit (Early Developmental Screening and Interven-
tion Initiative, 2011). The evaluation found that the parent education class
was associated with increases in parents preparation before health care
meetings, with about one-third of these parents reporting that they used
material they had learned in class. However, there was no change in par-
ents actions during their childs health care visits or their attitudes while
talking to their childs health care professional based on the survey findings
(Early Developmental Screening and Intervention Initiative, 2011). Another
evaluation found that 30 to 40 percent of parents participating in a Parent
Activation/Developmental Surveillance pilot reported discussing their con-
cerns about their childs development with a developmental specialist (Early
Developmental Screening and Intervention Initiative, 2011).
SNAP and National School Breakfast and National School Lunch

Programs
SNAP is the largest nutrition assistance program in the United States,
reaching an average of 22.5 million households each month in 2015 (U.S.
Department of Agriculture, 2016c). Many households receiving SNAP
(76% in 2014) include a child or an elderly or disabled individual (Gray
and Kochhar, 2015). By providing assistance for the purchase of food,
SNAP reduces poverty among disadvantaged populations, especially for

two-parent families (Center on Budget and Policy Priorities, 2015a; Tiehen

et al., 2013). A number of studies have found that SNAP reduces food
insecurity, while findings on improvements in diet quality have been mixed
(Andreyeva et al., 2015; Gregory et al., 2013; Hartline-Grafton, 2013). In
analyses of longitudinal data, SNAP participation has been found to de-
crease the probability of being food insecure by approximately 30 percent
and the likelihood of being very food insecure by 20 percent (Ratcliffe et
al., 2011) in both urban and rural areas (Mabli, 2014). Other longitudi-
nal analyses found that SNAP participation increased preschool childrens
intake of iron, zinc, niacin, thiamin, and vitamin A (Rose et al., 1998),
while another showed that young children participating in SNAP and/or
WIC had lower rates of nutritional deficit relative to nonparticipants (Lee
and Mackey-Bilever, 2007). However, other evidence shows that while
SNAP alleviates food insecurity, participants appear to be no more likely
than income-eligible nonparticipants to be meeting dietary guidelines. In
a systematic review of peer-reviewed studies, diet quality among children
and adults was similar for SNAP and low-income nonparticipants and of
lower quality than for higher-income individuals (Andreyeva et al., 2015).
The National School Breakfast and National School Lunch Programs
provide nutritionally balanced, low-cost or free breakfasts and lunches to
millions of children in public and nonprofit private schools and residential
child care institutions each day (U.S. Department of Agriculture, 2016a,
2016b). The evidence on the effects of these and other school-based nutri-
tion programs on child nutrition outcomes is limited (Gundersen et al.,
2012). Using National Health and Nutrition Examination Survey data for
2001-2004, Gundersen and colleagues (2012) estimate that the National
School Lunch Program reduced the rate of poor health among children
by at least 29 percent, the rate of obesity by at least 17 percent, and food
insecurity by at least 3.8 percent.
Health Care
As reviewed in Chapter 2 and above, various elements of the health
care system have the potential to affect parents positively in promoting the
health of their children. Health care providers have multiple contacts with
parents through the care of both children and the parents themselves.
Since the passage of the ACA in 2010, the number of adults without
health insurance is estimated to have fallen by 16.4 million (U.S. Depart-
ment of Health and Human Services, 2015a). This increase in insurance
coverage has expanded access to a number of services for families, such as
maternity care and pediatric services, preventive services, and screening and
treatment for mental health disorders.
Relative to insured children, uninsured children are more likely to have

problems with access to health care and unmet health care needs. They are
less likely to receive preventive care (well-child care, immunizations, basic
dental care) and almost 27 percent less likely to have had a routine checkup
in the past year (Alker and Kenney, 2014; White House, 2015). Medicaid
and the Childrens Health Insurance Program (CHIP) play an important
role in child coverage, currently providing coverage to more than one in
three children (Burwell, 2016). Evidence indicates that health insurance has
improved access to care for children, and utilization of primary and preven-
tive care appears to increase after CHIP enrollment (American Academy of
Pediatrics, 2014; McMorrow etal., 2014). Evaluations within and across
states generally have found that enrollees report improvements in having a
usual source of care, in visiting physicians or dentists, and in having fewer
unmet health needs after enrollment (American Academy of Pediatrics,
2014; Damiano et al., 2003; Fox et al., 2003; Selden and Hudson, 2006;
Szilagyi et al., 2004). Moreover, pre-post survey research with parents
suggests that racial/ethnic disparities in health care access and utilization
detected before enrollment are eliminated or greatly reduced after enroll-
ment (American Academy of Pediatrics, 2014; Shone et al., 2005). In a
cross-sectional analysis of data from the Health Reform Monitoring Survey,
compared with parents with employer-sponsored insurance, parents whose
children were covered under Medicaid or CHIP reported less difficulty
paying childrens medical bills (9.7% versus 19%) and paying less out of
pocket on health care (McMorrow et al., 2014).
McMorrow and colleagues (2014) found that 40 percent of children
with Medicaid or CHIP had a parent who obtained information on all
recommended anticipatory guidance topics during well-child visits (how to
keep a child from getting injured, how much or what kind of food a child
should eat and how much exercise a child should get, how smoking indoors
is bad for a childs health, how a child should behave and get along with
parents and others), versus 26 percent of those with insurance through
their parents employer (McMorrow et al. 2014). However, some research
has found that children with public coverage have more difficulty access-
ing specialist care, family-centered care, and after-hours care (Bethell et al.,
2011; Kenney and Coyer, 2012; McMorrow et al., 2014).
Parent Voices
[Issues around health are a concern for many parents.]

A father from Omaha, Nebraska, who had always provided for his fam-
ily experienced a medical condition that keeps him from working, and

he found it difficult to accept that he is no longer able to provide for his

family.
Some parents in this country, based on income, rely on government ben-
efits, but when you have higher income, you are not eligible. So when you
are not eligible for Medicaid, some parents wont take their kids to see
the doctor. At work, they can get insurance, but they have to pay more.
From my own experience, when a kid doesnt have Medicaid, they stop
seeing the doctor.
Housing Programs
Housing-related expenses (shelter, utilities, furniture) account for fami-
lies largest share of expenditures on children across income groups, rep-
resenting 30-33 percent of total expenditures on a child in two-child,
husband-wife families in 2013 (Lino, 2014). Balancing housing-related
expenses with expenses for other necessities, such as nutritious foods and
quality child care, can be especially difficult for low-income families.
The Housing Choice Voucher Program (HCVP) (often referred to as
Section 8) helps more than 5 million people in low-income families access
affordable rental housing that meets health and safety standards (Center
on Budget and Policy Priorities, 2015c). Studies show potential benefits of
participation in HCVP, including improved nutrition due to greater food
security, increased household stability after the first year, and reductions
in measures of concentrated poverty and the incidence of homelessness
(Carlson et al., 2012; Lindberg et al., 2010; Wood et al., 2008). A study of
8,731 families in six locations where housing vouchers were randomly as-
signed to eligible participants found that over a period of about 5 years the
vouchers reduced the incidence of homelessness and living with relatives: 45
percent of nonrecipients versus 9 percent of recipients spent time without
a place of their own in the 4th year of the study) (Wood et al., 2008). In a
review of published research on neighborhood-level housing interventions,
Lindberg and colleagues (2010) found that voucher holders were less likely
than nonvoucher holders to experience malnutrition due to food insecurity,
poverty, and overcrowding.
Another scientifically supported housing initiativehousing rehabili-
tation loan and grant programsprovides financial assistance to enable
low-income homeowners to repair, improve, modernize, or remove health
and safety hazards from their dwellings (U.S. Department of Housing and

Urban Development, 2015). Low-interest loans and grants are offered to

homeowners at the federal and state levels through local lenders based on
income level and rural versus urban residence. Evidence from systematic
reviews and randomized controlled research suggests that housing improve-
ments, especially those aimed at increasing household warmth, may posi-
tively impact physical and mental health and respiratory outcomes, as well
as absences from school for children and from work for adults (Gibson et
al., 2011; Howden-Chapman et al., 2007; Thomson et al., 2013).
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 childrens health needs by
national law. Of the 189 countries included in Heymann and McNeills
(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 childrens 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.
Needs of New Parents and Young Childrens Health Care Needs

Newborns and infants require substantial, focused, and responsive
care. Parents of newborns need time to bond with their child and adjust
to the demands of caring for an infant while also overseeing their childs
healthy development. In addition, mothers need time to rest and recover
from pregnancy and childbirth. Mothers who are breastfeeding also need
to be available for the needs of their newborns.
All children, even those who are healthy, have preventive and acute
health care needs (Schuster et al., 2011). In addition, about 20 percent of
children ages 0-17 in the United States are considered children with special
health care needs, defined as children who have or are at increased risk for
a chronic physical, developmental, behavioral, or emotional condition and

who also require health and related services of a type or amount beyond
that required by children generally (Child and Adolescent Health Measur-
ment Initiative, 2012; McPherson etal., 1998, p. 138). This category may
include children with such conditions as ADHD, asthma, autism, cancer,
cerebral palsy, cystic fibrosis, depression, and diabetes (Newacheck and
Taylor, 1998).
Childrens health care needs can be roughly divided into three catego-
ries: preventive care, intermittent acute care, and ongoing chronic care. All
children are expected to receive a substantial amount of routine preventive
care, including immunizations, most of which require multiple doses at
multiple visits; developmental surveillance, which detects delays in speech
and language development, gross and fine motor skills, and behavioral,
social, and emotional growth; screening for early or hidden illness; antici-
patory guidance; and dental care. At present, the American Academy of
Pediatrics and Bright Futures jointly recommend a minimum of seven visits
in a childs first year and seven more in the following 3 years, followed by
annual visits through age 21 (American Academy of Pediatrics, 2008).
Nearly all children will experience one or more episodes of illness seri-
ous enough to require a visit to the emergency room, hospitalization, or
care at home. Three in four children under age 18 have at least one office
visit in a given year, with most averaging about four visits per year, ex-
ceeding the recommended preventive visit schedule (Schuster et al., 2011).
According to a 2008 study on pediatric injuries across 14 states, one-third
of emergency department visits were for pediatric injuries (Owens et al.,
2008). In 2014, 23 percent of children under age 6 had visited an emer-
gency department one or more times in the past year (National Center for
Health Statistics, 2015). In addition to these acute health care issues, chil-
dren experience minor illnesses that may prevent them from attending day
care or school, which requires the presence of an adult in the home. Nearly
two-thirds of elementary school-age children miss some school each year
because of illness or injury, and nearly 11 percent of these children miss
more than 1 week (Bloom et al., 2013).
Children with special health care needs generally require ongoing
care that may involve frequent monitoring, interventions for preventing
and managing illness complications, and acute care for severe episodes
of illness (see also Chapter 5). At home, parents of children with serious
or complex illnesses may be required to provide treatment and care (e.g.,
respiratory treatments, feeding tube care, intravenous nutrition, physical
and occupational therapy, developmental interventions) in addition to
cleaning and maintaining devices, ordering supplies, obtaining techni-
cal support for m achines, and training other caregivers (Schuster et al.,
2011). Children with serious and complex illnesses account for a vastly

disproportionate number of hospital days, health care encounters, and

school absences.
Because children are unable to care for themselves, their parents are
expected to provide an array of health care services that are integral to the
current health care system for children, including, but not limited to, pro-
viding care at home, scheduling and attending outpatient visits, and super-
vision during emergency ward visits and hospitalizations (Schuster et al.,
2011). Parents are expected to be present whether the care is preventive,
acute, or chronic. Health care providers and public health officials recom-
mend that children experiencing acute illnesses stay home from school in
addition to visiting a clinician as needed. Otherwise, their illnesses can
worsen or spread to others, health care costs can increase, and small prob-
lems can become serious threats (Schuster and Chung, 2014).
Types of Support for Employed Parents

Many employed parents who must take time away from work to care
for a newborn or a sick child lose wages for hours not worked. Many even
risk losing their job. Employees in the United States rely on various types
of support to meet the health needs of their children, including a combina-
tion of employer benefits (if offered) and federal, state, and local leave laws
and programs.
EmployersParental Leave
Policies on offering parents of newborns time off to care for their child
vary by employer; some employers provide the option of taking time off
from work, while others do not. Moreover, the absence of a federal-level
paid parental leave policy in the United States leaves many workers in a
situation of combining a number of employee-provided benefits that may
include sick leave, holiday and vacation leave, disability insurance, and
paid or unpaid family leave in order to take time away from work to care
for a newborn.
EmployersFamily Medical Leave

The patchwork of formal and informal support provided by employers
to parents includes sick days; flexible paid time off that combines vaca-
tion, sick time, and family leave; telecommuting; and programs that allow
employees to donate or share unused paid leave. Parents who rely on sick
days to care for their children without explicit employer approval may place
themselves at risk for termination. Some supervisors may informally allow
parents to leave work for hours or days to care for their child (Schuster et

al., 2011). Some employers offer employee assistance or work-life programs

that can help families use employee benefits and access public and private
resources more effectively. According to data from the 2010 National
Paid Sick Days study, more than 60 percent of all workers reported that
their employer provided them with paid sick leave, which could include a
combination of sick leave, vacation, and other reasons. Less than one-half
reported that they received paid sick leave that they could use for sick fam-
ily members (Schuster et al., 2011; Smith and Kim, 2010).
Federal and State Programs and Legislation

The Pregnancy Discrimination Act of 1978 requires that employers
provide leave to women with medical conditions that are linked to preg-
nancy and childbirth, just as they would to any other employee with a
medical condition or temporary disability, such as a heart attack or broken
leg. Although the act does not require employers to provide paid leave,
they must provide the same leave (paid or unpaid) or disability benefits for
conditions related to pregnancy that they provide for other disabilities (U.S.
Equal Employment Opportunity Commission, 2016).
Five states offer Temporary Disability Insurance (TDI) programs, which
typically provide up to one-half of an employees wage for up to 52 weeks
of temporary disability; this includes disability or conditions related to
pregnancy (Lovell and Rahmanou, 2000). These programs are funded
through employee contributions or a combination of employer and em-
ployee contributions. Women with newborn children often take 6-10 weeks
of temporary disability leave for pregnancy, and those requiring longer
leave may take up to the maximum allowable by their states law. As this
program is intended to provide wages for leave related to disabilities or
medical conditions associated with pregnancy and childbirth, fathers and
adopted parents are not eligible for TDI (Hartmann et al., 2013).
With respect to family medical leave, while the federal government does
not mandate paid leave, it does guarantee unpaid leave to some workers.
Under the Family and Medical Leave Act of 1993 (FMLA), employees may
be eligible for up to 12 weeks a year of unpaid leave with job protection
for the following circumstances: serious health condition; birth of a child or
to care for the employees newly born, adopted, or foster child; or to care
for an immediate family member (spouse, child, or parent) with a serious
health condition. Eligibility is limited to employees who work for e mployers
with 50 or more employees and have worked for at least 1,250 hours for
the same employer in the past 12 months. Approximately one-half of em-
ployees meet these eligibility requirements, and many are unable to take
unpaid leave (Han and Waldfogel, 2003; Schuster et al., 2011). Cantor
and colleagues estimated that more than three-quarters of the 3.5 million

e mployees in need of leave in 2000 did not take it in order to avoid loss of
wages. The majority of these employees would have taken leave had they
received partial or additional pay (Cantor et al., 2001; Han and Waldfogel,
2003; Schuster et al., 2011).
The proposed Healthy Families Act (H.R. 932, S. 497) would require
certain employers to allow employees to earn paid sick leave that could be
used to meet their own medical needs or care for a child or other family
member. The proposed Family and Medical Leave Insurance Act (FAMILY
Act, H.R. 3712, S. 1810) would guarantee up to 12 weeks of paid family
leave, which parents could use to provide care for serious health conditions
faced by themselves or family members or to meet care needs associated
with the birth or adoption of a child.
At the state level, California, New Jersey, and Rhode Island have
established Paid Family Leave Insurance programs that provide wage
replacement to employees who take leave to care for a new child or an
ill family member; employees fund the leave through payroll deductions
to state-wide pools. Californias program covers most part- and full-time
employees at about 55 percent of their salary, limited to $1,129 weekly in
2016 (California Employment Development Department, 2016), although
prior research indicates that many parents were not aware of the benefits
(Schuster et al., 2008). Some states and municipalities have laws that entitle
employees with access to sick leave to use their leave to care for a new-
born or an ill family member. Further, Connecticut, New York City, San
Francisco, and Washington, D.C., among others, require employers to offer
paid sick leave to their employees. At present, more than 24 other states
and municipalities are working on legislation related to paid sick leave
(National Partnership for Women and Families, 2015).
Despite these developments, approximately one-half of employees in
the United States are not eligible to receive paid sick leave that they are
allowed to use to care for family members (Smith and Kim, 2010). Parents
without sick leave risk being penalized or losing their job when they must
stay home from work to care for a newborn or a sick child.
Disparities in Access
Rates of access to paid leave among employed parents tends to vary
with income, and are lower among lower-income relative to higher-income
families (Clemans-Cope et al., 2008; Heymann et al., 2006; Phillips, 2004).
Among women employed during pregnancy, rates of access to paid leave
were found to be higher for women who are married, ages 25 and over, and
college graduates (Laughlin, 2011).

Impact of Family Leave on Children and Families
Parental Leave
Research suggests that access to parental leave is associated with in-
creases in breastfeeding rates and duration, reduced risk of infant mortality,
and increased likelihood of infants receiving well-baby care and vaccinations.
For instance, cohort and case-control studies have shown that women who
take maternity leave are more likely to breastfeed, and longer leaves are asso-
ciated with an increase in both the likelihood and duration of breastfeeding;
by contrast, early return to work is associated with an increased probability
of early cessation of breastfeeding (Chuang et al., 2010; G uendelman et al.,
2009; Hawkins et al., 2007; Staehelin et al., 2007; V isness and K
ennedy,
1997). Mothers who took paid leave through C alifornias Paid Family Leave
Program were found to breastfeed twice as long as those who did not take
leave based on a cross-sectional survey and interviews (Appelbaum and
Milkman, 2011). Moreover, children whose mothers take leave from work
after childbirth are more likely to receive well-baby checkups and receive all
of their recommended vaccinations (Berger et al., 2005; Daku et al., 2012).
Analyses of international data have found that paid leave is associated with
lower mortality rates for infants and young children, whereas this associa-
tion is not seen for leave that is neither paid nor job protected (Heymann,
2011; Ruhm, 1998; Tanaka, 2005).
Access to parental leave can benefit maternal health as well. Longi-
tudinal survey data show that women who take longer maternity leaves
(more than 12 weeks) tend to experience fewer depressive symptoms and
a reduction in severe depression. Additionally, paid leave is associated
with improvement in overall mental health (Chatterji and Markowitz,
2012).
Paid leave also is associated with improved labor force attachment
among women. Research suggests that women who have access to parental
leave tend to utilize that leave period and stay home longer than those
without access to such leave, but they are also more likely to return to
work after that period of leave (Baum and Ruhm, 2013; Berger and
Waldfogel, 2004; Houser and Vartanian, 2012; Rossin-Slater et al., 2013).
While women with access to leave were less likely to return to work within
the first 12 weeks of giving birth, analysis of data from a longitudinal
survey has found that they were 69 percent more likely to return after
12 weeks than new mothers without leave (Berger and Waldfogel, 2004).
Offering paid leave is associated with increases in the amount of leave that
women take, with higher uptake among women who have less education,
are unmarried, or are black or Hispanic, which was found to largely re-
duce the pre-existing disparities in the amount of leave taken (Berger and

Waldfogel, 2004). Multiple studies have also found that availability of paid
leave is associated with increases in the number of hours that a woman
works after returning to work, which corresponds to a small increase
in wage income (Baum and Ruhm, 2013; Berger and Waldfogel, 2004;
Rossin-Slater et al., 2013).
Access to paid paternity leave appears to increase the use of leave
among fathers in the early weeks after childbirth and is associated with
greater paternal engagement in caregiving in cross-sectional research
(Milkman and Appelbaum, 2013). In a correlational analysis of data from
Australia, Denmark, the United Kingdom, and the United States to exam-
ine the effects of leave policies, fathers who took paternity leave of at least
2 weeks were more likely to engage in activities with the infant during the
first several months of the childs life relative to fathers who did not take
leave (Huerta et al., 2013).
Family Medical Leave

There are many benefits for children and parents when parents have
the ability to take leave that allows them to access recommended preven-
tive care for their children and to properly care for their children when
they are ill. Preventive care is crucial to child health and development. For
instance, immunizations protect recipients and the public against serious
and potentially debilitating diseases. Short- and long-term health benefits,
as well as improved educational and economic outcomes, have been linked
to the early detection and treatment of diseases (Levy, 2010; Whitlock et
al., 2005; Wilcken and Wiley, 2008).
Parents who have access to paid leave can keep an ill child home from
daycare or school, which minimizes the chances that their illness will spread
to others and maximizes the chances that they will receive timely medical
care, if needed, so their illness does not worsen. A 2010 survey found that
employees who are eligible for paid sick leave are less likely than employ-
ees without this benefit to report sending an ill child to school (Smith and
Kim, 2010).
When children are hospitalized, whether for acute or chronic condi-
tions, extended parental presence is crucial in many respects. For instance
parents may be required to wait with their child for long periods for an
opportunity to speak with the childs health care provider(s) about the
childs current clinical status, the anticipated course of illness, and treat-
ment plans going forward. Parents are also valuable sources of informa-
tion for clinicians, particularly when multiple clinicians are engaged in the
childs diagnosis and treatment. In this setting, parents are expected to act
as an additional, and sometimes essential, line of supervision and safety for
their children. Additionally, parents are able to provide care and comfort

to their hospitalized child, who may be frightened and dependent on their

presence to minimize anxiety. Indeed, family presence during health care
procedures has been shown to decrease anxiety for the child as well as for
the parents. The immediate presence of parents before and after surgery has
been linked in randomized controlled and quality improvement monitoring
research to faster recovery and earlier discharge (Fina et al., 1997; Kain et
al., 2007; Shelton and Stepanek, 1994).
For a child to be discharged from the hospital, parents must be present
to receive training and to demonstrate their understanding of care for their
child upon discharge from the hospital. Moreover, without adequate time
and resources for meeting the responsibilities for home care, there may be
an increase in emergency room visits, hospital readmissions, and health
care costs. Giving parents additional responsibilities without providing
them with more time and resources for meeting those responsibilities may
lead to increases in return visits to the emergency department, hospital
readmissions, morbidity, mortality, and health care costs (Schuster and
Chung, 2014).
Research has shown that parents, particularly parents of chronically
ill children, experience an unmet need for family medical leave (Chung et
al., 2007). Many parents of children with special health care needs who
have been able to take leave to care for their child believe it had positive
effects on the childs physical and emotional health. However, being away
from work may cause financial strain as well as job instability (Schuster et
al., 2009).
SUMMARY
An overarching finding of this chapter is that several of the inter-
ventions 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 committees review of evidence-based
and evidence-informed strategies for strengthening parenting capacity in
the areas of universal/preventive and widely used interventions; informa-
tion and communication technologies; income, nutrition assistance, health
care, and housing programs; and parental and family leave policies.

Universal/Preventive Interventions
Well-child visits reach the majority of children in the United States
and support parents in meeting goals for their childrens health (e.g.,
receipt of vaccinations), but few evaluations of well-child care as
a parenting intervention have been conducted. Some evidence sug-
gests that enhanced anticipatory guidance, such as that provided in
Healthy Steps, is associated with improved parental knowledge of
child development and improved parenting practices with respect
to vaccination, as well as discipline, safety practices, and reading.
Preconception and prenatal care optimize maternal health and
well-being prior to and during pregnancy. Most women in the
United States receive prenatal care, making it an important oppor-
tunity for intervention. Although further research is needed, there
is some evidence that providing pregnant women with information
on pregnancy and early childhood as part of prenatal care increases
parental knowledge of parenting practices that promote positive
child development and knowledge of how to access such services
as child care and medical care. Evidence also suggests that group
prenatal care is associated with improved birth outcomes, initiation
of breastfeeding, and parental knowledge.
Primary care-based educational interventions have been found to
be associated with improvements in parents breastfeeding and
vaccination practices and with reductions in childrens screen time,
their exposure to environmental tobacco smoke, and infants being
brought to the emergency room because of crying. Health care
interventions with a parenting component versus those without
a parenting component have been found to be more effective in
reducing childrens screen time and child overweight and obesity.
Few studies have explored the effect of public education efforts on
parenting knowledge or practices. However, mass public educa-
tion campaigns targeting safe sleep and child helmet use have been
followed by improvements in parental safety practices in these
areas. Likewise, evidence in other areas of public health (smoking
cessation, obesity prevention) indicates that broad public educa-
tion efforts can increase awareness of the benefits of health-related
behaviors.
No existing studies show that teaching parenting-related skills to
youth of high school age or younger in the general population (who
are not pregnant or parents), as in infant simulator programs, sup-
ports later parenting capacity or use of evidence-based parenting
practices. Since many adolescent parents face obstacles to continu-
ing their education, however, potentially impacting their future em-

ployment and income, adolescent pregnancy prevention programs

may strengthen future parental self-sufficiency and parenting.
Widely Used Interventions

Many individual evaluations of home visiting programs show posi-
tive effects on parenting, such as gaining knowledge of child devel-
opment, practicing contingent responsiveness, creating a safe home
environment, and reading to children, among others. However, no
strong pattern of effects has emerged across studies (even within
the same model). For several models, moreover, the list of outcomes
showing no effect is longer than the list showing impacts. Benefits
for child development and school readiness and for child maltreat-
ment have been observed for some models. Little assessment has
been done in the area of family economic self-sufficiency, although
some models show improvements in measures of education and
training, use of public assistance, and reductions in rapid repeat
pregnancies.
In the area of two-generation ECE interventions, national longitu-
dinal data on the impact of Head Start provide little evidence that
the programs parent components have a positive impact on the
use of evidence-based parenting practices. Data on child outcomes
are mixed, depending on the time of measurement and whether the
data are reported by parents or teachers. It is unclear whether
the observed changes in child outcomes are related to changes in
parenting or to other Head Start program components. Data on
Early Head Start indicate that sites using both center-based and
home visiting services tended to have more positive impacts on
parenting and child outcomes, perhaps indicating a need for flex-
ibility in programming.
Evidence from smaller-scale classroom-based and home visiting
studies indicates that programs aimed at improving parents en-
gagement in their childrens schooling and parents decision mak-
ing about their childrens academic experiences, as well as aligning
home and classroom learning, are associated with improvements
in child reading and language skills and other outcomes.
Multiple studies have found that intensive (as often as weekly)
parent training in the home aimed at promoting parent engage-
ment in the early home learning environment improves parenting
practices, such as contingent responsiveness, verbal stimulation,
and warmth, among socially disadvantaged mothers of infants and
preschool-age children. Such interventions also have been found to
improve child language skills and behavior problems. Less inten-

sive interventions that coach parents in dialogic reading have been

found to improve child literacy and language outcomes at least in
the short term.
Information and Communication Technologies

Information and communication technologies represent an opportu-
nity to improve the reach of evidence-based parenting information
and interventions. Preliminary research shows that integration of
the Internet and other technologies into parenting interventions can
be effective, but it remains to be seen whether the effects of such ap-
proaches are equal to those observed for face-to-face interventions.
Further studies are needed that include study populations that are
more culturally and socioeconomically diverse than those included
to date in studies of the use of these technologies to support parent-
ing, that incorporate electronic tracking to monitor u sage, that use
formatting for mobile devices, and that examine how entertainment
media socialize parents into norms of parenting.
Income, Nutrition Assistance, Health Care, and Housing Programs

A number of federal income, nutrition assistance, health care, and
housing programs support families by providing financial assis-
tance and reducing other stressors that can interfere with parent-
ing, as well as by supporting parents in meeting the nutritional,
safety, and health care needs of their children.
In the area of income support, nonrandomized studies show that
the generosity of EITC payments is associated with increases in
maternal work, improvements in maternal health-related outcomes
and behaviors (including food security and receipt of prenatal and
postnatal care), and better child academic and birth outcomes,
as well as reductions in maternal stress. Children whose parents
receive the Child Tax Credit also have been found to have better
academic outcomes. Evidence currently is mixed concerning the
effectiveness of TANF in improving health, employment, and edu-
cation outcomes among adults.
With regard to nutrition assistance programs, WIC participation
is associated with improved birth outcomes, especially among the
most disadvantaged mothers, as well as improved child and par-
ent nutrition, infant feeding practices, and receipt of medical care.
Mothers participating in WIC have been found to be less likely
than nonparticipants to breastfeed. Preliminary evidence shows
that children whose mothers participated in WIC while they were

pregnant have improved cognitive outcomes, but further research

is needed to confirm this association. Similarly, adults and children
who participate in SNAP have improved food security and dietary
intake and reduced poverty. Findings on the effects of SNAP on
dietary quality have been mixed, with some research showing no
difference in this regard between SNAP participants and eligible
nonparticipants. Sparse data are available on how the National
School Breakfast and National School Lunch Programs impact
childrens nutritional status.
The passage of the ACA has expanded access to health care coverage
to millions more Americans, including children. This expanded cov-
erage has increased families access to maternity care and pediatric
services, preventive services, and screening and treatment for mental
health disorders. Children with health care coverage (e.g., Medicaid,
CHIP) are more likely than those without coverage to receive recom-
mended services such as well-child care and immunizations.
Housing assistance programs help millions of parents find affordable
and safe housing for themselves and their young children, resulting
in improved food security and reduced poverty and homelessness.
Parental and Family Leave Policies

Parental leave is associated with positive maternal and child health
outcomes. Women who take maternity leave are more likely to
breastfeed than those who do not take such leave, and longer leaves
are associated with greater likelihood and duration of breastfeeding.
In addition, children whose mothers take leave are more likely to
receive well-child visits and vaccinations. Other benefits of parental
leave based on correlational research include fewer depressive symp-
toms for women, improved labor force attachment, and increases
in fathers use of leave in the early weeks after childbirth, as well as
greater paternal engagement and caregiving. Family medical leave
allows parents to better care for their children when they are sick
and ensure that they receive appropriate preventive care.
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Targeted Interventions Supporting

Parents of Children with Special
Needs, Parents Facing Special
Adversities, and Parents Involved
with Child Welfare Services
The previous chapter describes universal and widely available inter-

ventions designed to strengthen parenting and support parents of young
children. This chapter turns to evidence-based and evidence-informed inter-
ventions used in a variety of settings (e.g., health care, education, the home)
with some evidence of effectiveness in supporting parents and parenting
knowledge, attitudes, and practices among (1) parents of children with
special needs; (2) parents facing special personal and situational adversi-
ties; and (3) parents who have in some way been involved with the child
welfare system, including those who have a history of or are believed to
be at risk for maltreatment and foster parents. These interventions target
specific populations of interest named in the committees statement of task
(Box 1-2 in Chapter 1), such as parents of children with disabilities, par-
ents with mental health conditions, and parents with a history of substance
abuse, as well as other populations of parents the committee believes also
warrant specific attention based on its review of the evidence. The chapter
concludes with a summary.
In a well-known book published some years ago titled Disadvantaged
Children: What Have They Compelled Us to Learn?, Julius Richmond
advances the idea that much can be learned about the needs of all children
by studying populations at risk (Richmond, 1970). In much the same way,
the committee believes that examining the needs of specific populations of
parents and children, such as those with disabilities and families dealing
with mental illness or other challenges, can highlight important principles
that extend beyond the needs of those particular populations.
229

PARENTS OF CHILDREN WITH SPECIAL NEEDS

Among the challenges facing many parents is support and care of their
young children who are either born with special needs or develop such
needs early in life. This section describes research-based interventions for
parents of children with developmental disabilities, behavioral and mental
health disorders,1 and serious or chronic medical illnesses, as well as very-
low-birthweight, premature infants. Parents often seek out these programs
to help them develop skills, learn problem-solving approaches, or receive
support because of the challenges they face in carrying out the type of par-
enting they wish to provide. They recognize that their childs characteristics
may demand special skills in addition to the general knowledge, attitudes,
and practices needed by parents.
Parent Voices
[One parent noted that parents of special needs children need to take on
many roles and responsibilities.]
With a special needs child, a parent has to learn to be patient, to be a
nurse, to be a lawyer because I have to be a good mediator for all the
things that happen to my child.
Parents of Children with Developmental Disabilities

Parents, and indeed family members, of children with developmental
disabilities experience challenges that differ from those experienced by par-
ents of typically developing children (Woodman, 2014). When a child with
one or more disabilities is born into a family or when parents receive the
diagnosis of their childs disability, they often experience a range of emotions
(e.g., shock, grief, anger) that are somewhat similar to those experienced
upon learning about the death of a loved one (Kandel and Merrick, 2003).
Parents experiencing such emotional reactions require a period of time to
adjust, and during that time, parenting and caregiving may be affected.
Some children with disabilities pose particular challenges because of
developmental needs and behaviors that require specific parenting skills
1It is important to note that behavioral and mental disorders in children may represent
an adaptive response to adverse circumstances. In such cases, interventions need to focus on

improving the childs circumstances in addition to addressing the behavioral or mental health
disorder.

TARGETED INTERVENTIONS 231
or actions not required for children who are developing typically (Durand
et al., 2013). In addition, parents of children with disabilities tend to
experience challenges at certain points of transition during the early child-
hood years (e.g., hospital to home, entry to early intervention programs,
movement from early intervention to preschool programs, movement from
preschool to kindergarten) (Malone and Gallagher, 2008, 2009). Young
children with disabilities affect families in different ways, but a common
finding in the literature is that parents of children with disabilities experi-
ence more stress than parents of typically developing children (Woodman,
2014). Given the difficulties faced by parents of children with disabilities,
a range of programs focus on parenting skills and engagement for these
parents.
Several entities at the federal level define disability. The Eunice Kennedy
Shriver National Institute on Child Health and Human Development
(2012), drawing on definitions issued by the American Association on Intel-
lectual and Developmental Disabilities (2013) and the Centers for Disease
Control and Prevention (n.d.), states
Intellectual and developmental disabilities are disorders that are usually
present at birth and that negatively affect the trajectory of the individuals
physical, intellectual, and/or emotional development. Many of these con-
ditions affect multiple body parts or systems. Intellectual disability starts
any time before a child turns 18 and is characterized by problems with
both: intellectual functioning or intelligence, which include the ability
to learn, reason, problem solve, and other skills; and adaptive behavior,
which includes everyday social and life skills. The term developmental
disabilities is a broader category of often lifelong disability that can be
intellectual, physical, or both.
The U.S. Department of Education also has established numerous defi-
nitions for disabilities that qualify children and families for early interven-
tion and special education services through the Individuals with Disabilities
Education Act (IDEA) (U.S. Department of Education, 2015b). The defini-
tion of developmental delay is particularly relevant in the present context
in that it is used most commonly in early intervention and early childhood
programs, with carryover through the later grades. IDEA notes that states
are required to define developmental delay, but the term usually refers to a
rate of development that is slower than normative rates in one or more of
the following areas: physical development, cognitive development, commu-
nication, social or emotional development, or adaptive (behavioral) devel
opment. In addition, a growing population of infants and young children
are being diagnosed with autism spectrum disorder (ASD). Although IDEA
defines autism as one of its eligibility categories, the ASD definition that
researchers and practitioners typically use is from the Diagnostic and Statis-
tical Manual of Mental Disorders (DSM), fifth edition (DSM-5) (American

Psychiatric Association, 2013). According to DSM-5, defining features of

ASD are persistent deficits in social communication and social interaction
across multiple contexts (and) . . . restricted, repetitive patterns of behavior,
interests, or activities.
For parents of children with developmental disabilities, the com-
mittee expands on the scope of parenting to encompass family-centered
care as foundational for parenting practice (Dunst and Trivette, 2010).
Family-centered care is a critical concept in programs for young children
with disabilities and is written into the provisions of IDEA, which out-
lines how services to children with disabilities should be provided (see
below). The committee draws on a conceptual framework developed by
Dunst and Espe-Sherwindt (2016) that explains the linkage among family-
centered practices, early childhood intervention practices, and child out-
comes (see Figure 5-1) to organize the literature in this section. Dunst and
Espe-Sherwindt propose two primary types of family-centered practice
relational practices and participatory practicesthat underlie early child-
hood intervention. The early childhood intervention practices then lead to
child outcomes.
IDEA requires for each child and family receiving services establish-
ment of an Individualized Family Service Plan that includes family-directed
assessment of the resources, priorities, and concerns of the family and the
identification of the supports and services necessary to enhance the familys
capacity to meet the developmental needs of the infant or toddler (U.S.
Department of Education, 2015a). This provision applies to children with
disabilities from birth to age 3. After age 3, children with disabilities may
FIGURE 5-1 Linkage among family-centered practices, early childhood intervention practices,
and child outcomes.
SOURCE: Dunst and Espe-Sherwindt (2016).

begin special education services that public school programs are required
to provide. Families are involved in the development of their childs Indi-
vidualized Education Plan.
The three clearinghouses reviewed by the committee for this study (the
National Registry of Evidence-based Programs and Practices [NREPP],
Blueprints, and the California Evidence-Based Clearinghouse for Child
Welfare [CEBC]) do not cover the literature on programs for parents of
children with developmental disabilities, although some of the programs
developed for other populations that are included in these clearinghouses
have been used with families of children with disabilities (e.g., the Triple P-
Positive Parenting Program and Incredible Years, which are described in
greater detail in the following section). When available, the committee
drew on information from evaluations of those programs that is relevant
to children with disabilities, but the discussion in this section also includes
findings from studies accessed directly from the research literature. In all
cases, the findings reviewed here are from studies that employed random-
ized controlled trials, high-quality quasi-experimental designs, and/or high-
quality meta-analyses published in peer-reviewed journals.
Intervention Strategies
Interventions designed to support parents of children with developmen-
tal disabilities fall into four overlapping areas: family systems programs,
instructional programs, interactional programs, and positive behavior sup-
port. Each is discussed in turn below.
Family systems programs Family systems programs follow a systems ap-

proach in that they most commonly focus on parents internal variables,
such as stress, depression, or coping, based on the assumption that changes
in those variables will affect the quality of parenting. Singer and colleagues
(2007) conducted a meta-analysis examining the primary and secondary
effects of parenting and stress management interventions for parents of
children with developmental disabilities. Among the 17 studies with experi
mental or quasi-experimental designs that qualified for the analysis based
on the quality of their research methodology, the authors identified three
classes of interventions: behavioral parent training (i.e., teaching parents
behavior management skills); coping skills interventions, based on prin-
ciples of cognitive-behavioral therapy; and a combination of the two. They
found that interventions in all three groups had significant effects on re-
ducing psychological distress among mothers and fathers of children with
developmental disabilities. In a randomized controlled trial involving 70
families of children with ASD, for example, Tonge and colleagues (2006)
provided parent education and behavior management training in group and

individual sessions. They found significantly positive outcomes for parents

on the General Health Questionnaire postintervention and in follow-up.
Feldman and Werner (2002) provided behavior management training with
follow-up over a 3- to 6-month period for parents of children with devel
opmental delays and found significantly lower levels of depression for
parents randomized into the treatment group. In their summary, Singer and
colleagues (2007) note that interventions occurring over a longer period of
time and having multiple components (e.g., those that address parents well-
being as well as parenting skills) produced greater reductions in parental
stress relative to those of shorter duration and a simpler design.
In a recent randomized controlled trial of 59 parents of children with
autism, parents received six individual sessions in a problem-solving edu-
cation program, adapted from the well-known problem-solving treatment
(PST) (Feinberg et al., 2014). Each session focused on working through a
problem identified by the mother using the steps of PST (goal setting, brain-
storming, evaluating solutions, choosing a solution, and action planning).
Study findings showed that the intervention reduced parents depressive
symptoms, but not their stress levels.
A more recent trend has been the application of mindfulness training
for parents of children with developmental disabilities, with the goal of
reducing stress and potentially increasing self-efficacy. Benn and colleagues
(2012) conducted randomized controlled trials to examine the effects of
mindfulness-based stress reduction techniques, and found significantly
positive effects on stress reduction and associated variables (e.g., personal
growth). Collateral effects of these techniques are seen in caregiver com-
petence as reported by parents (Benn et al., 2012) and in fewer behavior
problems reported by teachers (Neece, 2014).
Instructional programs A large literature documents the effectiveness of

programs designed to instruct parents in implementing approaches that pro-
mote the skills (e.g., developmental, language, social, play) of their children
with disabilities (Girolametto et al., 1998; Green et al., 2010). Roberts and
Kaiser (2011), for example, found strong positive effects on the receptive
and expressive language skills of young children with intellectual disabilities
in a meta-analysis of 18 studies of parent-implemented language training
programs that utilized a control group. Effect sizes ranged from .35 to
.81 in studies in which parent-implemented treatment was compared with
nontreatment or business-as-usual comparison groups. Smaller effects were
found for studies comparing parent-delivered and professional-delivered
treatment. This finding suggests that children receiving the treatment from
parents and speech pathologists made comparable progress, which indicates
in turn that, when appropriately trained, parents can be effective facilitators
of the language development of children with disabilities.

Programs that have instructed parents in promoting the reading skills

of their young children with disabilities have likewise documented positive
effects. Two randomized controlled studies (Crain-Thoreson and Dale,
1999; Dale et al., 1996) document the efficacy of parent-implemented
dialogic (shared) reading approaches in improving the reading skills of
young children with language delays. Using a version of the dialogic reading
approach, parents read a book to their child, monitor the childs under
standing through questions, give the child opportunities to respond, repeat
and elaborate on what the child says, refer to illustrations to enhance
meaning, praise and encourage the child, and focus on making reading
a fun activity. The What Works Clearinghouse (2014) has examined this
literature and found that these studies meet their standards of acceptability.
Particularly for children with ASD, interventions involving parents have
generated positive outcomes. Many comprehensive treatment programs
have been designed for children with ASD, and almost all have a parenting
component (Odom et al., 2014). These comprehensive programs comprise
a set of practices that are based on an organizing conceptual framework,
address a variety of developmental needs of the child, and generally occur
over an extended period of time (e.g., 1-2 years or more). These elements
are detailed in program manuals. Some programs begin in a clinical set-
ting, with the clinician taking the lead, and also are implemented at home
by the parent. The Early Start Denver Model (ESDM) is the best and most
well-validated example of this approach. Dawson and colleagues (2010)
conducted an experimental evaluation of the ESDM, finding significant ef-
fects on cognitive developmental and adaptive behavior. They also found
differences in brain activation for children in the treatment and control
groups (Dawson et al., 2012), and the effects of the ESDM were partially
replicated with families in community settings (Rogers et al., 2012). In a
quasi-experimental design study of Project ImPACT (Improving Parents as
Communication Teachers) (Ingersoll and Wainer, 2013), an evidence-based
program that teaches parents of children with autism how to promote their
childrens social-communication skills during daily routines and activities,
Stadnick and colleagues (2015) found that parents could implement the
intervention with fidelity, and the program produced positive child out-
comes. In a review of eight intervention programs for toddlers with ASD,
Siller and colleagues (2013) document the variety of approaches used by
these programs, nearly all involving families and most employing experi-
mental designs to document efficacy (although this summative review does
not include effect sizes).
Other studies have documented the positive effects of early intensive
behavior therapy delivered by parents. For example, in a meta-analysis of
13 studies conducted in 2009-2011 using experimental and other design
types, Strauss and colleagues (2013) found that early intensive behavioral

interventions delivered by parents were more effective than those delivered

only by a therapist. In summary, it appears that involving parents is an es-
sential element of early interventions for children with ASD and in some
cases may produce stronger positive outcomes than such interventions in
which parents are not directly involved.
Interactional programs Interactional programs are designed to promote

positive social interactions between caregivers and young children with
disabilities. They are based on research showing that some young children
with disabilities have difficulty engaging in positive interactions with their
parents and others (Adamson et al., 2012), and parents at times may interact
with their children in ways that discourage social interaction (e.g., they may
be overly directive) (Cress et al., 2008; Lussier et al., 1994). In these inter
ventions, parents are taught how to set up play situations that encourage
interaction and to respond in particularly encouraging ways. In a number
of randomized studies, Mahoney and colleagues (2006) employed a respon-
sive parenting approach that resulted in increased social interactions among
children with disabilities (Karaaslan and Mahoney, 2013; Karaaslan et al.,
2013). For many young children with ASD, joint attentiona specific form
of parent-child interaction that is a building block for later communica-
tion developmentis limited or fails to develop. Several investigators have
developed interventions designed to promote joint attention among young
children with ASD and their parents that have demonstrated positive effects
in randomized studies (Kasari et al., 2010; Schertz et al., 2013).
Positive behavior support For parents of young children with disabilities,

their childs behavior often poses challenges, results in negative parent-child
interaction, and creates great stress for the parents (Hastings, 2002). A
variety of approaches have been developed to promote parenting practices
related to behavior management. One such approachpositive behavior
intervention and support (PBIS)is a multicomponent program involving
problem-behavior prevention strategies and increasing levels of behavioral
intervention (Dunlap and Fox, 2009). In a randomized controlled study,
Durand and colleagues (2013) examined the effects of PBIS on parents and
their children with a developmental disability and serious challenging be-
havior. They found significant improvement in challenging behavior, as well
as reduction in parent pessimism. Effects of the PBIS model were stronger
when it was paired with a complementary program of optimism training
aimed at helping parents identify and restructure their parenting-related
thought patterns.
The Triple P-Positive Parenting Program (Triple P) (Sanders et al.,
2008) was initially designed for school-age children with conduct disorders,
and has been used with parents of young children with behavioral and men-

tal health challenges (described in the next section). An adaptation of this

programStepping Stoneshas been used with parents of young children
with disabilities. Individual randomized controlled studies (Sofronoff et al.,
2011) and a meta-analysis (Tellegen and Sanders, 2013) of Stepping Stones
revealed strong effects on reducing challenging behavior and improving
broader parenting variables (e.g., style, adjustment, parental relationship).
Similarly, the Incredible Years Program was initially designed for parents
of school-age children with conduct disorders (Webster-Stratton, 1984),
but has been adapted for and applied with parents of young children with
disabilities. In a randomized trial, McIntyre (2008) found that the Incred-
ible Years Program reduced negative parent-child interactions and child
behavioral problems.
In another study focused on parents of children with autism, investiga-
tors evaluated a pilot study of 16 families with children ages 3-6 with a
diagnosis of autism and parent-reported disruptive behaviors (Bearss et al.,
2013). This study evaluated the RUPP (Research Units on Pediatric Psycho-
pharmacology) Autism Network Parent Training Program, an 11-session
structured program designed to teach parents of children with autism and
serious behavioral problems skills needed to reduce their childrens disrup-
tive behavior. In a single group pre-post evaluation, parents reported a
reduction in their childrens disruptive behaviors and improvements in their
adaptive functioning (Bearss et al., 2013).
Research Gaps
There are significant research gaps in the area of interventions for par-
ents of children with developmental disabilities, such as implementation
of interventions in natural environments and support for child and family
transitions. Although a primary feature of early intervention programs
funded through IDEAa feature required by the federal governmentis
that they must occur in natural settings, and although IDEA encourages
the creation of a transition plan for children moving from early interven-
tion to preschool, the committee found that little or no such experimental
research has been conducted, nor do these gaps appear to inform directions
for future program development and research.
Parents of Children with Behavioral Challenges

and Mental Health Disorders
Behavioral and mental health challenges encompass a range of behav-
iors and conditions. The psychiatric, psychological, and educational profes-
sional communities use somewhat different terminologies, but they agree
in identifying these behaviors and conditions as occurring in children who

present with externalizing (e.g., aggression, tantrums) or internalizing (e.g.,

childhood depression, social withdrawal) behavior. In addition, attention
deficit hyperactivity disorder (ADHD), while overlapping to some extent
with these behaviors, manifests more distinctly in high levels of physical ac-
tivity, difficulty with attention, and difficulty in completing tasks (American
Psychiatric Association, 2013).
Aggression and antisocial behavior in young children appear to reach
a peak between the ages of 2 and 4 and then decline, only to reemerge in
the adolescent years (Wahl and Metzner, 2012). Lavigne and colleagues
(1996) report that during the early years (ages 2-5), the prevalence of such
behavior problems in a sample of 3,860 children averages 8.3 percent,
with gender differences (boys having a higher prevalence than girls). In a
small proportion of children, however, studies have found that aggressive/
antisocial behavior is severe and persists through early childhood (Wahl
and Metzner, 2012). It is these children that are diagnosed as having oppo-
sitional defiant disorder (ODD) (American Psychiatric Association, 2013).
Children with ODD may lose their temper; argue with adults; actively defy
rules; and harm people, animals, and/or property.
Intervention Strategies: Parents of Children with Externalizing Behavior

A number of interventions have focused on improving the knowledge,
attitudes, and practices of parents of children with externalizing behavior.
For the most part, effective interventions have been designed to provide
parents with skills needed to better manage their childrens behavior. These
interventions have included applications of general parent management
training to parents of children with challenging behavior, as well as parent
training developed specifically for this population.
Triple POne of the most frequently used and internationally replicated

interventions for helping parents prevent and address behavioral challenges
in their children is Triple P (Sanders et al., 2008), a multilevel system of
support that provides increasingly intensive interventions based on parents
and childrens needs. The interventions range from basic information on
parenting at the least intensive level to behavior management through dif-
ferent modalities (e.g., group, one-on-one, or self-directed learning) (see
Box 5-1).
In experimental and quasi-experimental studies of the Primary Care,
Standard and Group, and Enhanced Triple P levels conducted in the United
States and in other countries, parents have reported less frequent use of dys-
functional parenting practices in such areas as discipline, laxness, and over-
reactivity and greater parenting competence. Improvements in observed and
parent-reported negative behavior in children relative to controls also have

been found (Hoath and Sanders, 2002; Sanders et al., 2000; Turner and
Sanders, 2006; Zubrick et al., 2005). A systematic review and meta-analysis
of the multilevel Triple P system that includes 101 studies shows signifi-
cant short-term improvements in parenting practices; parenting satisfaction
and self-efficacy; parental adjustment; parental relationship; and childrens
social, emotional, and behavioral well-being (Sanders et al., 2014).2 Triple P
has an average NREPP rating of 3 out of 4, where programs rated 4 have
the strongest evidence of effectiveness (National Registry of Evidence-based
Programs and Practices, 2016e). Triple P level 4 has a CEBC rating of 1
(out of 5), and the entire Triple P system has a CEBC rating of 2, where
programs rated 1 have the strongest evidence of effectiveness (California
Evidence-Based Clearinghouse, 2016n). The positive results from these
assessments provide empirical support for Triple P and a blending of uni-
versal and targeted parenting interventions to promote child, parent, and
family well-being (Sanders et al., 2014).
The Incredible Years The Incredible Years Program is a developmentally

based training intervention for children ages 0-12 and their parents and
teachers. Children of families in the program often have behavioral prob-
lems. Drawing on developmental theory, the program consists of parent,
teacher, and child components that are designed to work jointly to promote
emotional and social competence and prevent, reduce, and treat behavioral
and emotional problems in young children (National Registry of Evidence-
based Programs and Practices, 2016a). Incredible Years received an average
NREPP rating of 3.5 out of 4 in a July 2012 review and 3.7 out of 4 in an
August 2007 review. It has a CEBC rating of 1 (California Evidence-Based
Clearinghouse, 2016g).
The Incredible Years Program addresses parental attitudes by helping
parents increase their empathy for their children and educates parents about
2Some concerns regarding Triple P studies that report child-based outcomes are raised in a
2012 review of 33 such studies (Wilson et al., 2012). Among the concerns are the use of wait
list or no-treatment comparison groups in most of the studies reviewed and potential report-
ing bias attributed to author affiliation with Triple P and the fact that few of the abstracts
for the studies reviewed reported negative findings. A follow-up commentary (Sanders et al.,
2012) challenges the findings of this review, noting that it includes a limited subsample of
Triple P studies and pools findings from interventions of various intensities and types. Further,
the commentary notes that most of the studies reviewed included maintenance probes many
of which showed that post-treatment improvements were maintained over various lengths of
follow-up. With regard to author affiliation, the commentary states that while developers are
often authors of evaluations of Triple P and other parenting programs, the claim that most
Triple P evidence is authored by affiliates of the program is untrue (Sanders et al., 2012). The
controversy about the proper treatment of the Wilson and Sanders reviews continues in a
series of published papers, blog postings, and policy decisions in Australia, the United States,
and Europe.

BOX 5-1
The Triple P-Positive Parenting Program
Triple P is designed to prevent and treat social, emotional, and behavioral

problems in children by improving parents knowledge, skills, and confidence in
their parenting role. Drawing on social learning, cognitive, developmental, and
public health theories, Triple P incorporates five levels of intervention on a tiered
continuum of increasing strength and narrowing population reach for parents
of children from birth to age 16 (see Figure 5-1-1 below) (National Registry of
Evidence-based Programs and Practices, 2016e; Sanders et al., 2014).
Universal Triple P (level 1) takes a public health approach by using media to
increase awareness of parenting resources, programs, and solutions to common
child behavioral and developmental concerns at the community level. Selected
Triple P (level 2) gives parents who are generally coping well advice on practices
for accommodating common developmental issues, such as toilet training and
minor child behavior problems, via one to three telephone, face-to-face, or group
sessions. Primary Care Triple P (level 3) targets parents with children who have
mild to moderate behavioral challenges. Parents receive active skills training that
combines advice, skill rehearsal, and self-evaluation in three to four one-on-one
sessions in person or by telephone, or in a series of 2-hour group discussion
sessions. Standard and Group Triple P (level 4), designed for parents of children
with more severe behavioral challenges, provides parents with more intensive
training in how to manage a range of childrens problem behaviors. It is delivered
in eight to ten sessions in individual, group, or self-directed (online or workbook)
formats. Finally, Enhanced Triple P (level 5) is designed for families whose par-
enting challenges are heightened by other sources of family distress, such as
parental depression or relationship conflict. This level includes practice sessions
to enhance parenting, mood management, stress coping, and partner support
skills using adjunct individual or group sessions (National Registry of Evidence-
based Programs and Practices, 2016e; Sanders et al., 2014). Variants of Triple
P have been developed for parents of children with developmental disabilities
(Stepping Stones Triple P), parents at high risk for maltreatment (Pathways Triple
P), parents of children with obesity (Lifestyles Triple P), and divorcing parents
(Transitions Triple P), as well as for delivery over the Internet (Online Triple P)
(Sanders and Prinz, 2005).
healthy child development, positive parent-child interaction techniques,

and positive child behaviors (Marcynyszyn et al., 2011). Sessions focus on
building skills to strengthen the parent-child relationship; reduce the use
of harsh discipline; and support childrens social, emotional, and language
development, as well as their school readiness. The parent program varies
in length from 12 to 20 weekly group sessions, each of which lasts 2 to 3
hours. In the teacher program, presented in a workshop format, early child-
hood and elementary school teachers learn strategies for building positive

Triple P: Multilevel system
Breadth of reach
Intensity of intervention
Intensive family Intervention................ Level 5
Broad focused parenting skills training... Level 4
Narrow focused parenting skills training. Level 3
Brief parenting advice Level 2
Media and communication strategy. Level 1
FIGURE 5-1-1 Schematic of the Triple P system of tiered levels of intervention.

SOURCE: Prinz (2014).
All levels of Triple P are designed to encourage in parents developmentally

appropriate expectations, beliefs, and assumptions about childrens behavior and
the importance of the family environment in childrens development; impart knowl-
edge and teach practices related to providing a safe, supervised, and protective
environment and alternatives to coercive discipline practices; and teach parents
to take good care of themselves in order to be more effective parents (Sanders
and Prinz, 2005).
relationships with students and families, discipline techniques, and how to

stimulate and support childrens academic achievement. The child arm of
the program aims to improve childrens social and emotional competence
through more than 60 classroom lesson plans lasting about 45 minutes
each, delivered by teachers at least twice weekly over consecutive years.
Incredible Years has been implemented in almost every U.S. state and is
delivered in a variety of education, health, and social service settings.
A systematic review and meta-analysis of 39 randomized controlled

studies of Incredible Years found intervention effects in reducing disruptive

behavior and increasing prosocial behavior in children based on parent,
teacher, and observer reports (Menting et al., 2013). Perrin and colleagues
(2014) conducted a randomized trial of a 10-week Incredible Years parent
training program involving families in pediatric practices with toddlers with
disruptive behaviors. They found greater improvements in the intervention
group compared with the control group for parent-reported and observed
child disruptive behavior, negative parenting, and negative child-parent
interactions. In another primary care-based experimental study involv-
ing 117 parents of children with ODD, however, Lavigne and colleagues
(2008) compared Incredible Years led by a nurse, led by a psychologist, or
using materials only with no in-person sessions. Findings suggested that
all groups showed short- and long-term improvement, but there was no
intervention effect. In a randomized controlled trial (independent from the
developer, Webster-Stratton), Brotman and colleagues (2003) identified low-
income families with a child ages 2-5 at risk for disruptive behaviors as a
result of having a sibling or other relative with ODD or conduct disorder
or a criminal history. Using a fairly intensive version of Incredible Years,
they found that, compared with children receiving usual care, intervention
children had fewer behavioral problems, and intervention parents per-
formed better on observed parenting practices of responsiveness and affec-
tion. These postintervention improvements, however, were not sustained at
6-month follow-up (Brotman et al., 2003).
Parent Management TrainingOne of the earliest training programs for

parents, Parent Management Training (PMT), involving parents of children
with externalizing behavior, originated with Gerald Patterson and colleagues.
Parents participate in therapy sessions to learn behavior management tech-
niques they would use with their children. In an initial experimental study
(Patterson et al., 1982), observations revealed significant reductions in chil-
drens externalizing behavior relative to the control group. In a subsequent
randomized study, Hughes and Wilson (1988) followed the PMT model to
teach parents of children with conduct disorders to use contingency manage-
ment. They also found significantly greater changes in child behavior and
parent attitudes for the intervention relative to the control group.
Parent-Child Interaction TherapyElaborating on the model used by

Patterson and colleagues (1982), Eyberg and Boggs (1998) designed the
parent-child interaction therapy (PCIT) approach, which not only includes
a therapy-based child management component but also incorporates ele-
ments of play therapy that involve the child directly in clinic sessions. PCIT
is an evidence-based intervention developed as a treatment for children ages
2-7 with emotional and behavioral disorders and their parents. Evaluations

of PCIT have involved children ages 0-12. Parents learn skills to encour-
age prosocial behavior and discourage negative behavior in their children,
with the ultimate goal of developing nurturing and secure parent-child
relationships.
The intervention has two phases. In the first phasechild-directed
interactionparents learn nondirective play skills and engage their child in
a play situation with the objective of strengthening the parent-child relation-
ship. In the second phaseparent-directed interactionparents learn to use
age-appropriate instructions and consistent messages about consequences to
direct their childs behavior, with the goal of improving the childs compli-
ance with parental instruction. At the beginning of the child- and parent-
directed phases, parents attend a didactic session with a PCIT professional
to learn interaction skills. The entire intervention is typically delivered in
weekly 1-hour sessions over a 15-week period in an outpatient clinic or
school setting. PCIT has been applied with families with a history of child
abuse, as well as families of children who have developmental disabilities
or were exposed to substances prior to their birth (National Registry of
Evidence-based Programs and Practices, 2016c; Parent-Child Interaction
Therapy International, 2015).
In a randomized controlled efficacy study of PCIT involving parents
of children with externalizing behavior and noncompliance, Schuhmann
and colleagues (1998) found that parents in the PCIT group interacted
more positively with their child, were more successful in gaining their
childs compliance, experienced less stress, and reported more internal
locus of control relative to parents in the control group. Other randomized
studies comparing outcomes for parents participating in PCIT and those
participating in standardized community-based parenting classes or wait-
list controls have shown improvements resulting from the intervention in
parenting skills (reflective listening, physical proximity, prosocial verbaliza-
tion), parent-child interactions and child compliance with parental instruc-
tion, and child behavior. In addition, compared with controls, parents who
participate in PCIT are more likely to report reductions in parenting stress
and improvement in parenting locus of control (Bagner and Eyberg, 2007;
Boggs et al., 2005; Chaffin et al., 2004; Nixon et al., 2003; Parent-Child
Interaction Therapy International, 2015). Participants in evaluations of
PCIT have been relatively diverse in terms of race and ethnicity (National
Registry of Evidence-based Programs and Practices, 2016c). PCIT received
an average NREPP rating of 3.4 out of 4 and a CEBC rating of 1 (California
Evidence-Based Clearinghouse, 2016k; National Registry of Evidence-based
Programs and Practices, 2016c).
Several randomized controlled evaluation studies have documented the
efficacy of a PCIT intervention delivered in a pediatric setting to mothers of
infants and toddlers. Bagner and colleagues (2010) found significant effects

on positive parenting and reductions in ineffective parenting practices (as

reported by parents). Berkovits and colleagues (2010) compared a PCIT
intervention that included anticipatory guidance (i.e., receiving materials
ahead of time) with a standard PCIT intervention among mothers of young
children expressing subclinical levels of behavior problems. They found that
both groups of mothers reported positive effects on their parenting, with
no difference between versions at postintervention or 6-month follow-up
groups.
Other interventions for externalizing behaviorAlthough Triple P, The

Incredible Years, and PCIT have the strongest evidence of efficacy, docu-
mented through randomized controlled studies and international repli-
cations, a variety of other interventions have been designed to promote
parenting (primarily behavior management) skills among parents of children
with externalizing behavior. Play Nicely is a video-based training program
provided to parents during well-baby visits that is focused on discipline.
Randomized controlled studies have found effects on parents attitudes
toward spanking, as measured immediately after the training (Chavis et
al., 2013; Scholer et al., 2010). Early Pathways is an in-home therapy inter
vention for low-income children with severe externalizing behavioral and
emotional problems (e.g., aggression and oppositional behavior) and their
parents. In experimental evaluations of standard and culturally adapted
versions of Early Pathways, Fung and Fox (2014) and Harris and col-
leagues (2015) found improvements in parenting (caregiver limit setting and
nurturing), parent-child relationships, and child behavior and a decrease in
clinical diagnoses following treatment. Results were sustained several weeks
postintervention. Intervention components delivered in families homes over
8-10 sessions were child-led play to improve the parent-child relationship
and parent skills training related to maintaining developmentally appropri-
ate expectations of children and improving parents disciplinary practices
(time-outs, redirection, ignoring). Early Pathways has been rated by NREPP
as having strong evidence of a favorable effect.
Interventions for children with ADHDAs noted, children with ADHD

have characteristics and presenting issues that differ from those of children
with externalizing or internalizing behaviors; thus interventions targeting
ADHD address different issues from those addressed by the interventions
reviewed above. Lehner-Dua (2001) compared a 10-week program of par-
ent skills training based on the Defiant Children Program (Barkley, 1997)
with a parent support group for parents of children newly diagnosed with
ADHD ages 6-10. Parents in both groups reported significant improvement
in parenting-related competence, while parents randomized to skills train-
ing were more likely to report reductions in childrens problem behavior.

Mikami and colleagues (2010) in a randomized controlled study provided

the Parental Friendship Coaching intervention to parents to teach them
strategies they could use to promote the social skills and peer relation-
ships of their children with ADHD ages 6-10. The intervention resulted
in parents greater provision of corrective feedback and reduced criticism,
and improvement in childrens social skills based on parent but not teacher
reports.
Working with fathers of children with ADHD (average age around 8),
Fabiano and colleagues (2009) developed a program called COACHES
(Coaching Our Acting-Out Children: Heightening Essential Skills), which
included parent behavioral training and sports skill training. Although in-
vestigators found no significant intervention effects on child ADHD-related
behavioral outcomes, fathers participating in the program scored higher on
satisfaction measures and were significantly more likely to attend sessions
(76% of intervention fathers versus 57% of controls attended 75% of
sessions) and complete parent training homework compared with the
control group of fathers who only received parent behavioral training.
Intervention Strategies: Parents of Children with

Internalizing Behavior and Mental Illness
Internalizing behavior and mental illness are manifest in young children
primarily as anxiety and depression. Most of the literature on interventions
that involve parents has focused on externalizing behavior, given that inter-
nalizing behavior is less prevalent (McKee et al., 2008). Yet the trajectory
of internalizing behavior across childhood is often persistent, serious, and
linked to adult outcomes (Dekker et al., 2007). DSM-5 (American Psychi-
atric Association, 2013) includes diagnostic classification and criteria for
both anxiety disorder and depression that extend to young children. Some
internalizing conditions have been inversely associated with certain parent-
ing practices, such as those that are overinvolved and those that display low
warmth (Bayer et al., 2006). Empirically validated intervention approaches
have been developed to address both anxiety disorder and depression in
children.
Anxiety disorder Anxiety in some situations is normal for young children,

such as when very young children are anxious around strangers or in new
places. However, severe and debilitating forms of anxiety may manifest in
phobias, sleep terrors, posttraumatic stress disorder (PTSD), and separa-
tion anxiety. Recent systematic, critical reviews by Anticich and colleagues
(2012) and Luby (2013) have identified empirically supported interventions
for anxiety disorder in young children. Cognitive-behavioral therapy, once
used primarily with older children and youth and in clinical settings, has

been adapted for young children in several approaches that involve parents
directly (Cohen and Mannarino, 1996; Deblinger et al., 2001; Hirshfeld-
Becker et al., 2010; Kennedy et al., 2009). PCIT, described earlier as treat-
ment for externalizing conditions, also has been adapted for anxiety in
young children (Comer et al., 2012; Pincus et al., 2008). In addition, other
supported treatments have employed psychoeducational approaches ad-
dressing anxiety disorders (Rapee et al., 2005) and play therapy (Santacruz
et al., 2006). All of these studies used experimental designs with active
control, passive control, or wait list control groups.
Childhood depression The intervention studies discussed above for anxi-

ety have at times included children with depression. Luby and colleagues
(2012) adapted the PCIT intervention specifically for parents and their
young children with depression. They found significant improvements in
childrens executive functioning and decreases in parents stress relative to
randomly assigned active control group participants.
Parents of Children with Serious or Chronic Medical Illness

For parents of children with serious or chronic medical illness, the con-
cern for their childs welfare and the challenges related to health care provi-
sion and coverage may affect their ability to provide positive parenting. One
of the most promising approaches for supporting these parents is problem-
solving therapy. Bright IDEAS is a problem-solving skills training program
provided by a mental health professional over eight 1-hour individual ses-
sions (Sahler et al., 2002, 2005, 2013). It has been tested in a randomized
controlled trial involving mothers of children newly diagnosed with cancer
at hospitals/cancer centers in the United States and Israel (Sahler et al.,
2002); in a second, larger trial involving mothers at U.S. hospitals/cancer
centers, with the intervention being expanded to include Spanish-speaking
participants (Sahler et al., 2005); and in a third trial u
sing an active therapy
control (Sahler et al., 2013) (the first two trials used standard psychosocial
services in the hospital as the control). Significant differences between inter
vention and control mothers were documented for the mothers report of
her mood, depressive symptoms, and stress across multiple studies (Sahler
et al., 2005, 2013).
Melnyk and colleagues developed an educational-behavioral interven-
tion called Creating Opportunities for Parent Empowerment (COPE) for
mothers of critically ill children in pediatric intensive care units. In this
intervention, mothers are provided information about their childs course
of treatment and recovery, and then trained in structured interaction activi-
ties in which to engage when the child is discharged. In two randomized
controlled studies (Melnyk et al., 1997, 2007), researchers found that,

compared with mothers in the control group, mothers in the COPE group
provided more emotional support for their child during invasive proce-
dures and experienced less stress, and their children showed less internal-
izing or externalizing behavior after discharge. Researchers also found that
treatment effects were mediated by parent beliefs and (inversely) negative
maternal mood state.
A number of other programs have tested cognitive-behavioral ap-
proaches as well as training in communication and social support for
parents of children with illnesses ranging from cancer to diabetes to other
chronic diseases. Unfortunately, most of these studies have either been
underpowered or shown no significant benefits.
Parents of Very Low-Birth Weight, Premature Infants

Very low birthweight is defined as less than 1,500 grams at birth and
extremely low birthweight as less than 1,000 grams. The terms are most
commonly used to designate an infant as being born prematurely. Very-
low-birth weight infants are admitted to neonatal intensive care units
(NICUs), may reside in those units for weeks to months, and at times
sustain chronic health or developmental conditions. Because these infants
do not come home immediately after birth, a concern is that the normal
formation of attachment and transition to parenthood (especially for first-
time parents) may be disrupted (Odom and Chandler, 1990). In addition,
the children may have ongoing and significant medical needs (e.g., use of
respirators or heart monitors) after transitioning home to which the par-
ents must attend.
A range of studies have focused on supporting parents of infants ad-
mitted to the NICU (Heidari et al., 2013; Obeidat et al., 2009). Some have
evaluated parenting training designed to support effective early parenting
skills, while others have looked at psychosocial support for parents to pre-
vent or address posttraumatic stress or depressive symptoms. An approach
that has been used for decades is called Kangaroo Mother Care (KMC).
This program involves mothers and infants having consistent skin-to-skin
contact during the hospitalization period and care providers supporting
mothers appropriate interactions with their child. In a Cochrane-like quan-
titative review, Athanasopoulou and Fox (2014) evaluated 13 experimental
and quasi-experimental studies of KMC. They found that, although the
outcomes of these studies were mixed, mothers in the KMC groups experi-
enced significantly less negative mood and more positive interactions with
their infant relative to mothers in the control groups.
Schroeder and Pridham (2006) examined a guided participation ap-
proach to supporting mothers competencies in relating to their preterm
(less than 28 weeks gestation) infants admitted to the NICU. Compared

with mothers receiving standard care teaching, mothers in the guided par-
ticipation group developed expectations and intentions that were more at-
tuned and adaptive to their infants needs and showed consistently higher
relationship competencies in a randomized clinical trial. In a study of the
impact of providing information about prematurity to mothers of preterm
infants, Browne and Talmi (2005) provided educational materials about
the infants behavior and development delivered either through videos and
slides and written information or one-on-one teaching sessions. Mothers
receiving both interventions scored higher on knowledge of preterm infants
behavior and reported lower parenting stress at 1-month postdischarge
from the NICU relative to control mothers who participated in an infor-
mal discussion about care for preterm infants (Browne and Talmi, 2005).
To examine the effects of the COPE model, described previously, applied
with mothers with very low-birth weight infants in the NICU, Melnyk and
colleagues (2008) conducted a secondary analysis of a larger randomized
controlled study. They found that mothers experiencing COPE had less
anxiety and depression and higher parent-child interaction scores compared
with the control group. Segre and colleagues (2013) used the Listening
Visits intervention, consisting of six 45- to 60-minute individual sessions
provided by a trained neonatal nurse practitioner. The sessions entailed
empathic listening on the part of the nurse practitioner to understand the
mothers situation and collaborative problem solving. Improvements were
detected in primary outcomes of maternal depressive and anxiety symp-
toms, as well as quality-of-life measures in a single group pre-post test trial
(Segre et al., 2013).
Much of the research in this area has focused on low-birth weight in-
fants in the NICU, and there is a set of well-articulated programs that can
be beneficial to these parents. Given the stress created by a premature birth,
the psychological trauma associated with prolonged stays in the NICU, and
the possible chronic health and developmental conditions that may emerge
in these infants, these programs may produce ongoing benefits. It is also
important to note the long-standing finding that low-birth weight children
born to families living in poverty often have poorer outcomes relative to
those born to families not living in poverty (Sameroff and Chandler, 1975),
even when interventions are implemented to support their early develop-
ment (Brooks-Gunn et al., 1995). Parents with limited financial resources
or social supports who have premature and low-birth weight children may
well need more assistance than their better-off counterparts.
PARENTS FACING SPECIAL ADVERSITIES

This section reviews programs addressing the needs of parents facing
special adversities related to mental illness, substance abuse disorders,

intimate partner violence, and parental developmental disabilities, as well

as adolescent parents, who often face a number of challenges. It is im-
portant to emphasize that approaches for intimate partner violence differ
from those applied, for example, with parents with mental illness in that
concerns about the safety of the childeven removing the child from the
homemust be the priority rather than providing treatment for parents and
supporting them in their parental role. Certainly, concerns about the safety
of the child are part of the evaluation in the latter cases, but they are not the
central focus. It should also be noted that, because of the lack of definitive
research on support for parents facing other adversities, such as homeless-
ness or incarceration, the discussion does not address these adversities, even
though they affect the lives of millions of children.
The fact that parents are experiencing one or more of these adversities
does not necessarily mean that they need help with parenting. Many parents
facing such problems are able to provide adequate parenting. However,
these adversities can impair parents ability to provide their children with
the safe, nurturing environment they wish to provide. Coping with these
adversities can reduce parents overall coping ability and their ability to en-
gage in the types of positive parenting behaviors identified in Chapter 2. As
discussed below, it is well established that children living with parents fac-
ing these adversities are less likely to attain the desired outcomes identified
in Chapter 2 relative to children whose parents are of similar socioeconomic
status but do not face these adversities. Providing effective interventions for
these parents to support and strengthen their parenting is therefore critical
for both them and their children.
At present, the majority of parents experiencing one or more of these
adversities are receiving no services for their condition. For higher-risk
families most in need of effective treatment programs, engagement rates
may be even lower (Ingoldsby, 2010). Although not specific to parents, one
study estimates the percentage of persons who needed but did not receive
substance abuse treatment to be about 90 percent (Batts et al., 2014). With
respect to mental health, a national study of low-income women found that
just one-quarter of those with any mental health disorder had sought treat-
ment in the past month (Rosen et al., 2006). Again, even when individuals
do receive services, the services generally focus on the presenting problem
but do not address parenting issues; in fact, individuals receiving treatment
for mental health or substance abuse disorders frequently are not asked
whether they are parents.
Three interrelated factors are particularly common barriers to seeking
and receiving support among the parent populations discussed in this sec-
tion: stigma (e.g., that associated with having a mental illness or substance

use disorder),3 parents fear that they will be reported to child protection
agencies, and distrust of service providers. Parents facing adversities may
have an internalized sense of stigma about their condition that affects their
sense of self-worth and competence (Borba et al., 2012; Krumm et al.,
2013; Nicholson et al., 1998; Wittkowski et al., 2014). The widespread
stigma associated with mental illness often increases parental and family
stress and poses a barrier to seeking any parenting support, even basic
health care (Blegen et al., 2010; Borba et al., 2012, Byatt et al., 2013,
Dolman et al., 2013; Gray et al., 2008; Henderson et al., 2013; Krumm
et al., 2013; Lacey et al., 2015; Rose and Cohen, 2010; Wittkowski et al.,
2014). This appears to be particularly true for parents with severe mental
illnesses. Similarly, societal stigma may increase the self-blame, remorse,
and shame already felt by mothers with substance abuse disorders, pushing
them further away from seeking help and contributing to the denial that
is a hallmark of the disease of addiction. Substance abusing mothers cite
enormous guilt and shame for failing as mothers as a major barrier to
accessing treatment (Nicholson et al., 2006).
In addition, many adults living with mental illness, substance abuse,
developmental disabilities, or intimate partner violence are cognizant that
their condition negatively influences other peoples beliefs about their par-
enting abilities. Mothers report feeling significant vulnerability based on
fear of not being perceived as a good mother. They recognize that as a
result of their condition, they can be at risk for involvement of child pro-
tective services and loss of child custody, a perception that is based in fact
(Berger et al., 2010; Cook and Mueser, 2014; Fletcher et al., 2013; Niccols
and Sword, 2005; Park et al., 2006; Seeman, 2012). For example, using
Medicaid and child welfare system data, a large study of Medicaid-eligible
mothers with severe mental illness found almost three times higher odds
of being involved with child welfare services and a four-fold higher risk of
losing custody at some point compared with mothers without psychiatric
diagnoses (Park et al., 2006). In the case of mothers with substance abuse,
caseworkers may be more likely to perceive that children have experienced
severe risk and harm (Berger et al., 2010). And the law in many states
requires that reports of domestic violence be investigated by child welfare
agencies (Blegen etal., 2010; Cook and Mueser, 2014; Dolman et al., 2013;
Wittkowski et al., 2014), which makes some victims reticent to invite ser-
vice providers into their homes (Brown, 2007).
3The Substance Abuse and Mental Health Services Administration and other stakeholders
are moving away from the use of the term stigma, as noted in the recent report Ending
Discrimination Against People with Mental and Substance Use Disorders: The Evidence for
Stigma Change (2016). Because the word stigma continues to be widely accepted in the
research community, the committee chose to use this term in this report.

These factors also contribute to parents distrust of service providers.

Ambivalent feelings about parenting support programs may come from
past experiences, as well as familial or social histories or perceptions
(McCurdy and Daro, 2001). Some parents report stigmatizing remarks or
comments from health care or social service providers. Parents with sub-
stance use problems, for example, frequently report that they experience
anger and blame from medical and other treatment professionals instead
of being viewed as suffering from an illness and treated as such (Camp and
Finkelstein, 1997; Nicholson et al., 2006). In the case of parents with men-
tal illness, the distrust may be part of the general attitudes associated with
paranoia or delusions (Healy et al., 2015; Stepp et al., 2012).
Although generating participation can be challenging, a wide range
of programs are available that are designed to meet the needs of these
populations, both by addressing the underlying problems and with respect
to supporting and strengthening parenting. High-quality trials of such
interventions are limited, however. Although there have been random-
ized controlled trials, many smaller studies, observational research, and
case-control studies provide some guidance on best practices. This section
reviews the available evidence on interventions designed specifically to sup-
port parents facing adversities related to mental illness, substance abuse dis-
orders, intimate partner violence, and parental developmental disabilities,
since each has unique needs that should be considered in offering services
to strengthen and support parenting. As noted, many parents face two or
more of these challenges, and some face nearly all of them. There has been
almost no rigorous evaluation of interventions for these very complex cases,
and many of these families are referred to child welfare agencies. Later in
this chapter, the committee assesses parenting interventions offered through
the child welfare system.
Parents with Mental Illness

Many parents struggle with mental illness at the same time they are try-
ing to provide a safe, nurturing environment for their family. It is estimated
that 43.6 million adults in the United States experience mental illness annu-
ally, and 9.8 million of them are living with serious mental illness (Center
for Behavioral Health Statistics and Quality, 2015). Research indicates that
one-half of all lifetime cases of diagnosable mental illness occur by age 14
and three-fourths by age 24 (Institute of Medicine and National Research
Council, 2009; Kessler et al., 2005), suggesting that the onset of mental
illness precedes or overlaps with the parenting years in most cases.
Determining the prevalence of mental illness specifically among par-
ents is more challenging. Depression is the most common mental illness.
A report issued by the National Research Council (NRC) and Institute

of Medicine (IOM) estimates that in a given year, as many as 15 million

children may live in a household with a parent experiencing an episode of
major depression (Institute of Medicine and National Research Council,
2009). Depression occurring around the time of childbearing is common,
with 13 to 19 percent of women experiencing postpartum depression and
many others experiencing depressive symptoms during pregnancy (OHara
and McCabe, 2013). But many parents who experience mental illness have
not been formally diagnosed, and patients with a diagnosis of mental ill-
ness often are not identified as being parents. It is particularly challenging
to estimate the number of parents with severe mental illness (often defined
as schizophrenia, psychosis, and bipolar disorder). The relevant research
typically has assessed individuals in community settings (community service
agencies, mental health clinics, child welfare agencies, prisons, or hospi-
tals), who likely do not represent the broader population (Nicholson et al.,
2006). Analysis of data from the National Co-Morbidity Survey suggests
that approximately one-half of mothers (46.8%) and one-third of fathers
(29.5%) have had a psychiatric disorder at some point during their lifetime
(Nicholson et al., 2002). In another study, among adults identified with
severe persistent mental illness, approximately two-thirds of women and
three-quarters of men were also parents (Gearing et al., 2012; Nicholson
et al., 2002).
Mental health disorders encompass a wide spectrum of illnesses and
levels of severity, and symptoms may wax and wane over time; thus their
impact on parenting and the supports these parents need can be quite vari-
able. As with prevalence, far more is known about the impact of depression
on parenting (Institute of Medicine and National Research Council, 2009)
than about the impact of severe mental illness (Bee et al., 2014; Schrank et
al., 2015). The 2009 IOM and NRC report describes research showing that
parental depression is associated with more negative and withdrawn parent-
ing and with worse physical health and well-being of children. But the same
report describes a number of promising two-generational programs focused
on prevention and emphasizes the potential for helping parents with treat-
ment and parenting programs.
For individuals with mental illness, being a parent is not only a chal-
lenge but also often one of the most rewarding parts of their lives (Dolman
et al., 2013; Lacey et al., 2015; Wittkowski et al., 2014). Many of these
parents are motivated to cope with their own symptoms by focusing on
meeting their childrens needs, and they value these relationships (Barrow
et al., 2014; Oyserman et al., 2000; Wittkowski et al., 2014). However,
mental illness also can interfere with the quality of parenting. A cross-
sectional study using video observation of 251 depressed mothers with their
toddlers demonstrated that those with more severe depressive symptoms
engaged in fewer positive interactions and more negative interactions with

their children and also provided less developmental stimulation (Beeber et

al., 2014). Children of parents with mental illness also have a higher risk
of developing their own mental health issues, developmental delays, and
behavioral problems (Beardslee et al., 2011; Craig, 2004; Dean et al., 2012;
Friesen et al., 2009; Gearing etal., 2012; McCoy et al., 2014). Childrens
development of these problems can add to the challenges parents face in
childrearing and also can increase the fear and guilt they may feel about
the impact of their own illness on their child.
There have been few high-quality large-scale evaluations of interven-
tions designed for parents with mental illness and even fewer of those for
parents with severe mental illness. The 2009 IOM and NRC report notes
that few studies of parental depression focus on parental outcomes or issues
specific to parents (Institute of Medicine and National Research Council,
2009). However, many universal interventions have the potential to prevent
or mitigate mental illness before it has serious impacts on parenting, and
a number of smaller studies have shown positive or promising results of
such interventions. For example, the MOMS Partnership, operated by Yale
University, interviewed more than 1,300 low-income urban mothers of
young children to create a set of developmental and community-based men-
tal health and workforce supports (Smith, 2014). These supports included
cognitive-behavioral therapy delivered by community mental health am-
bassadors, along with phone applications to help strengthen mothers
executive functioning skills and capacity for stress management and reduce
depression. Early results based on a participant questionnaire reveal an
increase in positive parenting and reduction in depression (Smith, 2014).
Interventions for Parents with Depressive Disorders

A number of programs are designed to prevent adverse child outcomes
among families with known parental mental illness. For postpartum depres-
sion, limited controlled research indicates that simply treating the illness
leads to gains in the quality of parenting (OHara and McCabe, 2013).
An analysis of the Sequence Treatment Alternatives to Relieve Depression
(STAR*D) trial found that treatment leading to remission of mothers
depression was associated with improved mental health among their chil-
dren in a nonexperimental study, although the mechanism of change was
not assessed (Institute of Medicine and National Research Council, 2009;
Weissman et al., 2006). The evidence for treating maternal depression for
mothers of infants, however, is mixed. Several reviews found that while
sustained interventions may improve the cognitive development of the child,
additional research is needed to determine the success of these treatments
over time, particularly with regard to the benefits for the child as well as the
mother (Nylen et al., 2006; Pooblan et al., 2007). Forman and colleagues

(2007) found in an experimental study that relieving maternal depression

alone affected only parenting stress and did not necessarily improve the
mother-infant relationship or child outcomes (Forman et al., 2007).
Nonetheless, most studies have demonstrated that interventions com-
bining mental health treatment and parenting support, or at least including
a component focused on parenting, often lead to better outcomes relative to
programs that focus solely on the illness. A systematic review of the impact
of maternal-infant dyadic interventions on postpartum depression included
19 single group pre-post and randomized controlled studies. The author
concluded that strategies focused on the dyad and maternal coaching were
most effective at reducing psychiatric symptoms and demonstrated modest
improvements in the mother-child relationship and maternal responsive-
ness (Tsivos et al., 2015). Not all such approaches are successful, however.
A 2015 Cochrane review assessing the impact specifically of parent-infant
psychotherapy versus control or an alternative intervention found no sig-
nificant effects of the psychotherapy on maternal depression or the mother-
child dyad (Barlow et al., 2015).
With the advent of primary care medical homes and the resultant in-
tegration of physical, mental, and behavioral health care, there has been
growing interest in incorporating parenting interventions and support into
primary care settings. This may be a particularly effective way of diagnosing
and addressing parental mental health issues. Parents may be more willing
to seek health care for their children than for themselves, but during pedi-
atric visits, health care providers may identify a parent who would benefit
from mental health treatment (Nicholson and Clayfield, 2004). Screening
adults for depression in primary care settings with the capacity to provide
accurate diagnosis, effective treatment, and follow-up is endorsed by the
U.S. Preventive Services Task Force (2009). Models of stepped collaborative
care entail screening for and identifying depression in primary care set-
tings and providing straightforward care in those locations while referring
patients with more severe or resistant illness to mental health specialists
(Dennis, 2014).
Additional primary prevention programs for parental depression have
focused on the period from conception through age 5, although most ad-
dress parents with infants rather than those with toddlers (Bee et al., 2014;
Craig, 2004). Selective primary prevention of depression among parents has
been tested most frequently in the perinatal period, with most programs tar-
geting high-risk groups, such as mothers with preterm infants or those at in-
creased risk for postpartum depression (Ammerman et al., 2013; B eardslee
et al., 2010; Dennis, 2014; Silverstein et al., 2011). The perinatal period
appears to be an effective time to reach a broad population of parents.
Home visiting programs (discussed in detail in Chapter 4) serve parents
with high rates of depression, interpersonal trauma, and PTSD, yet less than

one-half of state-based home visiting programs currently have improving

parental mental health as an objective (Johnson, 2009). Early studies exam-
ining the mental health benefits of home visiting interventions for parents
had mixed results, but the results of more recent studies have been positive.
In recent studies, for example, home visiting that includes psychotherapy
for mothers has been found to improve depression, and as depression im-
proves, so do many measures of parenting (Ammerman et al., 2011, 2013,
2015; Paradis et al., 2013; Tandon et al., 2014). A randomized controlled
trial enrolled women in home visiting programs who were identified as
being at risk for perinatal depression (Tandon et al., 2014). The interven-
tion consisted of six 2-hour group sessions focused on cognitive-behavioral
therapy, with skills being reinforced during regular home visits. At 6-month
follow-up, 15 percent of mothers in the intervention group versus 32 per-
cent of the control mothers had experienced an episode of major depres-
sion (Tandon et al., 2014). In a randomized trial of the Building Healthy
Children Collaborative, there was no difference in rate of referral to child
protective services for mothers who received mental health services as part
of home visits and women in a comparison group who did not receive such
services; in both groups, almost all mothers avoided referral to child protec-
tive services (Paradis et al., 2013).
There also have been efforts to help parents with children in center-
based care. In a randomized controlled trial of depressed mothers who
had infants and toddlers in Early Head Start, investigators tested inter-
personal therapy combined with parenting enhancement training versus
just treatment for the depression (Beeber et al., 2013). Both groups had a
significant improvement in depression scores, but only the group with par-
ent training showed enhanced parent-child interaction skills. Beardslee and
colleagues (2010) describe a nonrandomized, multiyear, multicomponent
pilot intervention with parents, staff, and administration in an Early Head
Start program serving up to 200 children a year.The intervention, F amily
Connections, was intended to help staff with strategies for addressing
mental health problems in the families they served. The program, which
was provided to all the families, not just those identified as suffering from
depression, utilized widespread education of staff and parents and a par-
ent support group. It resulted in improved parent self-reported parenting
knowledge and social support and increased parent engagement with the
center.
Other approaches have been tried in public health settings. A random-
ized study tested two different parenting interventions (Family Talk Inter-
vention and Lets Talk about Children) in families with a parent diagnosed
with a mood disorder (Solantaus et al., 2010). Both interventions improved
child mental health symptoms and behaviors. Family Talk utilizes manual-
based psychoeducation prevention strategies. One study of 93 families with

at least one depressed parent and one child ages 8-15 found significant
and sustained improvement in parental attitudes toward parenting and
reduction in internalizing symptoms (predictive of future depression) in the
children whose families were assigned to a lecture or clinician-facilitated
intervention, although outcomes in terms of levels of parental depression
are not described (Beardslee et al., 2003, 2011).
Interventions for Parents with Severe Mental Illness

While parents with brief or time-limited mental health problems
can benefit from brief interventions, those with severe mental illness or
more complex mental health disorders are likely to need ongoing support
and crisis intervention services. Unfortunately, interventions to support and
strengthen parenting for parents with severe mental illness have typically
not been rigorously evaluated using the types of well-designed random-
ized controlled trials used to test other parenting interventions described
in this report, and this is an identified area of need (Schrank etal., 2015).
Shrank and colleagues (2015) conducted a systematic review of parenting
studies involving parents who had severe mental illness (psychosis or bipo-
lar disorder) and at least one child between the ages of 1-18. The review
included a heterogeneous range of interventions, and child outcomes were
evaluated. Four of six randomized controlled trials included in the review
showed significant benefits from the interventions, which included intensive
home visits, parenting lectures, clinician counseling, and Online Triple P;
the lower-quality studies showed mixed results.
A 3-year observational study of mothers with severe mental illness with
children ages 4-16 demonstrated that over time, as serious symptoms remit-
ted, parents became more nurturing, raising the hope that treatment could
lead to improved child outcomes (Kahng et al., 2008). A meta-analysis of a
variety of parenting interventions found a medium to large effect size in im-
proving short-term parent mental health but noted that these benefits may
wane over time, again emphasizing the need for longer and more enduring
programs (Bee et al., 2014).
One approach for parents with severe mental illness that appears to be
promising is to provide parenting interventions during intensive outpatient
treatment or inpatient treatment for mental health crises (Krumm et al.,
2013). A few hospitals in the United States (many more in Europe and
Australia) have mother-baby mental health units where the baby can stay
with the mother while she is hospitalized. A systematic review of inpatient
parenting programs for women with schizophrenia evaluated 29 studies of
interventions in mother-baby units and found improved maternal outcomes,
but the review included no randomized controlled studies, and most such
studies have been descriptive, observational, and/or quasi-experimental

designs (Gearing et al., 2012; Hinden et al., 2006). A newer observational

study in the United Kingdom using a video feedback intervention found that
between the time of admission and discharge, mothers with schizophrenia,
severe depression, and mania became more sensitive and less unresponsive,
and their infants became more cooperative and less passive (Kenny et al.,
2013). Notably, mothers at discharge had better outcomes on all parent-
ing measures than both a comparison group of nonhospitalized mothers
with mental illness of comparable severity and a group of mothers without
mental illness in the community.
Interventions and treatment for parents with mental illness have been
found to significantly reduce the risk of children developing the same
mental health problems as well as behavior challenges. A meta-analysis
included 1,490 children in 13 randomized controlled trials of interventions
with cognitive, behavioral, or psychoeducational elements for parents with
a variety of mental illnesses and substance use problems (Siegenthaler et al.,
2012). The studies included in the review focused on maternal stress reduc-
tion, family interventions, home visits, or parenting skills, and reported a
40 percent reduction in the risk of new diagnoses of mental health disorders
in the children as well as a significant decrease in the childrens internalizing
and externalizing symptoms.
Given the enormous complexity of comorbidities and varieties of pre-
sentation in mental illness, sorting out which risks to children derive from
parental mental illness and which should be attributed to other stressors is
challenging. Doing so is critical, however, for identifying the best strategies
for helping families and in considering interventions at both the micro and
macro levels. For example, many parents living with severe mental illness
will need support in learning parenting knowledge, attitudes, and practices,
specifically in understanding normal child development and milestones
and how to provide emotional support for their children. They, like all
parents, may also benefit from training in such skills as getting children to
have a consistent bedtime routine, feeding them, administering nonphysical
discipline, and providing emotional support (Nicholson and Henry, 2003;
Stepp et al., 2012). Mothers living with severe mental illness themselves
have identified generic parenting issues for which they may need helpboth
in accessing essential resources and in developing critical parenting skills
(Nicholson and Henry, 2003).
Tailoring of Services to Individual Needs

Mental illnesses include a wide range of conditions. One mother may
have severe depression and struggle with lifelong, recurrent episodes, while
another may have a single episode of mild postpartum depression. One
disorder may cause symptoms that make it difficult to recognize the emo-

tions or affect of others, while another may cause a parent to display odd
behaviors or make unusual comments, and still another may lead to social
withdrawal (Healy et al., 2015; Stepp et al., 2012). Even a single diagnosis
can manifest with different symptoms and severity at different stages of
the illness, and the illness itself can lead to complications. Parents with
severe or recurrent illness also may face separation from their children due
to hospitalization or temporary or permanent loss of custody, which can
impact parental self-efficacy as well as attachment (Gearing et al., 2012;
Nicholson et al., 2006). Thus it is important for programs to tailor services
to the individual needs of parents. Programs that offer service coordina-
tion are likely to be effective for parents with mental illness who face other
adversities as well, such as poverty, family violence, housing instability, and
substance abuse. Providers and policy makers also need to be mindful of
the multiple layers of risk these co-occurring conditions pose to families,
since childhood outcomes will be affected by far more than the parenting
behaviors or knowledge targeted by many programs.
Parents with or Recovering from Substance Abuse Disorders

Like mental health conditions, substance use and abuse can affect
parenting attitudes and practices, as well as engagement and retention in
parenting programs. It has been estimated that nearly 22 million Americans
have a substance use disorder (Center for Behavioral Health Statistics and
Quality, 2015). Yet in 2014, only 4.1 million out of 21.6 million people
ages 12 and older with illicit drug or alcohol dependence or abuse received
treatment (Substance Abuse and Mental Health Services Administration,
2014b). Moreover, both research and clinical practice have seen little inte-
gration of child development and parenting with addiction prevention and
treatment. Most studies on substance abuse to date have measured mainly
retention in treatment and reduction in maternal substance use as the pri-
mary outcomes, with less attention to parenting and work with children
(Finkelstein, 1994, 1996; Nicholson et al., 2006).
Abuse of alcohol and drugs can impact parenting in multiple ways.
Prenatal exposure to substances can significantly affect infants, resulting in
behaviors that are extremely challenging to parents (OConnor and Paley,
2006; Preece and Riley, 2011; Schuetze et al., 2007). Potential neonatal ef-
fects include prematurity and low birth weight; greater reactivity to stress;
increased arousal; higher irritability and restlessness; disordered sleep and
feeding; tremulousness, high-pitched cry, and startled response; difficulties
with sensory integration, such as abnormal responses to light, visual stim-
uli, and sounds; and hyperactivity (Iqbal et al., 2002; U.S. Department of
Health and Human Services, 2014a). An infant who cannot regulate sleep,
wakefulness, or stress is therefore often partnered with a mother who has

reduced capacity to deal with stress and to respond to infant cues (Beeghly
and Tronick, 1994; Pajulo et al., 2012).
Research has recently combined the neurobiology of addiction with
the neurobiology of parenting, and has examined how the disregulation
of the stress-reward neural circuits in addiction may impact the capacity
to parent (Rutherford et al., 2013). It is well documented that increases in
stress result in increases in cravings and substance use (Sinha, 2001). More
specifically, the rewarding value of drugs for a substance-dependent indi-
vidual comes from ameliorating withdrawal and other stressful situations,
and this value may diminish biochemically the rewarding and pleasurable
aspects of parenting (Rutherford et al., 2013).
One suggested mechanism by which substance abuse impairs parenting
is its impact on the neurocircuitry of the mothers brain, particularly the
oxytocin and dopamine systems (Strathearn and Mayes, 2010). Oxytocin
motivates social behavior by stimulating a reward response to proxim-
ity and social interaction and has been shown to increase significantly in
both mother and infant during periods of close contact and breastfeeding
(Strathearn et al., 2008). Substance abuse interferes with this process. For
example, cocaine specifically coopts this neuropathway by decreasing the
production of oxytocin and thereby making maternal care less rewarding
for a cocaine user (Elliott et al., 2001). Dopamine operates similarly: it
rewards social behavior and regulates the production of stress-response
chemicals. Most addictive substances affect dopamine production by pro-
viding drug-induced surges of dopamine, decreasing the bodys natural
production of the chemical, and nullifying the rewarding effects of normal
human behavior. The dysregulation of dopamine also impairs a mothers
ability to regulate stress, making her more susceptible to the exhaustion
and frustration inherent in early parenting (Strathearn and Mayes, 2010).
From a neurobiological perspective, therefore, the motivation to engage
with and respond to infants may be compromised in the presence of ad-
diction, and this diminished motivation may result in part from infant
signals holding less reward value (Rutherford et al., 2013). In addition, the
increased stress inherent in the parenting role may increase cravings, drug-
seeking behaviors, and relapse to substance use (Rutherford et al., 2013).
The few studies that have been conducted on parenting and substance
use/abuse have focused primarily on adults entering treatment, who ac-
count for a relatively small share of the broader population of parents with
substance abuse disorders (Mayes and Truman, 2002). From this limited
sample, studies have described a range of parenting deficits and conse-
quences, sometimes associated with specific drugs (including alcohol), as
well as the amount, frequency and duration of use.
Chronic substance abuse affects parents ability to regulate their own
emotions, to provide safe and consistent care for their child, and to be men-

tally alert for bonding and intellectual development (Suchman et al., 2013).
Parents may become preoccupied by drug cravings and drug-seeking behav-
iors, which in turn may lead to physical absences and multiple disruptions
in parenting. Studies have found a strong association between substance
abuse and emotional/physical neglect and physical abuse (Suchman et al.,
2004, 2008).
Further complicating this picture is that all too frequently, the sub-
stance-dependent mother has herself been a victim of violence and abuse.
High levels of trauma history and moderate to high levels of PTSD diagno-
sis co-occur among both men and women with substance abuse disorders
(Back et al., 2003; Miller et al., 2000; Najavits et al., 1997; Read et al.,
2004). Women whose childhood history includes sexual abuse are signifi-
cantly more likely than women without such a history to report substance
use and abuse, as well as depression, anxiety, and other mental health
problems (Camp and Finkelstein, 1997).
Although prenatal substance exposure and early mother-child inter-
actions characterized by intoxication and withdrawal have independent
affects, it is the cumulative risk of chemical, psychological, and environ-
mental disturbances related to substance abuse disorders that interferes
with parenting and child development (Huxley and Foulger, 2008; Mayes
and Truman, 2002). These secondary risk factors are amenable to early
intervention, identification, and comprehensive treatment modalities, offer-
ing an avenue for improved outcomes for both mother and child (Barnard
and McKeganey, 2004). Indeed, childrearing conditions appear to greatly
outweigh substance abuse in predicting adolescent outcomes for drug-
exposed children (Fisher et al., 2011b).
Parenting status is nonetheless frequently neglected in the development
of treatment interventions for parents with substance abuse, and rarely are
critical needs for child care or childrens services taken into account in devel-
oping services and parenting programs for these parents ( Finkelstein, 1994,
1996). In addition, most adult and infant/child mental health professionals
view families affected by addiction as highly challenging to treat, frequently
eliciting feelings of frustration, helplessness, and lack of empathy. The result
too often is that individuals suffering from addiction are excluded from
community programs, as well as research and evaluation studies (Camp and
Finkelstein, 1997; U.S. Department of Health and Human Services, 1999).
This exclusion includes home visiting programs, which may screen out par-
ents who use alcohol and drugs. According to the Department of Health and
Human Services recent report on the Maternal, Infant, and Early Childhood
Home Visiting (MIECHV) Program (discussed in Chapter 4), only 12 per-
cent of enrolled families had substance use issues, and only 21 percent of
grantees selected alcohol, tobacco, or other drug use as issues to monitor
in their families (U.S. Department of Health and Human Services, 2014b).

Substance abuse can be successfully treated. However, while there is

good reason to believe that decreased substance use should lead to im-
proved parenting, there have been no experimental evaluations of whether
successful treatment of substance abuse disorders, in and of itself, leads to
better parenting. Described below are interventions for substance abuse that
include a specific focus on parenting.
Residential Treatment Programs for Mothers with Their Children

The standard of care for womens residential treatment for substance
abuse disorders has shifted over the past 15-20 years from mothers being
treated in single-adult programs apart from their children to women and
children residing together and mothers receiving integrated addiction treat-
ment and parenting education and services (Bromberg et al., 2010). Re-
search suggests that mothers who reside with their children are more likely
to enter, remain in, and complete treatment, as well as remain drug free for
longer periods of time, relative to mothers who are separated from their
children (Clark, 2001; dArlach et al., 2006; Grella et al., 2000; Lundgren
et al., 2003; Metsch et al., 2001; Pajulo et al., 2006, 2012).
The literature describes a number of specific residential treatment pro-
grams for mothers with their children. The majority of studies report
positive parent and child outcomes using pre-post evaluation designs (Allen
and Larson, 1998; Conners et al., 2001; Grella et al., 2000; Jackson, 2004;
Metsch et al., 2001; Moore and Finkelstein, 2001; Porowski et al., 2004;
Szuster et al., 1996; Wobie et al., 1997). The Substance Abuse and Mental
Health Services Administration (SAMHSA) conducted a national cross-
site study of 24 of its funded residential treatment programs for pregnant
and parenting women and their children. Data on 1,847 women showed
positive results, including an infant mortality rate 57 percent lower than
that in the general population. Seventy-five percent of 97 mothers at one
site reported improved relationships with their children and learned better
stress coping skills (Clark, 2001).
Family Drug Courts

In response to high rates of nonviolent drug-related arrests in the early
1990s, the United States began utilizing drug courts as an alternative to
traditional sentencing procedures. These courts often mandate treatment
for substance abuse disorders, frequent drug testing, and periodic court ap-
pearances for status hearings (Mitchell et al., 2012). If drug court sentences
are completed successfully, the individual will have the charges against him/
her dropped or, if postconviction, will receive a sentence of time served.

As of 2014, nearly 3,400 drug courts were operating in the United States
(National Institute of Justice, 2016).
An expansion of the adult drug court model, family treatment drug
courts (FTDCs) were created as an alternative pathway to reunification in
child protective cases. Parental substance abuse is one of five recognized risk
factors for involvement in the child welfare system; once child protective
services are involved, children of parents with substance abuse disorders
tend to stay in the system longer and spend more time out of their home
of origin (Child Welfare Information Gateway, 2014). The aim of FTDCs
is to combat these trends by giving parents with these disorders access to
treatment, accountability, support, and a system of structured rewards and
sanctions aimed at their ultimately regaining full custody of their children.
One large-scale outcome study compared 301 families served through
three FTDCs with a matched control group of more than 1,200 families with
substance abuse issues who received traditional child welfare services. This
study found that the FTDC mothers were more likely to enter treatment,
entered treatment more quickly, and were twice as likely to complete at least
one treatment relative to the control group. Also, children of mothers who
participated in FTDCs were more likely than children in the control group
to be reunited with their mothers (Worcel et al., 2008). Another, smaller,
quasi-experimental study showed that parents participating in FTDCs were
significantly more likely than those not participating to enter treatment, en-
tered treatment more quickly, received more treatment, and were more likely
to complete treatment successfully. The FTDC-group children spent less time
placed out of home, their involvement with child welfare services ended
sooner, and they were more likely to return to p arental care upon discharge
(Bruns et al., 2012). Other nonexperimental research has found FTDCs to
be one of the most effective ways to increase initiation and completion of
treatment for substance abuse disorders among those involved in the child
welfare system (Marlowe and Carey, 2012). Reviews of FTDCs have found
some evidence of positive findings related to reunification, completion of
treatment episodes, fewer parental criminal arrests, and significant cost sav-
ings for the child welfare system (Brook et al., 2015; Marlowe and Carey,
2012). However, the lack of rigorous, randomized, intent-to-treat studies
leaves unaddressed the possibility that those women who elect to participate
in FTDCs are different from those who do not.
Parenting Skills Training for Parents with or Recovering from

Substance Abuse Disorders
While research has demonstrated that family and parenting skills can
be improved when specific parenting programs are integrated into treatment
for substance abuse (Camp and Finkelstein, 1997; Kerwin, 2005; Suchman

et al., 2008, 2010), few targeted parenting interventions have been devel-
oped for parents who have or are recovering from such disorders. A study
published in 2013 sampled 125 addiction programs in the United States
with respect to the extent and nature of parenting skills interventions of-
fered. Only 43 percent of addiction programs surveyed reported offering
formal classes on parenting. Of programs that did offer such classes, only
19 percent stated that they had a standardized curriculum. In general,
programs did not rate parenting as a high priority relative to other issues
addressed in treatment (Arria et al., 2013). Few programs have reached the
threshold of a high evidence rating by NREPP and CEBC.
Strengthening Families and the Nurturing Parenting Programs (NPP)
are two of the few highly rated group-based parenting programs. Strength-
ening Families and the NPP for Families in Substance Abuse Treatment
and Recovery specifically target substance abuse and parenting. Both of
these curriculums are widely used in substance abuse treatment programs
nationally, often within residential, day treatment, or FTDC settings. Both
emphasize reducing parents alcohol and drug use while helping them learn
new patterns of nurturing their children to replace existing, possibly abusive
patterns. Strengthening Families also has a youth prevention focus, with the
goal of reducing risk factors and building resilience against childrens future
alcohol and drug use. Strengthening Families and NPP have average NREPP
ratings of 3.1 and 3.0, respectively, and the NPP received a CEBC rating of
3 for the version of the program for parents of 5- to 12-year-olds (however,
the specific adaptation for substance abuse was not rated independently)
(California Evidence-Based Clearinghouse, 2016j; National Registry of
Evidence-based Programs and Practices, 2016b, 2016d).
Strengthening Families is one of the first structured group parenting
programs developed within an addiction framework (reviewed by NREPP
in 2007) (National Registry of Evidence-based Programs and Practices,
2016d). Developed by a university-based research team, the program has
been able to gather higher-quality data relative to most other parenting
programs that address parental substance abuse. A family-skills training
program targeting parents of children ages 3-16, Strengthening Families
consists of three coursesparenting skills for parents; life skills for chil-
dren; and family life skills for the entire family, consisting of structured
family activities. All three courses have a strong emphasis on communica-
tion skills, effective discipline, reinforcing positive behaviors, and planning
family activities together. The goal is to reduce risk factors for behavioral
and emotional problems such as substance use. Findings from evaluations
of this intervention include improvements in childrens behavior, mental
health, and social skills and in parental involvement, parenting supervision,
and parenting efficacy. Improvements also have been found in family cohe-

sion and communication, including a decrease in family conflict, as well as

reduced alcohol and drug use (Kumpfer et al., 2007).
The NPP was developed specifically for families involved with child
welfare services. The emphasis is on participants learning how to nurture
themselves while developing nurturing families and parenting skills. The five
core domains of the intervention are age-appropriate expectations; empathy,
bonding, and attachment; nonviolent nurturing discipline; self-awareness
and self-worth; and empowerment, autonomy, and healthy independence.
Multiple adaptations, focused on the same core domains, include the NPP
for Families in Substance Abuse Treatment and Recovery, which integrates
recovery from substance abuse disorders with improved parenting and nur-
turing relationships with children. Correlational evidence relevant to parent-
ing practices indicates improvements in such parenting outcomes as parental
empathy, reduced child abuse and neglect recidivism, decreased family con-
flict, and decreased support for corporal punishment (Bavolek et al., 1983,
1988; Camp and Finkelstein, 1997; Hodnett et al., 2009).
Other well-supported programsadult-focused family behavioral ther-
apy and behavioral couples therapy for alcoholism and drug abuseutilize
individual therapy for addressing co-occurring problems so as to improve
family relationships and parenting skills. Both of these interventions are
conducted primarily in outpatient mental health settings. Adult-focused
family behavioral therapy, with a CEBC rating of 2 (supported by research
evidence), focuses on adults with drug abuse, as well as other co-occurring
problems such as depression, trauma, and child maltreatment (California
Evidence-Based Clearinghouse, 2016b). This intervention, based in out-
patient behavioral health systems, requires delivery by licensed mental
health professionals. It includes a focus on improving family relationships;
communication skills; and child management skills, including effective
discipline. Outcomes in randomized and longitudinal studies that utilized
control groups include improvements in family relationships and parental
employment as well as reductions in parental substance use and depres-
sion (Azrin et al., 1994, 1996; Donohue et al., 2014). Behavioral couples
therapy for alcoholism and drug abuse, rated highly by NREPP, is an
intervention for couples focused on reducing alcohol and drug use and in-
timate partner violence and increasing treatment compliance. Although not
used solely with parents, its outcomes, in addition to reduction in intimate
partner violence, have been found to include improvement in childrens
psychosocial functioning and decline in childrens clinical impairment in
randomized controlled research (Kelley and Fals-Stewart, 2002).
Schaeffer and colleagues (2013) describe a pilot study of Multisystemic
Therapy-Building Stronger Families (MST-BSF), an integrated treatment
model designed to address parental substance abuse and child maltreatment
among families in the child welfare system. A quasi-experimental study

of 43 mother-youth dyads (25 MST-BSF participants and 18 comparison

dyads) found fewer substantiated maltreatment reports and reduced time
out of the home in the MST-BSF group (Schaeffer et al., 2013). This home-
based intervention is currently being studied in a large, randomized clinical
trial funded by the National Institute on Drug Abuse.
A recent review of 21 outcome studies on parenting programs used in
substance abuse disorder treatment included 17 different parenting inter
ventions. Studies consisted of 9 randomized controlled trials, 3 quasi-
experimental studies, and 9 studies with no comparison group. Results
indicate that combining substance abuse treatment with a parenting inter-
vention may be more effective than substance abuse treatment alone for
reducing parental substance use and improving parenting. Parents appeared
to benefit the most when, prior to learning specific parenting techniques,
they learned general psychological coping strategies, such as developing
emotional regulation. In addition, many of the parenting programs showed
common obstacles to attendance, including lack of transportation, hunger,
unsupervised children, and stigma (Neger and Prinz, 2015).
Helping Parents Nurture Child Security

Given the complexity of addiction and the way it impacts parenting and
the parent-child relationship, a number of newer, promising interventions
grounded in attachment theory and focused on the parent-child relationship
have been developed and described in the literature (Pajulo and Kalland,
2013; Pajulo et al., 2006; Suchman et al., 2008). These newer interventions
focus mainly on assisting parents in being more emotionally attuned to
their children and in developing their own capacity for emotional regula-
tion. They include individual and dyadic interventions, such as child-parent
psychotherapy, parental reflective functioning (Fonagy et al., 2012), and
mentalization-based therapythat is, keeping the child in mind (Suchman
et al., 2013). They also include parenting program adaptations for adults
with substance abuse disorders that have been the subject of several small
pilot studies.
Berlin and colleagues (2014) in a randomized study piloted Attachment
and Behavioral Catch Up, a residential treatment program for new mothers
focused on coaching parents in nurturing that follows the childs lead and
reducing frightening caregiving behaviors. Mothers who received 10 ses-
sions of this attachment-based parenting program revealed more support-
ive parenting behaviors relative to controls. However, the pilot was very
small, with only 11 mothers in the intervention group and 10 in the control
group (Berlin et al., 2014). In a randomized pilot study testing the efficacy
of the Mothers and Toddlers Program (MTP), a 12-week attachment-
based parenting intervention for mothers enrolled in methadone treatment,

mothers participating in MTP demonstrated better caregiving behaviors

compared with mothers enrolled in a traditional parenting education pro-
gram (Suchman et al., 2010). This individual psychotherapy intervention
emphasized reflective functioning and mentalization and targeted mothers
of children ages 0-3. MTP, now known as Mothering from the Inside Out,
is currently undergoing a 5-year randomized clinical trial targeting children
12-60 months of age (Suchman et al., 2013).
Preventing Substance Use during Pregnancy

Another promising intervention, known as the Parent-Child Assistance
Program (PCAP), follows pregnant and parenting mothers with alcohol
and/or drug abuse to prevent substance-exposed births. The program pro-
vides office- and home-based substance abuse treatment and case manage-
ment services over several years that include attention to parenting, family
planning, education and employment, and reunification with children. Eval-
uations of PCAP in experimental and single group pre-post studies show
increased substance use disorder treatment completion rates and reductions
in substance-exposed births and disrupted parenting (Grant and Ernst,
2014; Grant et al., 2005; Ryan et al., 2008). In one experimental study,
12 percent of mothers participating in PCAP had a subsequent a lcohol- or
drug-exposed infant within 3 years, compared with 21 percent of similar
mothers in typical substance abuse disorder treatment that did not include
case management (Ryan et al., 2008). Data from Washington State for the
period 2007-2014 show that after 3 years in PCAP, 90 percent (of 924)
of mothers had completed substance abuse treatment, and 83 percent of
children whose mothers were in the program were living with their own
families (Grant and Ernst, 2014).
Recently, several federal agencies have evaluated programs and systems
of care that coordinate substance abuse disorder treatment with childrens
physical and mental health services (including trauma-specific services), as
well as child welfare. In the Children Affected by Methamphetamine (CAM)
Grant Program, SAMHSA funded 12 grantees to develop integrated and
coordinated approaches to care for parents with substance abuse disorders
and child welfare involvement, as well as to expand and enhance services
for children ages 0-17 in families participating in an FTDC. Specialized cli-
ent outreach and engagement strategies, as well as strengthened care coor-
dination, were part of the program design. Data from 1,850 families served
through the end of program year 3 show that parents stayed in substance
abuse treatment an average of 6 months, and 42 percent completed treat-
ment. The percentage of adults with reduced substance use at treatment
discharge ranged from approximately 33 to 63 percent, depending on the
substance. Families showed statistically significant improvements in over-

all child well-being and family functioning, including safety and parental
capabilities (Substance Abuse and Mental Health Services Administration,
2014a). This was not a randomized controlled demonstration.
A second program designed to enhance collaborative projects between
child welfare and substance abuse treatment servicesthe Regional Part-
nership Grant Programhas been funded by the U.S. Childrens Bureau.
Fifty-three grantees representing state, county, and tribal partnerships were
funded initially, during 2007-2012, and a 2-year extension was awarded to
eight of these grantees. A second 5-year cohort of 17 grantees is funded for
2012-2017, with a more specific focus on both trauma and child well-being,
as well as participation in a national cross-state evaluation. All grantees
were required to provide activities addressing child maltreatment; safety;
parenting capacity; family well-being; and substance abuse treatment, in-
cluding reduced substance use, care coordination, and cross-system col-
laboration. Grantees were not required to implement a specific intervention
or program model. Interim findings from a subset of 10 grantees based on
the North Carolina Family Assessment Scale showed that the percentage of
overall parental capability with a rating of mild to clear strength increased
from 16.6 to 49.7 percent. Parents in the grant program showed significant
improvements in four of seven parental capability areas, including develop-
ment/enrichment opportunities and supervision of children (U.S. Depart-
ment of Health and Human Services, 2014a).
Parents Affected by Intimate Partner Violence

A major issue to be addressed in designing any approach for strength-
ening and supporting parenting is the impact of high levels of intimate
partner violence on the quality of parenting and on outcomes for children.
Intimate partner violence often affects parenting capacity and can have a
direct effect on children who witness its occurrence. While most attention
has focused on the impact of physical intimate partner violence, children
exposed to a parents threatening or otherwise verbally abusing a partner
also are at elevated risk for a variety of mental health and other develop-
mental problems, especially when such behavior is frequent, intense, and
poorly resolved (Geffner et al., 2014; Repetti et al., 2002). For example, a
child who regularly watches or hears one parent4 threaten or scream at the
other may feel fear, anxiety, and anger similar to what is experienced by
a child who regularly sees one parent slap or shove the other. Infants,
toddlers, and preschoolers in particular cannot distinguish between the
severity of aggressive verbal threats and that of mild physical violence.
4The term parent here refers to biological parents as well as to any other intimate partners
who are regularly a part of the household.

While a number of national studies have found that as many as one-

third of women and one-fourth of men are exposed to intimate partner vio-
lence at some point, the evidence regarding the number of exposed children
is limited, and there are no data on the number of children exposed to all
forms of high family conflict (Black et al., 2011; Finkelhor et al., 2009). Ac-
cording to the 2008 National Survey on Childrens Exposure to Violence,
6.1 percent of all children in the United States had witnessed an interparental
assault in the past year, and 17.3 percent had witnessed an interparental
physical assault at some point in their lifetime (Finkelhor et al., 2015).5
Like parents with mental illness or substance abuse, parents experienc-
ing intimate partner violence often feel ashamed and guilty about what has
happened to their children. These feelings, plus fear of being reported to
child welfare, discourage many victims from reporting the violence and may
affect parents willingness and capacity to engage in parenting programs, as
well as other support services (Lieberman et al., 2005).
Impact
Various studies have found that, across a number of measures, 4-20 per-
cent of individual differences in childrens functioning can be attributed
to exposure to intimate partner violence (Davies and Cummings, 2006).
Numerous studies have found that children living in households with inti-
mate partner violence evidence a variety of emotional and developmental
problems (Edleson, 1999; Holt et al., 2008; Wolfe et al., 2003). Witnessing
intimate partner violence is a traumatic event for children and can directly
impact their mental health and behaviors by undermining their sense of
safety, security, and support (Lieberman et al., 2011). School-age children
and adolescents exposed to intimate partner violence perform more poorly
than their peers in school (Kitzmann et al., 2003; Koenen et al., 2003) and
are more likely to display externalizing behaviors, conduct and oppositional
defiant disorder, and aggressive interactions with peers (Cummings and
Davies, 2011; Voisin and Hong, 2012). Exposure to intimate partner vio-
lence also is associated with depression and anxiety, poorer physical health,
and increased risk of involvement in teen pregnancy (Anda et al., 2001), as
well as juvenile delinquency (Herrera and McCloskey, 2001). Additionally,
longitudinal studies have found an association between childhood expo-
sure to intimate partner violence and adult alcohol abuse, particularly in
5This study was based on interviews with parents and children, with assault broadly defined.
It included pushing and shoving, as well as more serious forms of violence. The lifetime expo-
sure percentage was almost three times as high as the past year exposure percentage, suggesting
that many of the children who had witnessed domestic violence in the past had not recently
been exposed to this particular form of violence (Finkelhor et al., 2015).

women (Repetti et al., 2002). Moreover, one analysis of school and court
record data of 3rd through 5th graders and their families found that being
in a class with children exposed to domestic violence was associated with
significantly decreased reading and math scores and significantly increased
misbehavior among other children in the classroom (Carrell and Hoekstra,
2010).
Mechanisms
Many researchers have sought to identify the mechanisms through
which exposure to intimate partner violence affects childrens development.
Summarizing this research, Davies and Cummings (2006, p. 88) conclude
that interspousal conflict increases child vulnerability to maladaptive tra-
jectories through multiple mechanisms and pathways.
Physical or verbal violence in the home can impair parental function-
ing, the parent-child relationship, and the co-parenting relationship and can
impact children directly. For example, parents in a violent home often suffer
from trauma and physical and mental problems. As a result, they may be un-
able to provide consistent nurturing and support or appropriate discipline for
their children, which may in turn have an effect on childrens externalizing
or internalizing behaviors, thereby making parenting more difficult. Parents
experiencing intimate partner violence often engage in overly harsh or
overly permissive parenting or have difficulty responding to children in a
consistent and positive manner (Conger et al., 2011; Cowan et al., 2014;
Cummings and Davies, 2011). In some situations involving intimate part-
ner violence, children are subjected to physical punishment that constitutes
legal child abuse.
Not all exposed children will experience adverse outcomes. There is
evidence that parenting practices can either buffer or exacerbate the effects
of intimate partner violence on childrens behavior. For example, longitudi-
nal research has found that high maternal control and appropriate authority
mitigate the effects of a partners violence on childrens externalizing behav-
iors (Tajima et al., 2011). But while a body of research has tested various
theories, the nature of the interplay between marital conflict and parenting
practices is not well understood (Davies and Cummings, 2006, p. 103).
The majority of families reporting intimate partner violence face a host
of other challenges in their daily lives. Common co-occurring risk factors
include drug and alcohol abuse, low parental educational attainment, and
maternal depression (Riggs et al., 2000; Stover et al., 2009). The highly
violent neighborhoods in which many families live may increase the likeli-
hood of intimate partner violence (Benson et al., 2003). The complexity of
understanding the mechanisms by which intimate partner violence affects
both adults and children and the associated variations in family and child

dynamics poses challenges for designing interventions that can improve

parenting in these families.
Interventions Designed to Address Intimate Partner Violence and Parenting

While the harmful impact of intimate partner violence on children
and adults is widely recognized, no system is in place for identifying these
families and providing assistance to all family members, including children.
The nature of the response and services provided generally depends on
how the violence comes to light, the attitudes of the parent suffering the
violence, and the nature of the available local services. Most interventions
focus primarily on mothers. Programs often focus solely on the intimate
partner violence, without addressing parenting strategies in general or par-
enting behaviors that might buffer children from the risks stemming from
the violence.
Intimate partner violence raises a special issue with respect to inter-
ventions designed to strengthen and support parenting in these families, in
that such interventions must consider the repetitive nature of the violence
in many families, which may pose an ongoing threat to the safety of one
of the adults. Many researchers and clinicians believe the use of violence
often is part of perpetrators need to exercise complete control over their
partner (and often the children in the home), which is harmful to both the
nonviolent partner and the children (Bancroft et al., 2011). As discussed
below, this raises both policy and programmatic issues related to determin-
ing whether interventions should target just one or both partners.
Programs in connection with a parental report of violence Intimate part-

ner violence comes to official attention most commonly when a victim,
usually female, calls the police (although most female victims do not report
their victimization to the police [Catalano et al., 2009]), requests protec-
tion from a court, seeks shelter, or is treated for injuries in an emergency
room, or the issue of violence is raised in the context of divorce and child
custody proceedings. While historically, few of these families received par-
enting services, recent years have seen the provision of such services, most
commonly to the mother and children, and in a small number of cases to
the perpetrating father. (Although more women are now being arrested for
intimate partner violence, there is little information on what happens in
these situations.)
Parenting services may become available when the custodial mother
enters a domestic violence shelter (which occurs for only a small portion of
families), and such services are offered during the stay or when the parent
leaves the shelter. Some shelters now offer structured parenting programs,
although there is very little evidence on the nature or effectiveness of these

programs (Sullivan, 2012). Moreover, many women bring their young

children with them to shelters, and over time, shelter-based programs have
been developed to meet some of the childrens basic needs (e.g., periodic
visits from a public health nurse). Many shelters also offer counseling for
children.
Increasing numbers of community programs outside of the shelter sys-
tem work with mothers, couples, and children experiencing intimate part-
ner violence. Mothers may enter these programs following a stay in shelter
care; through a referral from police, a court, or a domestic violence support
agency; or on their own initiative (few programs serve fathers who have
been subject to intimate partner violence). Prosecutors in a number of c ities
have established specialized domestic violence units, and there are now
more than 100 specialized domestic violence courts (Labriola et al., 2010).
These programs use a variety of approaches. Four programs focused on
parenting are considered evidence-based as the result of randomized con-
trolled trials: child-parent psychotherapy, parent-child interaction therapy
(PCIT, discussed earlier), Kids Club and Moms Empowerment, and Project
Support (Chamberlain, 2014). These programs have been found effective
in reducing childrens behavioral problems, reducing mental health issues
for mothers and children, and reducing mothers stress and improving
their parenting (Chamberlain, 2014; Lieberman et al., 2005; Van Horn
and Reyes, 2014).
Three interventions focused on helping children exposed to intimate
partner violence also have proven effective. Trauma-focused cognitive-
behavioral therapy works directly with children to reduce posttraumatic
stress. Cognitive-Behavioral Intervention for Trauma in Schools, developed
for children who have experienced trauma, including witnessing domestic
violence, is delivered by school-based mental health cliniciansprimarily
to children, but there are sessions for parents. Finally, Child and Family
Traumatic Stress Intervention provides brief psychoeducation and early
intervention to address posttraumatic stress reactions and prevent the onset
of PTSD among children and adolescents ages 7-18 who experience trauma,
including intimate partner violence. Each of these programs has been shown
to reduce symptoms resulting from trauma in children (Chamberlain, 2014),
but not through changes in parenting.
Men also may receive counseling services for intimate partner violence,
often through the criminal justice system. These programs focus largely or
exclusively on trying to prevent further violence rather than on improving
the couple or parent-child relationship. A few programs, such as Caring
Dads, are available to batterers who have not been arrested or convicted
of intimate partner violence, and these programs may also focus on family
issues. A small number of studies have evaluated programs for men who
commit intimate partner violence, with recidivism being the measured

outcome. Meta-analyses of experimental and quasi-experimental studies of

these programs have found small to no effects on recidivism, and dropout
rates are very high (Babcock et al., 2004; Feder and Wilson, 2005; Stith
et al., 2012). Some evidence suggests that men are more likely to change
their violent behavior when they understand the impact of the violence
on their children.
Debates are ongoing in the field about the best approach to strengthen-
ing and supporting parenting following reports of intimate partner violence.
Reports to the police or a court may lead to the arrest of the perpetrator
and his or her removal from the home; many jurisdictions have mandatory
or preferred arrest policies if a victim calls the police (Goodmark, 2012).
In recent years, many in the field have questioned the heavy reliance
on arrest and prosecution in these cases (Goodmark, 2012), arguing that
these actions often fail to promote the well-being of the parent experiencing
violence or that of the children, although some people with extensive expe-
rience strongly advocate for separating all perpetrators of violence from the
family and against working jointly with the parents (Bancroft et al., 2011).
Clearly, it often is inappropriate to treat couples together, at least initially,
since doing so may pose a threat to a parent or child (Babcock et al., 2004).
There is some evidence from experimental and quasi-experimental research,
however, that working with couples can be beneficial to the parents and
children (Babcock et al., 2004). It may be that interventions at the couple
level best follow after some initial individual work and assessment of the
potential danger to the victim of working with the couple.
In some states, a report of intimate partner violence can lead to in-
volvement by child welfare services. There is high overlap between intimate
partner violence and physical abuse of children, which often justifies that
involvement. In many jurisdictions, the fact that a child has witnessed inti-
mate partner violence is a basis for investigation by child welfare services.
The appropriateness and impact of these interventions are discussed in the
section below on child welfare services.
Court-affiliated parenting education for divorcing parents As noted, fam-

ily conflict, including intimate partner violence, may come to light through
divorce and child custody proceedings. In most jurisdictions, public policy
or case law favors continued involvement of both divorcing parents in
custody of the child through various living or visitation arrangements. Yet
substantial clinical evidence shows that high conflict following divorce has
extremely negative impacts on children (Amato and Keith, 1991).
A small number of states have mandated that all divorcing parents
participate in court-affiliated parenting education programs, with the goals
of preventing future parental conflict and minimizing negative effects of the
divorce on children (Sandler etal., 2015). A number of small studies have

evaluated such programs using a no-treatment control group design. Over-

all, these studies have found a moderate positive effect in reducing conflict
and improving parenting after divorce (Pruett and Barker, 2010; Sandler
et al., 2015). However, most of these programs were conducted under
controlled, experimental conditions. Several studies suggest that parenting
programs are less effective when implemented as community-based services
delivered at scale. . . . (Sandler et al., 2015, p. 169).
These studies, moreover, have not examined mandatory counseling
in situations involving intimate partner violence. Some experts oppose re-
quired counseling, especially joint counseling, in these cases. Joint counsel-
ing, and especially any form of joint custody, can entail continued efforts at
coercive control by the violent parent, with traumatic effects on the other
parent and the children. Some evidence shows that courts may ignore these
potential harms and may even penalize the parent who has suffered the
violence if she or he resists contact with the other parent (Meier, 2015). No
studies on the impact of court decisions or procedures in custody disputes
involving intimate partner violence have been conducted.
Parents seeking help in dealing with childrens problem behaviors associ-

ated with intimate partner violenceAs discussed earlier in this chapter,
many programs, such as PCIT, Incredible Years, and Triple P, are available
for parents seeking help when their child is exhibiting problem behaviors.
Childrens problem behaviors often are associated with living in a family
experiencing intimate partner violence (Bancroft et al., 2011; Chamberlain,
2014; Tajima et al., 2011). Child-parent psychotherapy has been used with
preschoolers exposed to domestic violence and showing symptoms of PTSD
and behavioral problems. In randomized controlled studies, child-parent
psychotherapy has led to significant declines in these problems compared
with a control group, as well as improvements in maternal behaviors (Ippen
et al., 2011; Lieberman et al., 2005, 2006). PCIT, which works with families
in which intimate partner violence no longer exists, has been found in a non-
randomized controlled study to be effective in helping children and reducing
parental conflict as long as the violence has ceased (Timmer etal., 2010).
Couples seeking relationship counseling Many couples experiencing high

levels of conflict seek family therapy. This conflict may include intimate
partner violence that has not been reported to the police or led to separa-
tion (Jose and OLeary, 2009). Many family therapists now regularly screen
for intimate partner violence and try to assess whether joint therapy is safe,
although practices in this regard are highly uneven (Stith et al., 2012).
Several specific approaches for addressing violence in couples therapy
have been evaluated with respect to whether the treatment reduces inti-
mate partner violence. None of these studies has examined the impact of

the treatment on parenting behaviors or on the well-being of children in

the family. Behavioral couples treatment is a dyadic intervention used to
treat adults with substance abuse disorders. Studies of this intervention,
including several large, federally funded randomized controlled clinical
trials, have found significant reductions in both alcohol use and violent
behaviors among both males and females (Fals-Stewart et al., 2005, 2009).
Domestic violence-focused couples treatment is aimed at eliminating all
forms of violence (psychological, physical, sexual, and stalking); promoting
self-responsibility; and, if the couple chooses to remain together, enhancing
their relationship (Stith and McCollum, 2009; Stith et al., 2012). Finally,
the Couples Abuse Prevention Program is a cognitive-behavioral treat-
ment intended to address the risk factors for intimate partner violence in
couples with a history of minor to moderate physical and/or psychological
aggression when there is no threat of imminent harm (LaTaillade et al.,
2006). The small number of studies that have assessed these approaches
have found that they decreased future violence and risk factors for violence
(LaTaillade et al., 2006; Moore, 2012). None of these studies looked at the
process for such change, for whom the interventions are successful, or how
they work with different cultural groups. Based on the preliminary results
from these small-scale studies, the federal government funded two random-
ized trials of systemic interventions to prevent intimate partner violence:
Couples Together Against Violence (CTAV) and Couple Care for Parents
(CCP). One study showed improvements in relationship satisfaction for
both men and women in CCP relative to participants in a mother-focused
program, but found little effect on parenting outcomes (Petch et al., 2012).
Although therapy for couples experiencing intimate partner violence is
relatively new, there is a long history of therapy for couples experiencing
high levels of conflict without intimate partner violence (Gottman et al.,
2010). While little of this therapy has undergone evaluation, experimental
studies have found that therapies based on cognitive-behavioral principles
can reduce verbal aggression and coercion and help couples develop more
positive ways of interacting with each other (Shadish and Baldwin, 2005).
Parent Voices
[Some parents recognize that co-parenting is difficult in practice.]

I want to talk to a therapist and I want [us] to sit down so we can both
open up . . . were not together but I think we still need to co-parent a little
bit to see what is really going on.
Mother from Washington, DC

Home visiting Few home visiting programs have focused on reducing inti-
mate partner violence as an outcome, although studies have found that up
to 48 percent of the women receiving such services have reported incidents
of domestic violence since the birth of the study child (Eckenrode et al.,
2000). One randomized follow-up study found that the positive effects of
home visitation were reduced when a mother was experiencing intimate
partner violence, and for those experiencing high rates of intimate partner
violence, the beneficial effects of home visiting in terms of preventing child
abuse disappeared completely (Eckenrode et al., 2000).
A number of clinicians and advocates have proposed that all home
visiting programs be redesigned to address intimate partner violence and
that home visitors be trained accordingly (Futures Without Violence, 2010).
Home visitors well trained in the dynamics of intimate partner violence might
be able to identify situations involving intimate partner violence, link
mothers to appropriate community resources, and help the mother improve
her safety and the safety and stability of her children. In recent years, a small
number of home visiting programs have been developing, implementing,
and testing interventions designed specifically to address intimate partner
violence as part of the home visitors activities (Chamberlain, 2014; Futures
Without Violence, 2010; Sharps et al., 2013). Few of these interventions
have as yet been evaluated. Results from an evaluation of the Enhanced
Yakima County Nurse-Family Partnership at Childrens Village in Yakima,
Washington, indicate decreased family conflict/family management prob-
lems, improved parent-child interaction, and reduced child maltreatment
(Yakima Valley Farm Workers Clinic, 2013).
Many home visitors, however, are not well trained in recognizing inti-
mate partner violence. They may have a suspicion that it is occurring based
on the childs or caregivers behavior. But confirming this suspicion presents
significant challenges. The visitor may encounter hostility from one or both
caregivers if the issue is raised. Furthermore, many professionals who work
with young children have not been trained to communicate effectively with
women victimized by domestic violence and thus may be uncomfortable
having such conversations. There is concern that without training, a home
visitor may make an inappropriate report of child abuse or neglect that
results in the needless separation of a nonoffending mother and her child.
Parents with Developmental Disabilities

Although exact numbers are not available, many of the estimated
15 percent of children and adolescents with developmental disabilities
(Boyle et al., 2011) go on to become parents. Whether and the extent to
which such disabilities may impair parenting has been a subject of debate
over many years (Reinders, 2008).

Several studies have examined the predictors of success or difficulty

in parenting for individuals with intellectual disabilities. To differentiate
high-risk and low-risk parents with such disabilities, McGaw and
colleagues (2010) conducted a secondary analysis of data on a sample
of mothers and children from the United Kingdom. They found that risk
was not predicted by intellectual ability; rather, the major predictors were
mothers reports of their own trauma in childhood, the presence and char-
acteristics of their partner, other special needs the parent might have, and
special needs of the children.
For many parents, individualized programs based on assessment of
needs, level of stress in everyday life, and parenting skills appear benefi-
cial (Aunos et al., 2008). Systematic reviews of experimental and quasi-
experimental efficacy studies (Feldman, 1994; Wade et al., 2008) indicate
that home-based, didactic programs can result in improved childrearing
skills for parents with developmental disabilities, although the effects
on family functioning and other family measures remain unexamined. A
Cochrane review by Coren and colleagues (2011) found three randomized
controlled studies of such programs that met their criteria for inclusion.
First, in a Canadian sample of mothers with intellectual disabilities and
their children, Feldman and colleagues (1992) implemented a home-based
individualized intervention to teach the mothers infant and child care skills,
and found significantly more competent parenting in child care routines
during the day at postintervention and follow-up. Working with mothers
with such disabilities in the United States, Keltner and colleagues (1995)
developed and implemented the Support to Access to Rural Services inter-
vention, which focused on building sensitivity to childrens cues; increases
in maternal-child interaction, including providing children with verbal
feedback, were seen at 12 months postintervention. A third program for
parents with intellectual disabilities, conducted in Australia, delivered a
home-based intervention focusing on child health and home safety, finding
significantly more positive health outcomes for children in the experimental
group (Llewellyn et al., 2003). Finally, although falling below the scientific
threshold for inclusion in a Cochrane review because it employed only a
single-group, pretest-posttest design, an adaptation of Triple P was pro-
vided to a group of Belgian parents with intellectual disabilities. All parents
completed the program and reported significant reductions in psychological
stress, maladaptive parenting, and child conduct problems (Glazemakers
and Deboutte, 2013).

Adolescent Parents
While adolescent childbearing (births to a mother between the ages of
15-19) in the United States has fallen to an historic low in recent years,6
6 percent of live births were to females under age 20 in 2014 (Hamilton
et al., 2015). Most adolescents who give birth are 18 or older; in 2014,
about 73 percent of adolescent females who gave birth were ages 18-19,
while 23 percent were 16-17 and 4 percent were 15 or under (Hamilton et
al., 2015). It is estimated that 77 percent of births to 15- to 19-year-olds
during 2006-2010 were unintended (Mosher et al., 2012).
Pregnant adolescents and adolescent parents may need special attention
and support with respect to parenting for a number of reasons. Relative
to older females, pregnant adolescents are less likely to receive adequate
prenatal care and are more likely to smoke and have inadequate nutrition
during pregnancy, posing risks to the development of the fetus. Adolescent
parenthood also is associated with worse mental health outcomes among
mothers, which may affect the parent-child relationship (Anderson and
McGuinness, 2008; Boden et al., 2008; Hodgkinson et al., 2010, 2014;
Siegel and Brandon, 2014). In particular, having a child during adolescence
is associated with poorer mental health in mothers, including depression,
suicidal ideation, anxiety disorders, and PTSD, both prenatally and post-
partum (Anderson and McGuinness, 2008; Boden et al., 2008; Hodgkinson
et al., 2010, 2014; Siegel and Brandon, 2014). While adolescent parenthood
does not necessarily end the mothers education or pursuit of career or other
goals (Assini-Meytin and Green, 2015; Gruber, 2012), adolescent mothers
compared with their nonparent peers are much more likely to drop out
of high school, although many go on to complete their general education
diploma (GED) (Jutte et al., 2010; Perper et al., 2010). Adolescent moth-
ers and fathers also are more likely than those who have children at a later
age to face poverty and unemployment and to depend on welfare (Asheer
et al., 2014).
Many adolescent mothers (12-49%, according to one study [Meade
and Ickovics, 2005]) become pregnant for a second time within 1 year of
a first delivery. In 2014, 17 percent of births to 15- to 19-year-olds were
to females who already had one or more children (Hamilton et al., 2015).
These rapid repeat pregnancies have been linked to even poorer health, edu-
cation, and economic outcomes for adolescent mothers and their children
(Chen et al., 2007; Hoffman and Maynard, 2008; Manlove et al., 2000;
Stevens-Simon et al., 2001). Accordingly, avoiding repeat births among
adolescents is a goal of federal initiatives such as the Office of Adolescent
6The birth rate for teenagers fell 9 percent between 2013 and 2014 among females
ages 15-19. The rate has declined 42 percent since 2007 (the most recent peak) and 61 per-
cent since 1991 (Martin et al., 2015).

Healths Pregnancy Assistance Fund grants to states and tribes (Office of

Adolescent Health, 2015).
The children of adolescent parents relative to those of older parents are
more likely to be born preterm and at a low birth weight and have a greater
risk of developmental challenges (Chen et al., 2007; Pinzon et al., 2012). In
longitudinal research, children born to adolescent mothers on average fare
worse in cognitive, academic, and behavioral domains during childhood
and adolescence relative to those born to older parents. They also have
worse employment outcomes and are at higher risk for mental illness and
substance abuse in adulthood (Dahinten et al., 2007; Morinis et al., 2013;
Pogarsky et al., 2006). The children of adolescent parents themselves are
more likely than their peers with older parents to become parents during
adolescence (Meade et al., 2008; Pogarsky et al., 2006; Wu et al., 2012).
For many underserved adolescents, pregnancy and parenthood repre-
sent an opportunity to enter a comprehensive system of supportive care
that can address multiple needs for themselves and their children. Some re-
searchers argue that the experience of parenthood orients many adolescent
parents toward self-improvement and enhances their sense of responsibility,
making this an important time for intervention (Gruber, 2012; Hotz et al.,
2005; Shanok and Miller, 2007).
The core parenting knowledge, attitudes, and practices for adoles-
cent parents are not different from those for other parents. As described
above, however, adolescent parents are at increased risk for adversities
that affect their parenting capacity. Strategies discussed below that are
used in evidence-based and evidence-informed interventions have targeted
some of these risks, focusing on preventing rapid repeat births, promoting
economic self-sufficiency, and improving birth and developmental out-
comes for children of adolescents. Multigenerational approaches also are
discussed, as many adolescent parents reside with their own parents or
other individuals who may play a role in the parenting and development
of young children.
The Nurse-Family Partnership

The Nurse-Family Partnership (NFP), discussed in the previous chapter,
is an evidence-based program involving prenatal and postpartum home
visitation by nurses for low-income first-time mothers, many of whom are
adolescent. Home visits begin as early as the mothers first trimester and
continue until the childs second birthday. Among NFPs many objectives
are to promote the economic self-sufficiency of young mothers by support-
ing educational attainment and employment and delaying subsequent preg-
nancy. NFP also aims to improve child health and development (Middlemiss
and McGuigan, 2005).

A number of experimental studies have found participation in NFP to

be associated with a decrease in rapid-succession second pregnancies (Bouris
et al., 2012; Conroy et al., 2013; Kitzman et al., 2000; Olds et al., 2004,
2007). In one relatively large randomized trial involving primarily adoles-
cent mothers, those who received NFP home visits had fewer births and
longer intervals between births of first and second children at 7-year follow-
up compared with mothers who did not receive visits (Olds et al., 2007).
In general, NFP has been found to have little to no effect on indicators of
continued education, such as graduation from high school and highest level
of education completed for parents. However, some studies have found
positive short- and long-term effects on indicators of family economic self-
sufficiency, such as reduced use of Temporary Assistance for Needy Families
(TANF) and the Supplemental Nutrition Assistance Program (SNAP, for-
merly the Food Stamp program) (Administration for Children and Families,
2015). Studies of NFP that have evaluated birth outcomes generally have
found no effects on gestational age or birth weight, but have found longer-
term positive effects for children in the areas of school readiness, substance
use, and adolescent parenthood years postintervention (Administration for
Children and Families, 2005). In addition, several experimental evaluations
of NFP have found positive effects on parenting related to the knowledge,
attitudes, and practices identified in Chapter 2, including using appropriate
discipline and creating a safe home environment.
The Adolescent Parenting Program

The Adolescent Parenting Program (APP), rated by CEBC as having a
promising level (3) of research evidence, provides support to first-time
pregnant and parenting adolescents who are enrolled in school or a GED-
completion program and their children ages 0-5 (California Evidence-Based
Clearinghouse, 2016a). Through intensive monthly home visiting (using
either the Partners for a Healthy Baby or Parents as Teachers home visiting
curriculum), goal-setting and case management services, and peer group
education, APP aims to delay subsequent pregnancies and increase gradu-
ation and GED completion rates, as well as enrollment in postsecondary
education or vocational training, employment, and safe and stable housing.
APP also focuses on improving the developmental outcomes of the young
children of adolescent parents through prenatal and postnatal support
(California Evidence-Based Clearinghouse, 2014).
In a 2006 quasi-experimental study of 2,520 adolescent pregnant and
parenting females, participation in APP was associated with significantly
longer intervals between first and second births and increased likelihood
of normal birth weight and full-term birth. The groups had similar rates of
use of prenatal care (Sangalang et al., 2006). The authors point to case

management and provision of direct services as central to helping ado-

lescent mothers postpone subsequent births and achieve favorable birth
outcomes (Sangalang et al., 2006). In a more recent study, APP graduates
were found to have greater enrollment in higher education, job stability,
and focus on career goals relative to other adolescent parents, but the
study was not experimental and involved a very small number of partici-
pants (Gruber, 2012). In another nonexperimental study, a pre- and post
intervention comparison showed improvement in use of contraception and
parenting knowledge postintervention among 91 adolescents participating
in APP (Sangalang and Rounds, 2005). Although research on APP to date
has yielded promising initial findings, further experimental research with
larger study populations is needed to confirm those findings.
Other evidence-based home visiting programs that likely reach a large
number of adolescent parents (e.g., Family Check-Up, Home Instruction
for Parents of Preschool Youngsters [HIPPY], Durham Connects) also have
shown positive child health and developmental outcomes, but fewer posi-
tive effects have been observed for parents economic self-sufficiency (see
Table 4-1 in Chapter 4).
Computer-Assisted Motivational Interviewing

Computer-assisted motivational interviewing (CAMI) is another inter-
vention used with adolescent mothers to reduce rapid repeat births by
promoting consistent use of condoms and other forms of contraception. It
has been rated by CEBC as having a promising level of evidence (California
Evidence-Based Clearinghouse, 2016d). CAMI entails at least two 60-minute
sessions conducted in two parts by trained counselors, who meet one on one
with pregnant and parenting adolescent mothers in the home or in a com-
munity agency or outpatient clinic. In one study, adolescents randomized
to CAMI plus intensive home visiting or CAMI only who participated in
sessions at quarterly intervals until 2 years postpartum had nonsignificantly
lower birth rates compared with participants receiving usual care. Significant
effects were seen for those adolescent mothers in the CAMI-only group who
received two or more sessions of CAMI (Barnet et al., 2009). In a follow-
up study with the same participants, adolescent mothers in the CAMI plus
home visiting and CAMI-only groups had significantly reduced repeat births
compared with those in the usual-care group (Barnet et al., 2010).
In an older, nonequivalent control group study of a multicomponent
community-based intervention (the Family Growth Center [FGC]) designed
to provide adolescent mothers in high-risk neighborhoods with a range
of educational and support services for the prevention of rapid repeat
pregnancy and school dropout, mothers participating in FGC followed
over 3 years had a significantly lower rate of repeat pregnancy and signifi-

cantly higher rate of school completion compared with nonparticipating

adolescent mothers. However, the study sample was very small (Solomon
and Liefeld, 1998). FGC has received a rating of promising from CEBC
(California Evidence-Based Clearinghouse, 2016f).
School-Based Interventions
Provision of parenting-related interventions and child care in the school
setting may serve as a means of providing multidisciplinary services to ado-
lescents while keeping them engaged in school, but additional research on
the benefits of this approach is needed (Crean et al., 2001; Pinzon et al.,
2012; Sadler et al., 2003, 2007). In one study, adolescent mothers and their
children receiving on-site child care while participating in a school-based
program that included parenting classes and referral services were found
to have better school attendance than nonparticipants, with 70 percent
and 28 percent, respectively, graduating from high school (Crean et al.,
2001). Some states have implemented their own programs for pregnant
and parenting adolescents in schools as well as home settings, with posi-
tive impacts on education (e.g., completion of high school) and economic
self-sufficiency (National Association of County and City Health Officials,
2009). However, findings from evaluations of these programs often are not
published in the peer-reviewed literature.
Multigenerational Households
As noted above, many adolescent parents live with their own parents
or rely on family members for support in raising young children. Multi-
generational households are becoming more common in the United States,
especially among racial and ethnic minorities, but a dearth of research has
examined the nature and quality of parenting in these homes. Preliminary
research on multigenerational households indicates that parenting and child
development are influenced by interactions between parents and grand
parents in the household (Barnett et al., 2012). A few well-supported par-
enting programs, such as NFP, take family-level functioning into account,
but the committee was unable to identify any comparisons of the use and
nonuse of multigenerational approaches. The FGC model described above
did include an explicit focus on involving the mothers of adolescent parents
in the intervention (Solomon and Liefeld, 1998).
Summary
In summary, with the exception of NFP, many of the studies reviewed
are limited by small sample sizes and lack of follow-up. Taken together,

the studies reviewed provide good evidence that intensive home visiting
with adolescent mothers, as provided in NFP, APP, and CAMI plus home
visiting, is effective for reducing rapid repeat pregnancy and improving
birth and developmental outcomes in children of adolescent parents. While
other strategies (e.g., motivational interviewing provided in one version of
CAMI and services designed to address families multiple needs as provided
in the FGC model) also show promise with respect to these outcomes,
those preliminary findings need to be replicated. With respect to parent
self-sufficiency, intensive home visiting in NFP is associated in several
studies with improvements in indicators of economic well-being but not
continued education, although CAMI and school-based interventions and
child care have shown positive effects on continuation of schooling among
adolescent mothers. As with research on parenting in general, fathers are
underrepresented in evaluations of interventions to support adolescent
parents. Finally, because many adolescent parents live with their own par-
ents and rely on other family members to assist with childrearing, the lack
of research on the effectiveness of multigenerational approaches is a gap
in research on interventions for adolescent parents.
FAMILIES INVOLVED WITH CHILD WELFARE SERVICES

Child welfare services play a unique role in parenting policy and pro-
gramming. They represent the only universal set of services addressing par-
enting in every state. These services are, however, a residual system. Child
welfare services become involved with families when the quality of parent-
ing falls below what society considers a minimally adequate threshold. The
purpose of the services is to investigate allegations of child maltreatment
and intervene when it is established that the quality of parenting is deficient
and that as a result, the safety and/or basic physical or mental health of a
child has been put at substantial risk. In a large percentage of substantiated
cases of maltreatment, the threat to the childs safety requires monitoring
of the parents care; in almost a quarter of substantiated cases, the child
is removed altogether from parental care, and parents must participate in
parenting interventions if they want to regain custody.
The focus of child welfare services is protecting childrens safety, al-
though once involvement with a family is initiated, the focus extends to
enhancing childrens well-being. Parents involved with child welfare services
are most often formally designated by child neglect: failure to supervise
or child neglect: failure to provide, which indicates they have not ad-
dressed basic safety concerns, largely as the result of omission of effec-
tive parenting. Together, these designations represent more than one-half
of child maltreatment reports (Administration for Children and Families,
2005; Casanueva et al., 2012). In about a quarter of all cases, the parent

has engaged in behaviors that constitute physical abuse; a smaller and de-
clining percentage involve sexual involvement with the child by the parent
or a family member.
Even though child welfare services are recognized as a last-resort or
residual response for children whose parents are not meeting their responsi-
bility to provide a safe home environment, some contact with these services
is now broadly experienced. In 2014, an investigation or other intervention
by child welfare services was conducted for more than 3 million children (a
rate of 42.9 per 1,000 children) (Administration for Children and Families,
2016). Approximately 702,000 of these children (a rate of 9.4 per 1,000
children) were determined to have a substantiated or indicated finding of
abuse and/or neglect (Administration for Children and Families, 2016). A
study in California found that 5.2 percent of all children younger than age
1 are reported for child maltreatment each year (Putnam-Hornstein et al.,
2015), and 2.1 percent of children experience confirmed maltreatment by
age 1 (Wildeman et al., 2014). Although national data are lacking on the
reasons for these reports, they appear to be strongly associated with mater-
nal substance abuse (Wulczyn et al., 2002).
These findings reflect yearly contacts. Taking a longitudinal perspective,
one study concluded that one in eight children experience a substantiated
instance of maltreatment by age 18, and nearly 6 percent do so by age 5
(Wildeman et al., 2014). For African American children, the latter figure
is 1 in 5, and for Native American children, it is 1 in 7 (Wildeman et al.,
2014).Within some subpopulationsfor example, the children of young
adult parents who were clients of child welfare services as children
interaction with child welfare services is experienced by more than one-half
of children (Putnam-Hornstein et al., 2015).
The Impact of Inadequate Parenting on Children

In addition to threats to their safety, the children involved with
child welfare services have high rates of behavioral and developmental
problemsabout twice the rates found among children in the general
population (Burns et al., 2004; Casanueva et al., 2012). The largest study
of children receiving child welfare servicesthe National Survey of Child
and Adolescent Well-Being (NSCAW)found that at the time of entry into
child welfare, about one-third (37%) of children had a mental or medical
condition with a high probability of resulting in developmental delays and/
or of being 2 or more standard deviations below the mean in at least one
developmental area or 1.5 standard deviations below the mean in two areas
(Casanueva et al., 2014). Among children ages 0-2, 3-5, and 7-10, only
83 percent, 84 percent, and 78 percent, respectively, were in very good or
excellent health. Among children ages 3-5, fully 15.7 percent were reported

by their parents as having behavioral problems in the clinical range on

the Child Behavior Checklist (CBCL) (Achenbach, 1991a; Achenbach and
Rescorla, 2001). Among children ages 6-17, a significantly higher propor-
tion (about 26%) had a score in the clinical range for behavioral health
problems (as measured by the CBCL), about three times what would be
expected in the general population (Achenbach, 1991b).
The Impact of Child Welfare Services

A full evaluation of the functioning of child welfare services is beyond
the scope of this report, but a number of issues related to these services
have been identified in prior IOM and NRC reports (Institute of Medicine
and National Research Council, 2014; National Research Council, 1993).
As noted in those and many other reports, agencies providing child welfare
services throughout the country face many challenges both in protecting
the long-term development of children and in providing adequate services
to parents.
Given the scope and impact on children of parental behaviors consti-
tuting maltreatment, it is essential that these parents receive high-quality
parenting interventions. An effective response by child welfare services is es-
pecially needed for parents of young children. It appears clear, however, that
too many families are not receiving effective services. A large proportion of
childrenperhaps exceeding 80 percentremain in the home following the
initial report to child welfare services (Institute of Medicine and National
Research Council, 2014). A recent California using a longitudinal dataset
of birth and child protective service records found that nearly 70 percent of
infants who received ongoing in-home family child welfare services were
re-reported during the first 5 years (Putnam-Hornstein et al., 2015). Infants
whose reports were screened out were as likely to be re-reported as those
who received services. This finding is consistent with d ecades of research
showing that the future risks for unsubstantiated cases remain high (e.g.,
The Center for Community Partnerships in Child Welfare, 2006; Drake and
Jonson-Reid, 1999a, 1999b).
Caregiver instability is a significant factor in the lives of children who
have been maltreated and reported to child welfare services. Even though
most infants who come to the attention of child welfare services do not
go immediately into foster care, Casanueva and colleagues (2012) in an
analysis of longitudinal data from the NSCAW found that nearly all such
infants (about 86%) had one or more changes in caregivers by the end of
2 years, and approximately 40 percent had four or more placement changes
between infancy and entering school.
Children of any age with child welfare services involvement have a high
risk of continuing to experience developmental, cognitive, and behavioral

health problems regardless of whether they are placed in foster care or pro-
vided with ongoing services (Dolan et al., 2012). In another NSCAW analy-
sis that followed 5,872 children under the supervision of child welfare for a
5-year period, by 3-year follow-up, the proportion of children in any type
of placement setting who had developmental problems remained largely
unchanged from the high levels described above (Casanueva et al., 2014).
The impact of living in poverty is a critical factor. After controlling for
maltreatment type and severity, demographic traits, and a few caregiver
characteristics, the NSCAW revealed that infants who had remained in
foster care for the first 5 years of life were developing more slowly than
children who had been returned home or adopted (Lloyd and Barth, 2011).
Living in poverty in the final setting in which they were studied predicted
decreased cognitive development as well as academic problems and tended
to explain behavioral health. The well-being of children was powerfully
influenced by ongoing exposure to poverty, regardless of the poverty level
in which they lived at the time of original placement or the placement type
at the end of placement.
Intervention Strategies
According to the NSCAW, in about two-thirds of cases that enter child
welfare services, a recommendation for parent training is made, and nearly
three-fourths of cases also involve a referral for mental health counseling or
substance abuse treatment for the caregiver (Dolan et al., 2011). The form
of parent training is rarely specified, and no assessment is made of whether
parenting improved as a result of the training; at most, the courts learn
only whether parents have attended parenting classes (Barth et al., 2005).
While parent training has always been common for families receiv-
ing child welfare services, those services have lagged behind other mental
and physical health services both in the assessment of interventions and
in the adoption of evidence-based practices. In the past, lack of access
to research-based information about the effectiveness of parent training
programs and limited comfort with selecting and implementing evidence-
based interventions resulted in sluggish adoption of these practices among
child welfare services (Horwitz et al., 2009). It was not until 2004 and
thereafter, when resources such as the Journal of Evidence-Based Social
Work and CEBC became available that information on effective practices
became more widely available. As recently as 2006, a Cochrane review of
parenting programs for the treatment of physical child abuse and neglect
(Barlow et al., 2006) found insufficient evidence to support the use of the
reviewed programs, although limited evidence showed that some programs
could be effective in addressing outcomes associated with physically abu-
sive parenting practices.

Recent years have seen much greater focus on the use of evidence-based
practices among child welfare agencies, perhaps reflecting increased federal
policy direction and support for the use of these practices. In some cases,
agencies are adopting evidence-based programs used in helping parents
not involved with the child welfare system, such as Incredible Years, some-
times adapting the program to better meet the characteristics of families
that are involved with the system. Interventions also have been developed
specifically for parents involved with child welfare services. Given that the
implementation of evidence-based practices is relatively new in child wel-
fare services, the literature on evidence-based strategies to support these
families is emergent.
Skills Training and Family-Centered Treatment for Families with a

History of Child Maltreatment or with Child Maltreatment Risk Factors
Three parent skills training programs reviewed earlier (PCIT, Incred-
ible Years, and Triple P), often delivered in a group setting, have been
found in randomized controlled studies to be suitable for implementation
in the child welfare context (Linares et al., 2006, 2012, 2015) and effective
for reducing child abuse recidivism and coercive and punitive discipline
practices (Chaffin et al., 2004, 2011), as well as reducing parental stress
associated with childrearing and increasing parental confidence. A high cost
for the I ncredible Years materials and a small number of approved trainers
have slowed the adoption of Incredible Years by child welfare servicesa
problem that applies as well to other evidence-based practices (Powers et
al., 2010).
A number of programs have been designed specifically for families
involved with child welfare services. ABC (Attachment and Bio-Behavioral
Catch-up) is an evidence-based home visiting intervention (CEBC evidence
rating of 1) that utilizes videotape feedback to teach parenting skills over
a 10-week period (California Evidence-Based Clearinghouse, 2016c). The
program helps caregivers reinterpret childrens behavioral signals to offer
more nurturance, provide a responsive and predictable environment to
help children with self-regulation, follow their childs lead, and decrease
the use of behaviors that overwhelm and frighten the child. Randomized
controlled research has shown that children in families who participate in
the intervention are less disorganized in their attachment with their par-
ents and display less sadness and anger compared with controls (Bernard
et al., 2012). The attitudes and behaviors that change as a result of re-
ceiving ABC are, arguably, fundamental to helping parents and children
reduce stress-inducing interactions and enhance parent-child closeness.
There is, however, no direct evidence that child maltreatment is lowered
by such approaches.

Another program, discussed in Chapter 4, SafeCare (Lutzker and

Chaffin, 2012) (CEBC rating of 2), was designed for parents whose chil-
dren had been reported for neglect and who needed explicit, easily imple-
mented strategies for improving home safety and increasing the use of
needed medical or behavioral interventions (California Evidence-Based
Clearinghouse, 2016l). During weekly or biweekly sessions, home visitors
conduct baseline and follow-up assessments, observations, and trainings
with parents and provide parents with feedback. The trainings focus on
practices related to reducing the incidence of child maltreatment, enhanc-
ing home safety and supervision, and improving the parent-child relation-
ship. SafeCare home visitors are required only to have a bachelors degree,
and the program uses competency-based training approaches that make its
replication highly dependable and scalable. SafeCare has been the focus
of considerable implementation researchincluding studies focused on
variation in supervision, American Indian populations, and culturally
enhanced training methods for working with Latino professionals and
parents (Beasley et al., 2014). In randomized and single group pre-post de-
sign studies, caregivers who participate in SafeCare have been found to be
less likely to abuse their children. Participation also is associated with im-
provements in home safety (Chaffin et al., 2012; Gershater-Molko et al.,
2002, 2003). In a small pilot study of SafeCare that incorporated use of
flash cards to improve parents knowledge of developmental milestones
one of the core knowledge areas identified in Chapter 2the intervention
was found to be effective in improving parental knowledge in this area;
however, the findings of this study are preliminary, and additional research
is needed (Guastaferro, 2011).
Multisystemic Therapy for Child Abuse and Neglect (MST-CAN)
(CEBC rating of 2) and Trauma Adapted Family Connections (TA-FC)
are programs used with caregivers and/or children who have experienced
trauma. Both programs work with the entire family to address concerns in
the home so as to keep children safe (California Evidence-Based Clearing-
house, 2016i).
MST-CAN is an adaptation of MST for child welfare-involved families
that is supported by research evidence for children ages 6-17 (Swenson and
Schaeffer, 2011; Swenson et al., 2010) and founded on basic principles of
care coordination. Treatment entails safety planning, cognitive-behavioral
therapy for managing anger and addressing the impact of trauma, coun-
seling for adult substance misuse, family therapy, and getting parents to
take responsibility for events that brought the family to child protection.
Research indicates that MST-CAN is significantly more effective than en-
hanced outpatient treatment in reducing parents psychiatric distress and
behaviors associated with maltreatment, increasing parents social support,
improving childrens mental health symptoms, and reducing childrens out-

of-home placements and changes in childrens placement. Yet no statistically

significant difference was found for incidents of reabuse among participants
and families receiving outpatient treatment in a randomized effectiveness
trial (Swenson et al., 2010). One evaluation showed that MST was effective
in addressing the dual needs of families involved with child welfare services
and substance abuse (Swenson et al., 2009).
TA-FC builds on the service components of the Family Connections
model, a promising program (CEBC rating of 3) designed to reduce risk
factors for child maltreatment through family assessment and individual
and family counseling, emergency assistance, and service planning and
referral (California Evidence-Based Clearinghouse, 2016e). TA-FC inte-
grates a focus on trauma into family assessment and counseling, such as
by assisting families with identification of trauma symptoms and teaching
trauma-informed parenting practices (Collins et al., 2011, 2015). TA-FC
has not identified specific parenting knowledge, attitudes, and practices that
may be the active ingredient in reducing the likelihood of maltreatment,
but pilot noncontrolled evaluation of the program demonstrates reduc-
tions in child problem behaviors (Collins et al., 2011, 2015). Even though
this is not the explicit program target, these findings suggest that reducing
parental stress, recognizing and addressing a range of parental risk factors,
and matching services (e.g., special education) to parents can benefit family
functioning (DePanfilis et al., 2008).
Supporting Foster and Kinship Families to Improve Placement Stability

Many children involved with child welfare services are placed with rela-
tives or nonrelative foster parents. Foster and kinship providers often need
training in parenting skills that addresses the unique challenges associated
with parenting children who have experienced maltreatment. Treatment
Foster Care Oregon for Preschoolers (TFCO-P) (Chamberlain and Fisher,
2003; Fisher et al., 1999) is a well-supported treatment model (CEBC
rating of 2) designed for children ages 3-6 (California Evidence-Based
Clearinghouse, 2016m). The intervention is delivered through a treatment
team approach that incorporates training and ongoing consultation with
foster parents, skills training and therapeutic playgroups for children, and
family therapy for birth parents, with the goal of promoting secure attach-
ment with foster parents and successful permanent placement with birth
parents or through adoption. Randomized controlled evaluations compar-
ing TFCO-P with conventional foster care have shown that children who
experience the consistent, contingent, responsive parenting that is taught
in TFCO-P, along with other services, have reduced rates of problem be-
haviors (as reported daily by the foster parents), and the foster parents
demonstrate less stress. As a result, children in TFCO-P have more stable

placements relative to those in conventional foster care (Fisher et al., 2005,

2006, 2009, 2011a).
Keeping Foster and Kin Parents Supported and Trained (KEEP) (CEBC
rating of 3) is a derivative of Multidimensional Treatment Foster Care cre-
ated for use with children of elementary school age who are in out-of-home
care supervised by child welfare services (California Evidence-Based Clear-
inghouse, 2016h). The program model includes weekly group work among
foster families to learn effective parenting methods and daily or weekly
calls to check on problems with parenting, which are addressed using a
flexible curriculum (Price et al., 2009). KEEP is being implemented with
diverse populations in both urban and rural areas in a number of states.
Randomized controlled research has found foster family satisfaction and
improvements in child behavior and placement outcomes (e.g., chances of
a child being reunited with his or her biological parents) (Chamberlain et
al., 2008; Price et al., 2009), although a replication study does not show ef-
fects of the same size (Greeno et al., 2016). A program modeled after KEEP
showed increased positive behavior for foster youth in Chicago (Leathers et
al., 2011), and KEEP for preschoolers is under development as a plausible
alternative to TFCO-P.
Knowledge, Attitudes, and Practices and Child Welfare Services

The knowledge, attitudes, and practices needed by parents who become
involved with child welfare services are not different from those needed by
other parents. Knowledge of child development generally is considered a
necessary precursor to reducing maltreatment. Evidence indicates that mal-
treating parents often have unrealistic expectations for what a child is able
to do and may misinterpret a young childs actions and/or lack of capacity
as intentional. Further, parents who are depressed or angry about other
matters may be more likely than those who are not to view their childrens
behavior as controllable and negatively intended (Leung and Slep, 2006).
Yet changes in parental attitudes are not well articulated as a mediator of
the effectiveness of parenting training in achieving better outcomes with
respect to child maltreatment. Even when modest changes in knowledge
are achieved, an impact on reducing future child maltreatment is not highly
likely given the array of adverse influences on parents responses to their
childrens perceived misbehavior. As demonstrated by studies referenced
above, parenting programs based heavily on providing information are
typically outperformed by those with more of a behavioral focus (e.g., ABC,
SafeCare, PCIT).
Improving the executive functioning, actions, and circumstances of
parents is necessary for avoiding neglect and abuse, as is developing alter-
natives to neglectful and abusive practices (Knerr et al., 2013; Leung and

Slep, 2006). None of the programs reviewed here focus on specific measure-
ment of attitude change as an indicator of whether progress is being made;
instead, the programs require demonstration of desired behaviors during
the course of treatment. A potential limitation of current approaches for
families with a history of or at high risk for child maltreatment is that, with
the exception of ABC, they generally do not address how parents current
parenting styles developed or what trauma they themselves experienced
as children or parents, although ABC does systematically explore the way
experience as a child affects parents views about parenting.
Emerging knowledge about the core components that make evidence-
based practices successful can support the broader distribution of what
works, earlier rather than later, to the parents who need it the most. Barth
and Liggett-Creel (2014) explored the common elements of programs for
parents of children ages 0-8 involved with the child welfare system by
building on prior work in this area (Chorpita et al., 2005; Geeraert etal.,
2004; Kaminski et al., 2008). In a review of well-supported interventions in
CEBC, common elements were identifiable in training programs for parents
of children ages 4-8, but far less so in programs for parents of children
ages 0-3 (Barth and Liggett-Creel, 2014). CEBC includes four programs
(Incredible Years, PCIT, PMT-Oregon [PMT-O], and 1-2-3 Magic) with a
very similar history and operational components for the older age group.
Common treatment elements include being offered in a clinic setting (two of
the four are also offered in the home to allow for practicing newly acquired
skills) and the use of a group format. All four models have social learning
theory as their foundation. PCIT also uses attachment theory to guide its
work. The use of social learning theory across the four models and the core
set of parenting skills taught (i.e., attending, positive reinforcement, and
use of time-out) means that certain common practice elements are likely
to contribute to the success of interventions for child abuse and neglect.
SUMMARY
The following key points emerged from the committees review of
evidence-based and evidence-informed interventions for parents of children
with special needs, parents facing special adversities, and parents involved
with child welfare services.
Parents of Children with Special Needs

The efficacy research on programs designed to promote different
dimensions of parenting for young children with special needs
suggests that efficacious programs and resources are available to
support parenting knowledge, attitudes, and practices for these

parents. The strongest evidence is for programs that (1) teach par-
ents how to support the learning and development of their children
with disabilities, (2) promote positive parent-child interactions, and
(3) focus on reducing the childrens problem behaviors. Some of
these programs do appear to have secondary outcomes that affect
the larger family system, such as increased parental optimism, de-
creased parental stress, and generalized changes in parenting style.
Parents of Children with Developmental Disabilities

Research indicates the effectiveness of family interventions designed
to reduce stress among parents of children with developmental dis-
abilities, especially when such interventions occur over a relatively
long period and have multiple components (e.g., a combination of
group and individual elements).
Instructional interventions that teach parents how to facilitate the
language, social, and play skills of children with developmental
disabilities are effective in achieving these outcomes, indicating that
with appropriate supports, parents can help their children develop
these skills. For parents of children with ASD, instructional inter-
ventions focused on promoting childrens social- communication
skills show positive effects on childrens cognitive development
when they are based on a conceptual framework, address a v ariety
of developmental needs, and occur over an extended period
(1-2 years). Furthermore, interventions that involve parents appear
to be more effective than other approaches for these children.
Interventions that teach parents dialogic reading skills show posi-
tive impacts on the reading skills of young children with language
delays.
Interactional practice interventions that promote positive social
interactions between parents and young children with disabilities
by teaching parents how to arrange play in a way that encourages
parent-child interaction and facilitates parental responsiveness have
been found to improve responsive parenting and increase social
interactions among these children.
Parent training in support of positive behavior, such as that pro-
vided by the widely used Triple P and Incredible Years, including in
a group format, is associated with improved parent-child interac-
tions and reduced challenging behavior in children with develop-
mental disabilities.
Gaps in research and practice relevant to interventions for parents
of children with developmental disabilities include the development
and evaluation of interventions that take place in natural environ-

ments and that support parents and children during important life
transitions, such as that from early intervention to preschool.
Parents of Children with Behavioral Challenges and

Mental Health Disorders
Active skills training with rehearsal for parents of children with
externalizing behavior problems delivered in a series of one-on-one
and/or group sessions in community-based settings (as in Triple P
and Incredible Years) can lead to improved parent-child relation-
ships, less frequent dysfunctional parenting (e.g., harsh discipline),
improved parenting competence, and reduced child behavior prob-
lems. Multiple evaluations have found that therapy-based child
management combined with play therapy (PCIT), delivered in
weekly sessions in outpatient and clinic settings to teach parents
the skills to encourage prosocial behavior in their children, im-
proves parent-child interactions, imparts parenting skills related to
gaining childrens compliance, and reduces parental stress, among
other benefits. PCIT and cognitive-behavioral therapy have been
found to be effective among parents of children with internalizing
behavior problems such as anxiety and depression.
Other interventions have focused directly on a particular type of
externalizing or internalizing condition. More examples of these
interventions exist for externalizing conditions, although efficacy
studies for children with anxiety disorders also have been docu-
mented. Few interventions have been developed to help parents ad-
dress childhood depression, perhaps because depression is a fairly
low-prevalence disorder in children. However, the role of parents
in moderating the effects of childhood depression and potential
impacts on life outcomes certainly deserves more attention and
activity in intervention research.
Parents of Children with Serious or Chronic Medical Illness

Efficacious programs (e.g., COPE) are available to support fami-
lies of children with critical illnesses that require hospitalization
and intensive medical services. In general, much research has been
conducted on support for parents within other portions of the
health care sector, but such studies often are not well powered
and lack adequate evaluation. Data on long-term outcomes and
on fathers are lacking, and both of these areas deserve increased
attention.

Parents of Very Low-Birth Weight, Premature Infants

Research on mothers of very-low-birth weight infants shows that
interventions designed to encourage and support interactions and
physical contact between mothers and infants result in improved
mother-infant relationships, better maternal mood, and reduced
anxiety.
Parents Facing Special Adversities

Common barriers to receipt of support for parents facing special
adversities are stigma, such as that which can be associated with
having a mental illness, substance abuse disorder, or other condi-
tion; concerns that because of ones mental health, substance use,
or other condition, or because of a history of maltreatment, one
will be reported to child protective services; and distrust of service
providers.
Parents with Mental Illness

Recognition of individuals with mental illness as also being parents
is frequently lacking among service providers.
There have been few high-quality large-scale evaluations of inter-
ventions designed for parents with mental illness, especially those
with serious mental illness.
For parents with depressive disorders, interventions that combine
mental health treatment and parenting support lead to better out-
comes in terms of reducing psychiatric symptoms and increasing
maternal responsiveness relative to programs focused solely on
mental illness.
Integrating parenting interventions and support into primary care
may be an effective way of diagnosing and treating parents mental
health issues. The perinatal period appears to be an opportune time
to reach a broad population of parents.
Research provides preliminary evidence that home visiting pro-
grams that include therapy for parental depression improve paren-
tal mental health and parenting. Yet many home visiting programs
do not include mental health as an objective, and further research is
needed to confirm these preliminary findings. Efforts within Early
Head Start and public health settings also show promising effects
on depression, parenting practices, and child behavior, but further
research on these efforts is needed as well.

Research on strategies for supporting parents with severe mental

illness who may need ongoing and intensive support is lacking.
Some evidence indicates significant benefits for the parenting skills
of parents with severe mental illness and the behavior of their chil-
dren from interventions involving home visits, parenting lectures,
and clinician counseling. Triple P in particular has shown promise,
and intensive outpatient or inpatient treatment (e.g., in mother-
baby mental health units) may be effective as well. Available data
on interventions and treatment for parents with severe mental
illness indicate an association with significantly reduced risk that
children will develop the same mental health problems.
Parents with or Recovering from Substance Use Disorders

Mothers who are permitted to reside with their children during
substance abuse treatment are more likely to enter, remain in, and
complete treatment and remain drug free for longer. Evaluations of
specific residential treatment programs show improved parent-child
relationships as well as child outcomes.
FTDCs that provide parents with access to substance abuse treat-
ment along with accountability, support, and rewards and sanc-
tions aimed at regaining child custody result in improved entry into
and completion of treatment. Children of parents participating in
these programs are more likely to be reunited with their parents
relative to children of nonparticipants. However, these findings
may be biased by the fact that women who enter FTDCs may be
more motivated to change their behavior than women who do not
enter these programs.
Few targeted parenting interventions have been developed for par-
ents who have or are recovering from a substance abuse disorder.
However, available evidence indicates that combining substance
abuse treatment with parenting intervention improves parenting
beyond the improvement achieved with substance abuse treatment
alone. Parents may benefit most when instruction in specific parent-
ing techniques is preceded by instruction in psychological coping
strategies.
Data from evidence-based parenting programs (Strengthening
Families and the Nurturing Parent Program) indicate that family
skills training in residential, day treatment, and FTDC settings that
emphasizes reducing parents alcohol and drug use while helping
them learn new patterns of parenting results in reduced substance
use and also is associated with improved parenting (involvement,
supervision) and less family conflict and child maltreatment. In

addition, therapy in outpatient mental health settings designed to

improve family relationships and communication and child man-
agement is associated with improvements in family relationships
and other outcomes.
Substance use can interfere with parent-child attachment. Pre-
liminary data from pilot studies show that parent coaching ses-
sions aimed at improving parents nurturing of young children
provided in combination with substance abuse treatment improve
attachment-related parenting behaviors.
Findings from office- and home-based substance abuse treatment
and case management programs for pregnant and parenting women
focused on parenting, family planning, education, and other areas
indicate that these programs are associated with reduced likelihood
that a woman will give birth to a drug-exposed infant.
Parents Affected by Intimate Partner Violence

Community programs for mothers, couples, and children experi-
encing intimate partner violence that target parenting and/or child
outcomes have been found to be effective in reducing childrens be-
havior problems, mental health problems among both mothers and
children, and maternal stress and improving parenting. Programs
focused on reducing the effects of trauma in children have been
found to be effective, but not through changes in parenting. There
is little evidence that counseling services for men prevent further
violence, and although more women are now being arrested for
intimate partner violence, data on intimate partner violence per-
petrated by women are scarce. With regard to couples involved in
intimate partner violence who seek services, some research shows
that PCIT with families reduces conflict between parents if the vio-
lence has ceased. Dyadic interventions designed to treat adults with
substance abuse disorders (behavioral couples treatment) show
reductions in alcohol use and violent behaviors among both men
and women.
Few home visiting programs have focused on intimate partner
violence, but many women who receive home visiting services re-
port incidents of domestic violence. Some home visiting programs
are developing, implementing, and testing strategies for reducing
intimate partner violence, but findings from evaluations of these
strategies are not yet available.
A small number of studies on programs for couples designed to pre-
vent intimate partner violence have found that these programs can
reduce future violence and violence risk factors, but these studies

have not assessed the process for change or how the intervention
works with different cultural groups.
Parents with Developmental Disabilities

Many parents with intellectual disabilities provide adequate care-
giving and parenting for their young children, but for a substantial
minority, programs providing support for child caregiving, health
care, and home safety may be important. A moderate level of
evidence suggests that these programs have positive effects. The
Triple P program, which has been effective with other popula-
tions of parents, is being adapted for parents with intellectual
disabilities.
Adolescent Parents
Adolescents participation in intensive home visiting is associated
with a reduction in rapid repeat pregnancies and improved birth
and developmental outcomes in children of adolescent parents.
Several studies have found that the intensive home visiting offered
in NFP is associated with improvements in indicators of economic
well-being. While other strategies (e.g., motivational interviewing
and provision of services to address families multiple needs) also
show promise in improving these outcomes, preliminary findings
need to be replicated.
Many adolescent parents face barriers to continuing their school-
ing, although many go on to complete their GED. There is some
evidence that home visiting programs and school-based interven-
tions that provide child care have positive effects on continuation
of schooling among adolescent mothers, but further research in this
area is needed.
As with research on parenting in general, fathers are under
represented in evaluations of interventions designed to support
adolescent parents. Another gap in research on adolescent parents
is the effectiveness of multigenerational approaches, given that
many adolescent parents live with their own parents and rely on
them and other family members to help with parenting.
Families Involved with Child Welfare Services

Effective parenting programs in child welfare are rooted largely in
social learning theory. They focus on encouraging the use of antici-
patory guidance and timely attention to increase parents positive

behavior and, in turn, teach them to use these tools more effectively
with their children. The underlying theory is that positive changes
in childrens behavior will reinforce parents positive attitudes and
beliefs about their children and about the possibility of successful
parenting.
In families with a history of child maltreatment or at high risk for
maltreatment, both skills training in home and community set-
tings that involves observation and corrective feedback and multi-
pronged family-system approaches that address trauma and other
co-occurring challenges (e.g., substance use) can be effective for
improving child behavior and the parent-child relationship, par-
ents psychiatric distress, and behaviors associated with child mal-
treatment. In addition, successful interventions for prevention of
child abuse and neglect appear to include detailed, active methods
for increasing the frequency of effective parenting practices, often
without much attention to how parents originally began to rely on
ineffective methods.
Training and ongoing consultation with foster and kinship families
are associated with reduced rates of problematic behaviors among
children in these family arrangements, indicators of attachment
between caregivers and children, and greater placement stability.
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Elements of Effective Parenting

Programs and Strategies for Increasing
Program Participation and Retention
Parenting programs in the United States are reaching millions of par-

ents and their children annually, but as discussed in Chapters 4 and 5, only
a limited number of evidence-based, high-quality trials of the effects of
these programs have been carried out. It is costly to conduct such evalua-
tions, and they often are difficult to implement. Very few programs have
undergone multiple evaluations using such designs. Other parenting inter-
ventions have been assessed through smaller studies, observational research,
and case-control studies. Those studies indicate that these interventions
may be effective, achieving improvements in outcomes similar to those
found for the manualized parent training programs that have been studied
experimentally (Chorpita et al., 2013).
This chapter identifies major elements of those programs that have
been found to be effective through randomized controlled trials and other
approaches. The identification of these elements is based on the committees
review of multiple studies, literature reviews (Axford et al., 2012), informa-
tion provided by a number of invited speakers at open sessions held for this
study, and committee members own expertise and experiences. It should be
noted that even those programs involving manualized interventionswith
their relatively strict ordering of treatment components, each with a pre-
scribed lengthcan be broken down into those components, which can be
used more flexibly with success (Nakamura et al., 2014). Thus, in assessing
current and developing new programs for strengthening and supporting
parenting, a state policy maker or community service provider could use
these components as benchmarks in determining the likelihood that a pro-
gram will be effective. The identified elements may be especially important
325

in programs aimed at strengthening parenting in families that face multiple

adversities. Engaging and retaining these parents in parenting programs is
a challenge. They often live in areas without sufficient evidence-based ser-
vices, and they often lack the transportation needed to access such services.
For these families, providing programs that have not been shown to be
effective through experimental or quasi-experimental research but include
elements that are common to such programs may be necessary. Given that
parent participation and retention alone, however, cannot guarantee posi-
tive parent and child outcomes, these programs must have a sound theoreti-
cal approach to helping parents acquire the positive parenting knowledge,
attitudes, and practices discussed in Chapter 2.
Clearly, a parenting program cannot be successful unless parents par-
ticipate and remain in the program. As described earlier in this report and
by Breitenstein and colleagues (2014), studies of face-to-face parent train-
ing interventions indicate that 10 to 34 percent of parents of children in
the preschool to grade school age range enroll to participate (Baker et al.,
2010; Garvey et al., 2006; Heinrichs et al., 2005; Thornton and Calam,
2011). Among those who do enroll, average attendance ranges from 34 to
50 percent of sessions (Breitenstein et al., 2012; Coatsworth et al., 2006;
Scott et al., 2010). It has been estimated that between 20 and 80 percent of
families drop out of mental health prevention and intervention programs
prematurely with many of them receiving less than one-half of the interven-
tion (Armbruster and Kazdin, 1994; Ingoldsby, 2010; Masi et al., 2003).
Lower participation and retention rates limit program reach and dilute
program benefits for parents and families. Throughout the discussion in this
chapter of elements of effective parenting programs, therefore, approaches
that have shown success in increasing parents participation and retention
in such programs are noted. The following section of the chapter then de-
scribes some additional strategies for increasing participation and retention.
The final section presents a summary.
ELEMENTS OF EFFECTIVE PROGRAMS

The elements of effective parenting programs include parents being
treated as partners with providers, tailoring of interventions to the needs
of both parents and children, service integration and interagency collabora-
tive care, peer support, trauma-informed services, cultural relevance, and
inclusion of fathers.
Parents as Partners
A critical element of all parenting programs is viewing parents as equal
partners with the provider, experts in what both they and their children

ELEMENTS OF EFFECTIVE PARENTING PROGRAMS 327
need. The importance of this approach is evident in programs ranging from

patient-centered medical care to joint decision-making interventions for
parents engagement in childrens education (see Chapter 4).
Research has found that treating parents as partners enhances the qual-
ity of interactions between parents and providers and increases parents
trust in providers (Jago et al., 2013). This idea was supported by parent
commentaries offered as part of the information gathering for this study.
Findings from longitudinal and semi-structured interview research suggest
that the level of therapeutic engagement with parents, empathic interaction
style, and parents feelings of being valued are related to participation in
and completion of program activities (Jago et al., 2013; Orrell-Valente et
al., 1999). In a review of 26 qualitative studies (Mytton et al., 2014), hav-
ing an intervention delivered by individuals trusted by or already known
to parents was important in parents decisions to participate. (See also the
discussion of participation and retention later in this chapter.)
Tailoring of Interventions to Parent and Child Needs

Because the needs of individual parents and children vary greatly
and often depend on family context, strong programs, including those
using manualized approaches, generally try to tailor the services to fit
individual needs. The importance of such tailored approaches is widely
recognized. For example, organizations providing Part C services under
the Individuals with Disabilities Education Act (IDEA) look to individual
family needs and child characteristics in designing interventions. The im-
portance of personalized approaches to parenting skills also is central in
working with parents with mental illness. Depressed parents, for example,
may benefit particularly from training in dealing with conflict and diffi-
cult child behaviors, whereas those with borderline personality disorder
may gain the most from education in providing a consistent routine and
nurturing (Beeber et al., 2014; Stepp et al., 2012). Certain mental health
disorders, such as schizophrenia, can lead to difficulty responding to emo-
tional cues from infants and children, so programs that promote coaching
to increase these skills may be particularly useful for individuals with
those disorders, especially given the importance of early infant attachment
(see Chapter 2) (Craig, 2004; Gearing et al., 2012; Nicholson and Miller,
2008; Stepp et al., 2012). This tailoring of treatment requires highly quali-
fied and trained staff.
In addition, tailoring programs requires understanding and responding
to gender differences in both the needs and the receptivity of parents. For
example, mothers and fathers are likely to respond differently to program
support based not only on their gender and role differences but also such
factors as their engagement with the child and family, the level of respon-

siveness of program staff, the nature of familial and community expecta-

tions and supports, and their residential status.
As discussed in Chapter 1, many children are raised by a same-sex
couple or a sexual minority parent. Few studies have explored the par-
enting experience of sexual minority adults. Studies that have been done
suggest that lesbian and gay parents adjusting to parenthood generally
experience levels of stress comparable to those experienced by their het-
erosexual counterparts (Goldberg and Smith, 2014). Lesbian and gay
parents, particularly when new to parenthood, have many of the same
concerns as any other new parents and could benefit from the same sup-
port structures (e.g., those provided by parent support groups/classes,
medical professionals, teachers, or community groups). It is important
for these programs to recognize that some parents whom they are serving
might be sexual minorities and to adjust programming and terminology
to be inclusive of sexual minority parents and nontraditional families
more generally. Some studies have indicated that certain subsets of sexual
minority parents (e.g., female partners of biological lesbian mothers)

might have increased stress upon becoming parents, and it is important
for programs to offer support to these groups in particular (Tornello et al.,
2011; Wojnar and Katzenmeyer, 2014). In addition to experiencing the
routine stresses of parenting, sexual minority parents and their children
may face social stigma and discrimination.
Parents report that several of the barriers to participation in parent-
ing programs are practical, such as not having transportation to reach
the site where the intervention is being provided, being unable to arrange
for child care, and having work and scheduling conflicts (Morawska et
al., 2011). Many evidence-based parenting interventions provide trans-
portation assistance and child care (Snell-Johns et al., 2004), and there is
evidence that matching program scheduling with parents own schedules
is associated with higher rates of participation (Gross et al., 2001). In a
recent systematic review of 26 qualitative studies in which parents were
asked about why they did or did not enroll in or complete a parenting
program, the time and place of the program delivery and the lack of col-
location of classes with child care emerged as major factors related to
participation (Mytton et al., 2014). Transportation is a primary barrier
across multiple types of programs, not just those focused on parenting,
particularly for those with limited income and access to personal and reli-
able public transportation.

Parent Voices
[One parent described transportation and child care-related challenges to

participation.]
For us, we want our kids to go to school as soon as possible. Transporta-
tion is a problem. Head Start programs can start at noon or nine oclock
in the morning. Time is a challenge for parents. Some women dont know
how to drive. For our culture, we dont want to put kids in daycare either.
Service Integration and Inter-agency Collaborative Care

Service integration continues to be particularly important in the provi-
sion of services for families facing multiple challenges, including histories of
trauma, substance use, relationship instability, and lack of social supports
(Hernandez-Avila et al., 2004; Howell and Chasnoff, 1999). Integrated care
often includes using a centralized access point for treatment of the parents
condition(s), combined with services to improve their parenting skills,
such as parent training or child-related interventions (Niccols et al., 2012).
Integration of services gives parents easier access to resources that address
multiple needs and improves collaboration and continuity of care (Krumm
et al., 2013; Schrank et al., 2015), and may help to reduce the stigma that
can be associated with targeted interventions (Cortis et al., 2009). Service
integration can also ease scheduling and transportation challenges for fami-
lies (Ingoldsby, 2010).
Families contending with an array of adversities often also need services
to address such needs as job training, housing, and income support, as well
as active support to help them access and utilize those services (Gearing
et al., 2012; Hinden et al., 2005, 2006). Helping parents deal with these
stressors may free up personal resources, enabling them to focus better on
improving their parenting skills (Ingoldsby, 2010). Indeed, lower economic
stress and interparental conflict have been found to be associated with
increased enrollment and participation in parenting interventions (Wong
et al., 2013). Likewise, mothers in a study that included family coaches
who helped link parents to other services in addition to direct parenting
support reported strong satisfaction with the program (Nicholson et al.,
2009). Conversely, interventions that fail to address coping mechanisms
for family issues and parental stressors can drive families out of programs
(Prinz and Miller, 1994).

Peer Support
Engagement in services and positive outcomes can be increased by
linking behavioral supports with peer support (Axford et al., 2012; Barrett
et al., 2008). Beyond increased engagement, strengthening social support
among parents can have multiple benefits, including reduced stigma, in-
creased sense of connection, and reduced isolation. For example, research
using various methodologies indicates that interventions have successfully
addressed both the stigma of mental illness and the social isolation of many
parents by providing peer support via groups, classes, or even the Internet
(Cook and Mueser, 2014; Craig, 2004; Kaplan et al., 2014; Schrank et al.,
2015; Wan et al., 2008).
Parenting programs using a multifamily or multiparent group format
allow participants to share their parenting experiences with others who
serve as a source of social support and peer learning (Coatsworth et al.,
2006; Levac et al., 2008; McKay et al., 1995). The opportunity to exchange
ideas and receive support from peers may be an important reason why
parents join and attend group parenting classes (Jago et al., 2012, 2013;
Mytton et al., 2014). In experimental research, parents with serious men-
tal illness, for example, report that peer groups help them feel understood
and safe, and this may motivate them to return to the groups (Dixon et
al., 2001, 2011). Peer support helps parents learn how others successfully
provide guidance and set limits for and engage in other positive interac-
tions with their children. Including spouses or partners in mental health
visits is another way of decreasing stigma and encouraging support, based
on findings from randomized controlled trials (Dennis, 2014). Notably,
peer support services may be reimbursable by Medicare, Medicaid, states,
and private health plans (Daniels et al., 2013). While peer support can be
valuable in engaging and sustaining parent participation, however, it is not
a substitute for professional staff with training in working with parents
facing specific adversities.
Finally, it is important to note that, despite the limitations of evidence-
based approaches for fathers, fatherhood programs incorporating peer
support have shown success (Fagan and Iglesias, 1999). Evidence-based
approaches now being implemented in fatherhood programs are likely to
yield important data on the efficacy of peer support among fathers.

Parent Voices
[One parent described how she benefitted from peer support.]

Sometimes you dont realize stuff until you talk about it. You dont realize
how angry you was [sic] or how much you are over stuff or this or that
until you talk about it. And then talking to people that dont know you.
And not going to give you crazy feedback [from your family and friends].
And that advice never helps. Because as much as your family think [sic]
they know you, they have no idea.
Trauma-Informed Services
Considerable research over the past 10 years has demonstrated the
significant impact of traumatic experiences on a variety of outcomes during
childhood and into adulthood. The Adverse Childhood Experiences (ACEs)
study, which surveyed more than 17,000 members of a health maintenance
organization in California, found that a large percentage had experienced
traumatic experiences and demonstrated the connection between such ex-
periences in early childhood and later adverse health outcomes (Anda et
al., 2009). Relevant to the present context, trauma can have a significant
impact on parenting ability. According to Banyard and colleagues (2003,
p. 334) cumulative exposure to trauma is associated with less parenting
satisfaction, greater levels of neglect, child welfare involvement, and u
sing
punishment. Cumulative exposure to trauma is predictive of parents
potential for child abuse, more punitive behavior, and psychological aggres-
sion in correlational research (Cohen et al., 2008).
Trauma has a particularly damaging effect on childrens development.
Children exposed to trauma often experience problems with regulation of
affect and impulses, constricted emotions, and an inability to express or
experience feelings (Armsworth and Holaday, 1993; van der Kolk, 2005).
Children who have experienced significant trauma without adequate paren-
tal support tend to have a heightened sense of vulnerability and sensitivity
to environmental threats; experience high levels of guilt and shame; and
have high rates of anxiety and depressive symptoms, including hyper-
vigilance, hopelessness, anhedonia, suicidal ideation, and suicide attempts
(Armsworth and Holaday, 1993; van der Kolk, 2005).
Based on these findings, many parenting programs now adopt a trauma-
informed approach. Trauma-informed services are not about a specific in-
tervention or set of interventions. According to the Substance Abuse and

Mental Health Services Administration, a trauma-informed approach real-

izes the widespread impact of trauma and understands potential paths for
recovery; recognizes the signs and symptoms of trauma in clients, families,
staff, and others involved with the system; responds by fully integrating
knowledge about trauma into policies, procedures, and practices; and seeks
to actively resist re-traumatization (Substance Abuse and Mental Health
Services Administration, 2015b).
Trauma may affect provider relationships with parents and therefore
their children. In trauma-informed services, an understanding of trauma
permeates services, and all staff have the ability to view clients in the
context of their life histories. It is important that providers be able to rec-
ognize signs and symptoms of trauma, a history of trauma, and traumatic
stress, and have training in how to provide trauma-informed care (Institute
for Health and Recovery, 2016). Interventions for parents may include
present-focused trauma-specific therapies, such as Seeking Safety, Risking
Connection, and Sanctuary. All of these are considered present-focused
therapies, because they focus on developing skills to cope with trauma in
the present. These therapies teach such skills as self-soothing, grounding,
and engaging in healthy relationships, as well as other skills necessary for
coping with trauma (Substance Abuse and Mental Health Services Admin-
istration, 2015b).
It is important to note that trauma can occur within typical interac-
tions between parents and children or may be brought about as a result of
unusual circumstances. In both instances, parents must find safe places for
their children and navigate the turmoil that can have potentially deleterious
effects on their children and themselves. Considering the high prevalence
of trauma among at-risk parents and the impact of traumatic events on
parenting and child development, assessing for past traumatic experiences
and providing trauma-informed care for all at-risk parents can improve
outcomes and may be cost effective in the long run (Hornby Zeller Associ-
ates, 2011).
Cultural Relevance
Parenting programs have historically had low utilization, especially
among culturally diverse parents (Cunningham et al., 2000; Eisner and
Meidert, 2011; Katz et al., 2007; Sawrikar and Katz, 2008). If intervention
components and providers are not sensitive to cultural variations among
families with respect to their coping styles and expression of problems,
parents may be less likely to participate (Brondino et al., 1997; Moodie and
Ramos, 2014; Prinz and Miller, 1994). Baumann and colleagues (2015) ex-
amine the extent to which researchers and developers of several commonly
used evidence-based parent training programs (Parent-Child Interaction

Therapy [PCIT], Incredible Years, Parent Management Training-Oregon

[PMT-O], and Triple P) have used culturally adapted models. Of 610
articles on these programs, only 8 document a rigorous cultural adaptation
process, and just 2 of these programs used rigorous methods to test the
program implementation. Recent efforts to rigorously test cultural adap-
tations of PCIT (McCabe and Yeh, 2009), PMT-O (Parra Cardona et al.,
2012), and ParentCorps (Dawson-McClure et al., 2015) indicate growing
awareness of the importance of developing and testing innovative ways to
engage, retain, and educate Latino families.
At the same time, parenting programs delivered without significant
modification and not incorporating tested cultural adaptations are some-
times viewed as highly attractive by local communities. This was the case
with the implementation of SafeCare in American Indian communities
in Oklahoma, where researchers found that their manualized, structured,
evidence-based model was a reasonable fit with American Indian parents
in child welfare. SafeCare had higher client ratings of cultural competency,
working alliance, service quality, and service benefit than services as usual
(Chaffin et al., 2012). The Huey and Polo (2008) review of evidence-based
psychosocial interventions for children found no pressing need for such ad-
aptations. The culturally adapted interventions that have been tested have
shown little added benefit, and outcomes for minority children and families
who receive unadapted services generally are good, although this is not to
minimize the need for cultural sensitivity and clinical expertise in order to
engage families in treatment (Huey et al., 2014).
Inclusion of Fathers
As noted previously, fathers are underrepresented in research on
arenting-related interventions. Moreover, relatively few fatherhood studies
p
have examined the relationships between specific fathering behaviors and
desired child outcomes. Although further research is needed, available
studies indicate that parenting interventions would benefit from the use of
approaches giving greater priority to fathers participation, such as starting
with an expectation that they will participate and using content and activi-
ties that they will find pertinent, in addition to using strategies that may
improve participation more generally (e.g., providing financial incentives
[discussed below] and scheduling sessions at times that are convenient)
(Administration for Children and Families, 2015; Zaveri et al., 2015).
The data are clear and poignant regarding the lack of evidence-based
strategies in fatherhood programs. In a study by Bronte-Tinkew and col-
leagues (2008), only 4 of 18 programs reviewed had rigorous enough
designs to be considered model and promising. Much of the research on
fathers and programs that include them has examined low-income, non-

BOX 6-1
A Fathers Story
A proud husband and father of three children shared his story with the
committee during one of its open sessions. His experience of becoming a father
altered the direction of his life, influencing him to find the right path so as to be
a role model for his children. During his journey as a father, he became part
of a community in the Fatherhood Is Sacred Program in Sacramento. There he
realized the importance of community support in helping him achieve his goal of
becoming a good father.
He grew up in a tough neighborhood in North Sacramento, California. During
his childhood and adolescence, he was forced to stick up for himself and his
brothers. He came from a home in which the outward expression of love was rare.
He pinpointed this, along with the fact that he did not have a role model at home,
as the reason why he began hanging around with the wrong crowd. I would say
it was the wrong crowd of people to support me. He experienced a troubled
adolescence: I have been beat up, just been beat down by every obstacle that
I can imagine.
The birth of his first child, a daughter who is now 10 years old, helped him
start viewing his life from a different perspectivethe perspective of a father. He
worked toward becoming a better parent, but he struggled, as it was easy to fall
back into the habits he had developed in the first 32 years of his life. You learn
so much of this terrible way of living. . . . Yes, I did fall back.
After the birth of his two sons, he recognized the need for support in keep-
ing his family together and being a role model to his children, but this need was
something he tried to ignore. It was then that other fathers in his neighborhood
led him to Fatherhood Is Sacred, where he was immediately welcomed into a safe
environment. As a grown man, I felt safe and invited and welcomed, like I was
at home. Once he became engaged in the program, he began doing the work to
strengthen his parenting skillswork he had not been doing for 32 years. He has
been actively involved with Fatherhood Is Sacred for nearly 3 years.
He views Fatherhood Is Sacred as more than a program; for him, it is a fam-
ily. He works to engage families in the program throughout Sacramento, where
he grew up. For years, I took from our community. I was a big contributor to that
[and] it is all positive now. Doing this work has helped him strengthen his ties, not
only to his community, but also to his three children. In contrast with the house-
hold in which he was raised, he expresses to his children that he loves them. He
educates them, and he believes that education starts in the home. It is true, the
saying, a father is a sons first hero . . . and a daughters first love, because thats
where it starts. . . . I am very proud to be here and to be where I am at today, for
our next generation and generations to come for my family, for my friends, for the
people that look up to me, [and] for my community.
SOURCE: Perspectives from Parents, Open session presentation to the Committee on Sup-
porting the Parents of Young Children, June 29, 2015, Irvine, California.

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

PROGRAM PARTICIPATION AND RETENTION
As noted above, evidence indicates that parenting programs often ex-
perience substantial difficulty in engaging and retaining parents, especially
those facing multiple adversities. Some of the reasons for this difficulty are
discussed in Chapter 5 and above. In recent years, two strategiesmonetary
incentives and motivational interviewinghave been used to address this
problem. Although these are promising practices, more research is needed
to determine how they might best be utilized. Also important to engaging
and retaining parents in parenting programs is appropriate preparation of
the workforce, discussed in this section as well.
Monetary Incentives
Some parenting programs offer families modest monetary incentives in
an effort to improve enrollment and retention, but few randomized studies
have assessed the effectiveness of such incentives in increasing participa-
tion. In one randomized study, Dumas and colleagues (2010) evaluated the
effect of a small monetary incentive on low-income parents engagement
in sessions of the Parent and Child Enrichment (PACE) Program over an
8-week period. (PACE is a manualized intervention designed to address
parents challenges related to childrearing.) The monetary incentive encour-
aged some parents to enroll but not to attend sessions. Among parents who
both enrolled in the study and attended sessions (N = 483), attendance over
eight sessions was comparable between groups who did and did not receive
the incentive. There also was no major difference between the two groups
in the percentage of parents who dropped out of the program at any point
after the first session. Similarly, in a European randomized study (Heinrichs,
2006), low-income families who were offered a small payment to attend a
series of Triple P parent trainings did not attend at a significantly higher rate
than families who were not offered payment. Payment did appear to result
in a large increase in recruitment compared with the unpaid condition,

leading the authors to conclude that payment may be an effective strategy

for increasing recruitment and initial attendance for some populations (see
also Guyll et al., 2003). Older research on financial incentives and attrition
in parent education has yielded mixed findings, with some studies showing
a positive effect (Mischley et al., 1985; Rinn et al., 1975) and others not
(Lochman and Brown, 1980; Sadler et al., 1976; Snow et al., 2002).
Some evidence indicates that the use of an incentive that exceeds an
individuals perception of the value of an intervention may result in distrust
and be counterproductive (Snow et al., 2002). Consistent with cognitive
dissonance theory (Festinger and Carlsmith, 1959), if a potential partici-
pant thinks the incentive is too large, the value of the intervention may be
compromised by the persons discomfort stemming from the feeling that his
or her beliefs/values and behavior are incongruent. Moreover, while some
experimental research suggests that modest monetary incentives help attract
families that otherwise would not participate (Dumas et al., 2010; Guyll et
al., 2003; Heinrichs, 2006; Heinrichs and Jensen-Doss, 2010), these pay-
ments do little to mitigate practical (e.g., child care, transportation) and
other obstacles to parents attendance and retention over time.
Another approach to incentives is the use of conditional cash transfers
(CCTs). This approach entails providing cash payments to families living in
poverty based on the parents or childrens engagement in specific activities.
CCT programs traditionally have focused on improving childrens health
and well-being and conditioned families receipt of cash transfers on receipt
of recommended preventive health services or nutrition education and/or
childrens school attendance. CCTs are increasingly being used to promote
other behaviors as well (Fernald, 2013).
Building on some successes in developing countries (Engle et al., 2011;
Fernald, 2013; Rasella et al., 2013), the first demonstration of CCTs in the
United States was launched in New York City in 2007. Called Opportunity
NYC-Family Rewards, it provided cash assistance to families in the citys
highest-poverty communities with the goal of reducing intergenerational
economic hardship. Payments were conditioned on families efforts to im-
prove their health, increase parents employment and income, and support
childrens education. Children also were paid in response to their educa-
tional activities and performance.
An experimental analysis of this program involving 4,800 families who
participated for 3 years found that the families were transferred more than
$8,700 during the 3-year period and that poverty, hunger, and housing-
related hardships were reduced, but these effects weakened as the cash
transfers ended. Parents self-reported full-time employment also increased,
but not in jobs covered by unemployment insurance (Riccio et al., 2013).
Results for children varied by their age. Neither school attendance nor over-
all achievement improved among elementary and middle school students

whose families received the payments. But children in these families who
entered high school as proficient readers attended school more frequently,
earned more course credits, were less likely to repeat a grade, scored higher
on standardized tests, and had higher graduation rates. Families receipt of
preventive dental care increased, but there was no improvement in receipt
of other preventive medical care (which was already high) or in health
outcomes (Riccio et al., 2013).
Building on the findings from the Family Rewards demonstration,
in 2011 Family Rewards 2.0 was initiated in the Bronx, New York, and
Memphis, Tennessee. This version offers fewer rewards in each domain
(health, employment/income, and child education), offers rewards for edu-
cation only to high school students, provides payment on a more frequent
basis (once a month), and offers families guidance on how to earn rewards.
Findings from a randomized evaluation of the first 2 years of implementa-
tion involving 2,400 families show that by year 2, almost all families had
received rewards (totaling $2,160 on average in year 2). Perhaps as a result
of the guidance they received, moreover, parents understood the rewards
more completely and were more likely to earn rewards than families in
the original program. A follow-up analysis of Family Rewards 2.0 as an
improvement over the earlier version is pending (DeChausay et al., 2014).
Significant gaps in knowledge about CCTs remain. These include, for
example, differences in effects among subpopulations, strategies for increas-
ing efficiency, how the programs can be adapted to cultural contexts, and
longer-term outcomes (Marshall and Hill, 2015).
Motivational Interviewing
Motivational interviewing is an evidence-based, client-centered style
of counseling. Based on the assumption that an ambivalent attitude is an
obstacle to behavior change, motivational interviewing helps clients explore
and resolve ambivalence to improve their motivation to change their behav-
ior (Miller and Rollnick, 1991; Resnicow and McMaster, 2012; Substance
Abuse and Mental Health Services Administration, 2015a). Key features
of motivational interviewing include nonjudgmental reflective listening on
the part of the counselor, with the client doing much of the work him- or
herself. A concrete action plan for behavior change with measurable goals
is developed, and sources of support are identified. Motivational interview-
ing was initially developed and is still used to treat addiction and recently
has been used for other types of behavior change (Resnicow and M cMaster,
2012; Substance Abuse and Mental Health Services Administration, 2015a).
Motivational interviewing has been proposed as a potential strategy for
enhancing parents motivation to engage and remain in parenting programs
(Watson, 2011). Studies not focused specifically on parents have shown

that individuals who receive motivational interviewing, or therapy based

on its principles (e.g., motivational enhancement therapy), have improved
treatment adherence (Montgomery et al., 2012). But only a few randomized
trials have tested the use of motivational interviewing to improve parents
motivation to attend and adhere to mental health and substance use treat-
ment, and these trials have yielded mixed findings.
Although motivational interviewing is a core component of effective
programs designed for parents and families, such as Homebuilders and
Family Check-Up, very little research has evaluated the specific effects of
motivational practices on parents participation. In a study of 192 parents
that used a double randomized design, a self-motivational orientation inter-
vention combined with PCIT increased retention in child welfare parenting
services (Chaffin et al., 2009). The benefits were concentrated among par-
ents whose initial level of motivation to participate was low to moderate;
negative effects on participation were found for participants whose initial
motivation was relatively high (Chaffin et al., 2009).
Drawing on research on motivation enhancement and barriers to
treatment participation, Nock and Kazdin (2005) developed a brief inter
vention designed to increase parents attendance at Parenting Management
Training (PMT) sessions. (PMT is a well-supported program designed to
help parents prevent internalizing and externalizing conduct behaviors in
their children.) In a randomized controlled study, compared with controls
who received PMT alone, families receiving the intervention in combina-
tion with PMT had greater treatment motivation, attended more sessions
(completing 6.4 versus 5.2 sessions), and had higher retention in the
training (56% versus 35%) in training according to parent and therapist
reports (Nock and Kazdin, 2005).
Parent Voices
[Parents may not be naturally motivated to participate in programs, but

participate when sought out and urged.]
Like this [interview] is nice but I dont think I would have signed up for
it. Like if this was somewhere else, I wouldnt have really signed up for it.
. . . I dont think Im good in a group. . . . I have thought about going to a
lot of little groups like this but youve got to get yourself together before
you go and sit in something like this.

Workforce Preparation
A central contributor to parents participation and retention in
e vidence-based programs and services is a workforce that is appropriately
trained in how to refer families to programs, engage them in receiving ser-
vices, and deliver evidence-based parenting interventions.
As reviewed in earlier chapters, parents engagement in their childrens
learning, both in the school environment and at home, is associated with
improvements in measures of young childrens development and academic
readiness (Cabrera et al., 2007; Hart and Risley, 1995; Institute of Medicine
and National Research Council, 2015; Rodriguez and Tamis-LeMonda,
2011). A central component of effective parental engagement in childrens
learning is reinforcement of classroom material in the home, which can be
facilitated by positive relationships between families and teachers and other
providers (Porter et al., 2012; U.S. Department of Health and Human Ser-
vices and U.S. Department of Education, 2016). Thus, practitioners serving
young children and their parents need skills in communicating and part-
nering with diverse families (Institute of Medicine and National Research
Council, 2015). Parents engagement in their childrens health care also is
important. In pediatric care, family engagement focuses on parents under-
standing and using information about their childrens health, engaging in
shared decision making, and participating in quality assessment aimed at
improving care (Schuster, 2015). And enabling parents to play an effective
role in reducing childrens behavioral health problems likewise can benefit
from professionals understanding of the common elements of engagement
(Lindsey et al., 2014) as well as of treatment (Barth and Liggett-Creel,
2014). The recent Institute of Medicine and National Research Council
(2015) report Transforming the Workforce for Children Birth through Age
8: A Unifying Foundation reflects these research findings, identifying the
ability to communicate and connect with families in a mutually respectful,
reciprocal way, and to set goals with families and prepare them to engage
in complementary behaviors and activities that enhance development and
early learning as knowledge and competencies important for all profes-
sionals who provide direct, regular care and education for young children
to support their development and early learning.
The importance of professionals having skills in working with families
is currently reflected in several laws and policies pertinent to programs
supporting childrens education and in core competencies for care and edu-
cation professionals. The U.S. Department of Educations Dual Capacity
Building Framework for Family-School Partnerships offers research-based
guidance to states, districts, and schools on improving staff and family
capacity to work together to improve student outcomes (U.S. Department
of Health and Human Services and U.S. Department of Education, 2016).

IDEA emphasizes that services for young children with disabilities involve
childrens families and that services provided should improve families abil-
ity to meet their childrens developmental needs. For 20 years, the Adop-
tion and Safe Families Act has required that child welfare agencies engage
families and endeavor to maintain children in their own families whenever
it is reasonably safe to do so and, similarly, work to reunify children with
their parents, when safe, as a preference over long-term foster care or adop-
tion. Also, statements of core competencies for educators and health care
providers who work with young children often identify partnering with
families to support childrens development as a core area of focus (Institute
of Medicine and National Research Council, 2015). And as recommended
in a recent policy statement on family engagement in childrens education
from the U.S. Department of Health and Human Services and the U.S.
Department of Education, preservice and continuing in-service professional
development should include concrete strategies for building positive rela-
tionships with families (U.S. Department of Health and Human Services
and U.S. Department of Education, 2016).
Despite the important role of families in childrens learning and devel-
opment and the fact that family engagement is acknowledged in several
laws, policies, and core competencies as central to the success of programs,
workforce preparation for early childhood teachers and providers often
does not address working with families. When family engagement is imple-
mented, it may fail to take into account differences among families, such as
culture and variations in family forms (U.S. Department of Health and Hu-
man Services and U.S. Department of Education, 2016). The committees
scan of state, territory, and tribal credentialing for early childhood educa-
tion professionals revealed that only 12 states require a course or workshop
on families, and just 5 states require a course on addressing ethnic and
cultural difference or the needs of culturally and ethnically diverse families.
Professional schools (e.g., nursing, education, social work, medicine)
training health and human service providers rarely offer courses that pre-
pare students to work with parents of young children. For example, vir-
tually all of nearly 250 graduate schools of social work have courses on
working with families for their clinical students and taking diversity and
difference into account in social work practice. These courses focus on
family therapy, which is typically used for families with older children
who can participate in family communication. Many also have courses in
school social work, which emphasize working with families in relation
to special education services (Council on Social Work Education, 2012).
Few have courses on parenting or working with parents of young children.
A similar situation exists in education. Prospective teachers are required to
take courses focused on diversity, multiculturalism, and families, but the
requirement varies across context. In health care, challenges also have been

identified with respect to communicating with children and families in the

pediatric setting, such as about psychosocial and practical issues in families
(Levetown, 2008).
There are indications that effective intervention approaches often are
not used to the extent that they could be. For example, a recent Institute
of Medicine report notes that evidence-based interventions frequently are
not available as part of routine care for individuals with substance use and
mental health disorders (Institute of Medicine, 2015). The story is similar
with regard to parent training interventions in child welfare and other service
settings (Barth et al., 2005; Garland et al., 2010). It is important for prac-
titioners who work with families to be aware of evidence-based programs
and services that support families and how they can refer families to and
implement those programs and services. However, graduate schools that train
providers of childrens services and behavioral health (e.g., schools of social
work and nursing) have limited or no coursework on leading e vidence-based
parenting programs. With few exceptions, health and h uman service profes-
sionals also are not trained in the common components that make up most
evidence-based practices (Barth et al., 2014). One result of this neglect of
appropriate training is that few child welfare agencies refer parents to parent-
ing programs delivered by professionals trained in evidence-based practices
(Barth et al., 2005). Indeed, mental health providers typically offer a low-
intensity dose of treatments with inconsistent application of evidence-based
components when working with children and their parents (Garland et al.,
2010). Absent an expanded workforce prepared to deliver the evidence-based
practices described in this report, these programs cannot be brought to scale.
SUMMARY
The following key points emerged from the committees examination
of elements of effective parenting programs and strategies for increasing
participation and retention.
Although no single approach is applicable to and will yield the

same positive results for all parents, elements that the committee
found to be successful across a wide-range of programs and ser-
vices for parents are
viewing parents as equal partners in determining the types of
services that would most benefit them and their children;
tailoring interventions to meet the specific needs of families;
integrating services for families with multiple service needs;
creating opportunities for parents to receive support from peers
to increase engagement, reduce stigma, and increase their sense
of connection to other parents with similar circumstances;

addressing trauma, which affects a high percentage of indi

viduals in some communities and can interfere with parenting
and healthy child development;
making programs culturally relevant to improve their effective-
ness and participation across diverse families; and
enhancing efforts to involve fathers, who are underrepresented
in parenting research.
Studies of the effectiveness of the use of modest monetary incen-
tives to improve participation and retention in parenting programs
have had mixed findings. Some indicate that monetary incentives
may enhance initial interest in and recruitment into programs for
some parents, but do not necessarily lead to improvements in
attendance.
Preliminary experimental data on the use of conditional cash trans-
fers to incentivize low-income families engagement in behaviors
that can enhance their well-being show an association between
receipt of cash transfers and improvements in some economic out-
comes, such as reduced poverty, food insecurity, and housing hard-
ships and increased employment. These positive outcomes were not
sustained when the cash transfers ended.
Although available studies show that motivational techniques used
in combination with other supportive strategies may improve atten-
dance and retention in programs and services for some individuals,
there is a lack of data focusing specifically on these outcomes in
parents and identifying those populations of parents for which
these techniques are most effective.
Having a workforce that is trained in how to engage diverse fami-
lies in activities and decision making pertaining to their children
and how to refer parents to and implement evidence-informed par-
enting programs and services is essential to uptake. However, the
committee found that professionals who work with young children
and their families often lack appropriate training in these areas.
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Toward a National Framework
The statement of task for this study (Box 1-2 in Chapter 1) indicated
that the committees work will inform a national framework for strength-
ening the capacity of parents (and other caregivers) of young children
birth to age 8. In the preceding chapters, the committee has reviewed the
evidence relevant to informing the structure and elements of such a frame-
work. In this chapter, the committee looks to that evidence, coupled with
the cumulative experience and expertise of its members, to describe what
this framework might look like. The focus is on policies, programs, and
systems that address both the general population of parents and parents
who may need additional support in developing parenting knowledge, at-
titudes, and practices associated with positive developmental outcomes in
children. While the committees statement of task focused on a national
framework, the elements identified in this chapter are applicable to all levels
of government and can be enhanced by the participation of philanthropies,
community-based organizations, and the business community.
As described in Chapters 3, 4, and 5, governments at all levels fund
many programs designed to strengthen parenting, as well as a number of in-
come and other support programs and policies designed to enable parents to
better meet the needs of their children. The amount of support for parenting
programs from federal and state resources has grown over the past 15 years,
especially with respect to home visiting programs. Currently, many parents
of young children have the opportunity to participate in an array of federally
supported services designed to strengthen and support parenting, beginning
with prenatal care and including well-baby care and educational services.
Some programs, such as the Special Supplemental Nutrition Program for
351

Women, Infants, and Children (WIC), Early Head Start, Head Start, and
prekindergarten and early elementary services, are delivered by thousands
of local providers who are subject to differing degrees of federal regulation,
oversight, technical assistance, and assessment. There also are thousands of
other parenting programs, funded by state and local governments, as well
as foundations and other contributors that focus on a variety of parenting
skills. Some of these programs use the evidence-based approaches described
in Chapters 4 and 5, but many programs, large and small, have not been
evaluated to determine whether they are effective and meet their goals.
These programs do not serve all of the families and children that are
eligible to participate, because of both inadequate funding and the choices
of parents (Pew Research Center, 2015). Furthermore, while these programs
are available to parents who seek them out or accept offers of service from
home visitors or other providers, they are not coordinated and collectively
do not form a system of services for families. Some parents, especially those
who are more organized and self-directed, receive adequate services to
enhance their knowledge, attitudes, and practices within the existing loose
network of programs. A substantial portion of parents, however, especially
those facing substantial personal challenges, need a more coordinated,
ongoing set of services if they are to engage consistently in the types of
parenting represented by the knowledge, attitudes, and practices discussed
in Chapter 2 (Shonkoff, 2014; Wald, 2014). Thus, the suggested framework
includes both a set of individual programs available at key points and a set
of services that are connected and systematic. For families with ongoing
needs, services would also be continuous.
CRITERIA TO CONSIDER IN DEVELOPING A

SYSTEM FOR PARENTING SUPPORT
The committee considered several criteria in identifying the elements of
a strong system for strengthening and supporting parents. First, a system
that revolves around evidence-based programs is likely to be most effective
in helping parents achieve the knowledge, attitudes, and practices identi-
fied in Chapter 2. Ideally this evidence would be derived from randomized
controlled trials. As discussed in Chapter 1, however, programs that are
theoretically sound that have been evaluated in high-quality studies using
other research methodologies (e.g., quasi-experimental and longitudinal
studies) can be used to test logical propositions inherent to causal infer-
ence, rule out potential sources of bias, and assess the sensitivity of results
to assumptions regarding study design and measurement, and can work
well in specific contexts (see, Center on the Developing Child at Harvard
University, 2016; National Center for Parent Family and Community En-
gagement, 2015). The framework is founded on the concept that a system

TOWARD A NATIONAL FRAMEWORK 353
that starts with a clear set of desired outcomes, includes both evidence-
based and evidence-informed programs, and applies a continuous quality
improvement model in the context of existing service delivery platforms
offers the greatest potential to reach and support families while at the same
time improving programs and developing the evidence base (Center on the
Developing Child at Harvard University, 2016; Mackrain and Cano, 2014;
National Research Council and Institute of Medicine, 2009). Operational-
izing this concept would require incorporating evidence reviews into the
policy-making and funding system, promoting innovation and improve-
ment, and supporting implementation research.
Second, as described in a recent Institute of Medicine and National
Research Council workshop summary and other sources, issues of scal-
ability and implementation should be taken into account in developing a
system of effective, evidence-informed programs (Institute of Medicine and
National Research Council, 2014; National Research Council and Institute
of Medicine, 2000, 2009; Paulsell, et al., 2014). As noted above, services
aimed at supporting parents generally are delivered by thousands of local
entities, primarily nonprofit organizations. Implementing an effective sys-
tem of services requires having structures for quality control, assessment,
and technical support. In designing and implementing such a system, it may
be easiest to build on existing programs that are widely available, working
to enhance their quality and interconnectedness. Delivering services through
large-scale, widely available programs also facilitates program evaluation
and experimentation. A number of widely used, federally supported, locally
administered programsincluding prenatal care, WIC, home visiting pro-
grams, and Early Head Start and Head Startcan form the core of a strong,
coordinated system with multiple opportunities to engage parents. These
programs have been subjected to national and local impact evaluations and
use the resulting information to improve performance. Enhancing well-baby
care, which virtually all parents use, also would be central to developing
a system that reaches all parents (National Institute for Childrens Health
Quality, 2016). Expanded parent engagement in state and local preschool
and kindergarten through grade 3 education is another vehicle for reach-
ing all parents, with kindergarten entry being a particularly important
transition point for reaching out to all parents, especially those who have
never had contact with any part of the system except well-baby and child
health services. Through the graduated scale-up of proven programs and
implementation of new programs utilizing continuous quality improvement
methods, states and localities could create a set of programs at scale.
Third, an effective system would be structured in a manner that fosters
parent engagement in the services (Boller et al., 2014). Parents are likely
to be most willing to engage in parenting programs, especially those that
are intensive or home-based, when they believe that they and their children

need and will benefit from those programs (National Research Council
and Institute of Medicine, 2000; Pew Research Center, 2015). A number of
factors that have proven most important in engaging and retaining parents
are discussed in Chapter 6. Such programs are parent-centered and engage
parents and communities in program design and operation to align services
with the goals, needs, and culture of the parents (Fitzgerald and Farrell,
2012; Kreuter and Wang, 2015; Sarche and Whitesell, 2012). Parenting
programs also benefit from including activities that parents find motivat-
ing and that treat them as experts with respect to their children. Services
that arise from the universal or broadly available programs cited above,
all of which have considerable parent buy-in, may have some advantages
in this regard. Enhancing other widespread service delivery modes, such as
community health clinics and family resource centers that are scalable and
known in communities, is also likely to expand parental engagement. Fed-
eral and state quality standards and technical support for the organizations
that administer the various types of parenting programs can be utilized to
incorporate the core principles and elements identified in Chapter 6.
Fourth, if parenting programs are not made available to both m others
and fathers, program funders and operators cannot assume that what
works for and appeals to mothers will do the same for fathers. The com-
mittee believes that including fathers is critical to the success of programs
aimed at strengthening and supporting parents. Even when some compo-
nents of a national framework (for example, prenatal office visits) may lend
themselves more readily to serving mothers, staff could make services more
father-focused and relevant by asking about fathers participation, inviting
fathers to participate directly, and engaging fathers in helping to design the
services offered (Summers et al., 2004).
Fifth, an effective system requires a strong, well-trained workforce.
Establishing and disseminating effective parenting programs requires bol-
stering the preparation of a workforce capable of engaging the highly
diverse groups of parents in the United States (Coffee-Bordon and Paulsell,
2010; Institute of Medicine and National Research Council, 2015). Given
the wide array of settings in which professionals now engage parents
including the health, education, and human service programs previously
discussedadditional training opportunities addressing the skills needed to
support parents are necessary (Center for the Developing Child at Harvard,
2016). Meeting this need will require new expectations, courses, and sup-
ports for health professionals in pediatrics and primary care (e.g., nurses
and doctors), human service and behavioral health professionals (e.g.,
social workers), and staff in early education programs.
Although some trademarked parenting programs require that the per-
sonnel in organizations offering the intervention have training in the use
of the program-specific intervention components, this requirement creates

uneven availability of the training because there are not enough trainers to
meet the need for training on these specific elements. As a result, programs
that recognize the need for training in research-based parenting approaches
may wait for the training to become available, the cost involved is high, and
turnover among program staff leaves incoming staff without a ready source
of training. Ultimately, the needs of many families remain largely unmet
(Forgatch et al., 2013; Schurer et al., 2010). Given that a variety of similar
parenting programs that are not delivered by specially trained or supervised
therapists all appear to be effective in reducing disruptive child behavior,
a less specialized approach may allow for broader availability of effec-
tive services to parents (Michelson et al., 2013). An alternative approach
to training that consolidates the best parent training elements into more
readily available training programs could reduce the gap in availability of
effective parenting programs (Barth and Liggett-Creel, 2014).
Community colleges, 4-year colleges, and graduate programs could
play a major role in the professional development of individuals who work
with parents by providing training in the core skills that are commonly
used in parent training. Universities could train more parent educators
and therapists, thereby expanding the workforce, by instructing them in
how best to deliver the core elements of interventions with fidelity. A small
number of family science, social work, nursing, and clinical psychology
programs already are providing extensive didactic training and practicum
experiences in working with families, although these are often focused on
therapy with families of older children.The committee knows of relatively
few university programs that adequately prepare professionals for provid-
ing parent education or therapy for younger children. At present, existing
programs are unable to accept and train enough students to meet the need
(Stolz et al., 2013). To expand the training offered in these programs, more
support both for teaching and student stipends may be beneficial.
Many members of the early care and education workforce who provide
home visiting or classroom-based services that include parenting compo-
nents come to their work through schools of education (Whitebook and
Austin, 2015). The committee does not know of model postsecondary
training programs in schools of education that provide specific certification
in a parent engagement or parenting specialty concentration that would
provide the level of skills and knowledge needed by a professional working
with parents to implement existing evidence-based and evidence-informed
programs in the settings suggested by a national framework. Nor could the
committee find evidence that a significant proportion of social workers or
nurses have specific specializations in work with parents of young children.
Ideally, the workforce also would be trained in continuous quality improve-
ment techniques. It may be beneficial as well for supervisors to have access
to advanced training in the skills needed to conduct reflective supervision

and support staff as they work to engage families and implement the models
and continuous improvement and innovation strategies of the framework.
Sixth, the system would need to be cost efficient. Three key factors
in determining approaches that are most cost efficient in helping children
achieve the outcomes identified in Chapter 2 are as follows:
1. Examining whether the costs of generating benefits with respect to

the outcomes exceed the costs of the program itself.
2. Examining whether it is necessary or desirable for a given approach
(e.g., guidance in connection with well-child care) to be available
universally, or it is more cost efficient to target a particular service
to specific populations or through screening.
3. Examining whether the desired outcomes might be achieved most
effectively through interventions focused on the child rather than
the parent.
With respect to the latter factor, for example, while the nature and qual-
ity of parenting are important in helping children achieve all the identified
outcomes, there are some outcomes, especially academic achievement, for
which programs focused on the child (such as early education programs)
rather than on the parent may be a more effective investment, at least when
the parenting is minimally adequate (Duncan et al., 2010).
Finally, the evidence is clear that improving and expanding parenting
programs represents just one investment to support achievement of the
desired outcomes for children. Also essential are access to high-quality
health care, child care, and preschool for children; adequate resources for
parents; policies such as paid parental leave; and safe and active communi-
ties (National Research Council and Institute of Medicine, 2000). Parenting
programs, while often valuable, are not a substitute for access to economic
resources; parents who lack basic economic resources or who work in
jobs that leave no time for being with their children often cannot engage
in the types of parenting to which they aspire and that their children need
(Halpern, 1990; Mullainathan and Shafir, 2013). As a result of the impact
of stressors often associated with poverty, parents can be expected to expe-
rience diminished capacity to participate effectively in a range of activities,
including the implementation of parenting practices learned in parenting
programs that they do attend. Thus, the benefits that can be achieved
through investments in programs designed to strengthen parents knowledge,
attitudes, and practices may be reduced or eliminated unless parents are
provided with the resources needed to apply what those programs impart.
Based on the above considerations and the evidence discussed in Chap-
ters 4 and 5,a system for strengthening and supporting parenting would
include a variety of programs, ranging from universal to highly targeted

and specialized services. It would include programs providing universal and

low-intensity services and supports designed to reach a large percentage of
families; targeted programs addressing the needs of parents and children
with specific needs or risks, such as parents with low income or education
and those with children with developmental delays or significant behavioral
challenges; and still more specialized services for families experiencing mul-
tiple adversities. As discussed in Chapters 4 and 5, many of these programs
and services can be delivered on a relatively short-term basis. A great chal-
lenge is developing a system of services for families with multiple needs or
risk factors, such as parental mental health issues, substance abuse, and
intimate partner violence. These families often need intensive, therapeutic
strategies, such as parent-child psychotherapy, one-on-one parent guid-
ance, and home visiting programs that are connected to psychotherapeutic
interventions. Moreover, many of these families need more continuous and
coordinated support among different services, including access to income
supports, education, and other comprehensive services, such as housing
assistance or job training.
In the discussion below, the committee explores the potential elements
of a national and state framework by looking first at the types of programs
and approaches that have proven effective at the universal and targeted
levels, drawing on the assessments in Chapters 3-5. The committee then ex-
amines the factors to be addressed in developing a comprehensive approach
to meeting the needs of families facing substantial and chronic adversities.
CORE ELEMENTS OF A FRAMEWORK
Universal and Near-Universal Programs and Supports

This section focuses on a set of universal programs that might consti-
tute the core of a national and state framework for parenting services. The
section is organized primarily in terms of stages of parenting; it begins
by considering general parental education, and then looks at the prenatal
period, postnatal services, services for parents with infants and toddlers, and
finally, services connected with preschool and kindergarten through grade 3
education. While the discussion focuses on specific approaches and programs
that would be offered to support parents of children at different stages of
development, it is critical for many families that there be linkages of services
across stages and that support be provided for families in transition periods.
General Parenting Information

Most parents seek advice about parenting from family, friends, and
a variety of other sources (Pew Research Center, 2015). A strong system

for strengthening parenting would include efforts at improving access to

high-quality, culturally appropriate information on core aspects of parent-
ing for all parents. Both the federal and state governments, plus a number
of nonprofit organizations, now provide multiple types of information
to parents through a variety of channels. As described in Chapter 4, new
technologies can potentially increase access to such information. Ongoing
evaluation of the reach of the information and the effectiveness of various
means of conveying this information to parents can be expected to improve
parental uptake.
While most new parents are likely to benefit from basic information
on childrens development and the parenting behaviors that promote it, no
universal programs for providing this information to parents have been
convincingly tested for effectiveness. Some communities are testing the
implementation of level 1 of the Triple P-Positive Parenting Program, which
offers parenting information through several channels, but definitive evalu-
ations of this approach have not yet been conducted (Prinz, 2014; Prinz
et al., 2009; Sanders et al., 2014). In addition, some states offer all new
parents information kits, such as First 5 Californias Kit for New Parents.1
The success of public health campaigns related to smoking cessation,
obesity prevention, and use of car safety devices for children (see Chapter 3)
indicates that further efforts to improve public education on specific parent-
ing knowledge, attitudes, and practices may be warranted. For example,
public education efforts have improved mothers knowledge and behaviors
regarding response to a crying baby (Barr et al., 2009) and have reduced
unnecessary trips to the emergency room for healthy but crying babies
(Barr et al., 2015). At the same time, the parenting information needs to
be carefully crafted. Some public education efforts have failed to achieve
some of the main targeted outcomes, such as reducing traumatic brain in-
jury in infants in the case of public education on shaken baby syndrome
(Runyan, 2008).
Additional efforts at providing general parenting information might
focus on key transition points, such as the transition to kindergarten.
Parents often need advice on helping their children make this transition
and understanding their role in their childs education in this new setting.
A number of communities now offer such guidance through programs
provided by schools, including parent-accompanied classroom visits and
teacher home visits. The opportunity for school staff to get to know parents
at kindergarten entry can allow for assessment of both family risks and
strengths. School staff also can help parents during this transition by foster-
ing community among them, providing a channel for peer-to-peer supports.
Some high schools include information on parenting as part of health
1See http://www.first5california.com/services-support.aspx?id=21 [August 2016].

education or other courses. There is a paucity of research evidence on the

effectiveness, including the cost effectiveness, of these efforts.
As stressed throughout this report, it is important that public educa-
tion campaigns, efforts by schools, and all other universal strategies target
fathers as well as mothers.
Support in Preventing Unintended Pregnancies

More than one-half of pregnancies in the United States are unintended.
As discussed in Chapter 4, the evidence is clear that children born as a re-
sult of a planned pregnancy do better than those whose birth is unintended
(Institute of Medicine, 1995; Sawhill and Venator, 2015). Parents whose
pregnancies were planned are more likely to adopt parenting practices as-
sociated with favorable child outcomes, and child and parent outcomes
are generally better in these cases (Sawhill and Venator, 2015). Short birth
intervals place extra strain on parents. Therefore, systems designed to sup-
port parenting would benefit from including family planning as a key com-
ponent. Cost-effective interventions for reducing rapid repeat subsequent
births are available to support such efforts (Barnet et al., 2009, 2010).
Parenting Education and Support during Pregnancy

Parenting education and support during pregnancy, for both mothers
and fathers, are a cornerstone of any framework of parenting services. In
fact, programs offered at this point may have the greatest pay-off in increas-
ing the chances that children will achieve healthy developmental trajectories
(Currie and Reichman, 2015). As described in Chapter 4, programs that
provide parenting education during pregnancy can be highly effective in
increasing parental knowledge and improving behaviors related to produc-
ing positive outcomes for children (Currie and Reichman, 2015). Given
that the vast majority of women receive prenatal care from obstetricians,
family physicians, or midwives (although recent estimates indicate that
6% of women receive late or no prenatal care [Kids Count Data Center,
2015]), the most obvious channel for providing parenting information and
support may be obstetricians or other staff or volunteers at obstetric offices
and clinics. Expectant parents spend a great deal of time in those offices
waiting for appointments, and that time could be used to provide parenting
information in much the same way as time in pediatric offices is being used
to provide services and information about generally accepted approaches
to effective parenting.
At present, the extent to which obstetricians provide such informa-
tion and support is variable, and little evidence exists on the impact of
the efforts of those who do so. This is an area that might benefit from

more experimentation and evaluation. States could support experiments

in which obstetricians would use such tools as First 5 Californias Kit for
New Parents to determine whether different modes of delivering informa-
tion or different types of information lead to improved parental knowledge
and practices. Another possibility is the use of group programs to provide
information and support. Although one program, Centering Parenting (see
Chapter 4), has been shown to improve parental knowledge and behaviors
associated with positive child outcomes, the limited studies of other pro-
grams have found no effects on parent or child outcomes. Labor and deliv-
ery classes are another universal setting that could be used to give parents
important information about what to expect from their child and where to
obtain additional resources in the community as needed.
In addition to general prenatal medical care, low-income women are
eligible for WIC, which, in fiscal year 2015 served more than 8 million
women, infants, and children, impacting about 53 percent of all chil-
dren born in the United States (U.S. Department of Agriculture, 2015,
2016). Many interventions developed for WIC have improved outcomes
for mothers, including birth outcomes and dietary intake (see Chapter 4).
Since it is widely used and has been shown to support parenting, WIC may
be ideally suited to serve as a central component of a system for supporting
parents, especially given that parents may be eligible for WIC services until
their child is age 5.
A key issue with respect to building on widely available prenatal services,
whether in doctors offices or WIC, is the importance of regular screening
to identify significant issues that might affect parentingsuch as conflictual
relationships, substance use, and mental health problemsand then con-
necting these parents with treatment and, when needed, such supports as
housing, income programs, and social services. Referrals for help in address-
ing any such issues would depend on the types of resources available in the
communityperhaps in the health setting itself or in a managed care consor-
tium or community health clinics. One possible approach for addressing this
issue is use of a screening tool. For example, a recent adaptation of Family
Check-Up (see Chapter 4) was administered to families using WIC (Dishion
et al., 2014) and studied in a randomized clinical trial. In addition to screen-
ing and referral to needed auxiliary services, the intervention universally
included behavioral parenting training. Researchers followed the children in
these families through age 7.5 and found less increase in problem behavior
among children in the Family Check-Up group as described by both parents
and teachers (Dishion et al., 2014). Even though this experiment focused on
mothers with toddlers, the approach could be used during pregnancy as well.
While there is a strong case to be made for the use of screening and
referrals by health care providers in general and in WIC, a critical con-
sideration is whether those services can be expanded without compromis-

ing their basic mission. The current staff in both health care settings and
WIC generally are not trained to identify and respond to a broad range of
problems. For example, WIC staff currently are very knowledgeable about
issues related to nutrition, but indicate that they need additional training to
communicate more effectively with parents about other concerns (Guerrero
et al., 2013).It may be necessary to bring in different types of professionals
to deliver broader family support. This issue was successfully addressed in
the Family Check-Up experiment described above, because the WIC staff
were not asked to engage in work that competed with their primary role.
Thus, expansion of the services provided in these settings would need to be
carefully planned and monitored.
In developing prenatal support services, careful attention also would
need to be paid to involving fathers. Fathersespecially those in cohabiting
unionswho are engaged during pregnancy, such as by attending prenatal
classes and appointments or listening to sonograms, are more likely than
those who are not thus engaged to be set on a path of committed involve-
ment with both child and partner (Alio et al., 2013; Cabrera et al., 2008;
McClain and DeMaris, 2013; Sandstrom et al., 2015).
Parenting Education and Support for Parents of Children Ages 0-1

Access to parenting support is especially important during a childs first
year of life, given the extent of childrens brain and neurological develop-
ment during this period. This is also a period in which parents are especially
open to preventive parenting support (Feldman, 2004) and in which it is
particularly important to identify maternal (and paternal) depression and
perhaps other problems, such as interpersonal violence and substance use
(Golden et al., 2011), given the difficulty of intervening later and the high
percentage (around 5% in California) of children referred to child welfare
services by age 1 (Putnam-Hornstein et al., 2015). Two key s ystemswell-
baby care and home visiting programsnow provide services and support
to new parents. In addition, many communities offer a variety of parenting
education and support programs.
Well-baby careAs noted previously, preventive care visits for children

are a mainstay of families interaction with the health care system. These
visits include basic health care, vaccination, developmental assessment, and
anticipatory guidance for parents. Virtually all parents utilize this care.
The anticipatory guidance can be provided to each family in an individual
session or through group discussions in connection with individual visits.
Clearly, parents need access to regular, high-quality well-baby care
to meet their childrens health needs. However, there is currently very
limited evidence that these visits positively impact other aspects of parent-

ing. Anticipatory guidance obviously adds to the costs of the medical care
provided. It is important to develop more effective means of conveying
information and carrying out screening in connection with well-child visits
(National Institute for Childrens Health Quality, 2016).
There is evidence that this can be done. As discussed in Chapter 4, two
programsHealthy Steps for Young Children (which is physician based but
can include six home visits over 3 years) and the Parent-focused Redesign
for Encounters, Newborns to Toddlers (PARENT)both of which link
physician visits with screenings and guidance, have shown effectiveness
in improving parenting behaviors, although there is less evidence on child
outcomes. Assessments of these programs have found that they produce
substantial savings in terms of reductions in emergency room visits. These
programs might be implemented on a much wider scale, again with an
evaluation looking at a variety of outcomes. If the findings on effectiveness
and cost savings held as the programs were expanded, a case might be made
for making them universal.
Home visiting Home visiting programs designed to support parenting dur-

ing a childs first year (see Chapter 4) are now found in almost all states.
By 2009, 40 states had a combined total of 70 state-based home visiting
programs (Johnson, 2009).
As described in Chapter 4, some of these programs are offered to all
new parents, while others are available to specific groups of new parents,
usually based on income or age. There is some variation in the approaches
and services offered by different programs, but there are also common
approaches. Most home visitors provide parenting education directly and
also use screening instruments to determine whether the parents may need
additional supports. Those additional services may be provided by home
visitors or via referral to such programs as WIC and Early Head Start that
work closely with parents and children. Especially high-risk families may
be referred to more intensive services, which may include full-day child care
in special developmental centers (beginning at birth) and/or some form of
parent-child therapy (Shonkoff, 2014; Wald, 2013, 2014). Some states such
as New Jersey conduct universal screening to determine family needs and
identify families that need specific types of home visiting services, and then
do their best to match the families to those programs (Maternal Infant and
Early Childhood Home Visiting: Technical Assistance Coordinating Center,
2014).
Home visiting can be a critical element of a system for strengthening
and supporting parents. As described in Chapters 3 and 4, evaluations of
home visiting programs have found several models with positive impacts on
aspects of parenting and child outcomes. At least one model (Nurse-Family
Partnership) has demonstrated significant effects on long-term as well as

short-term positive outcomes for children (e.g., Kitzman et al., 2010; Olds
et al., 2004, 2010). As discussed in Chapter 4, however, a number of ap-
proaches have shown no or minimal effects on parenting. The number of
outcomes for which null effects have been found often exceeds the number
for which impacts have been found. Few home visiting programs are univer-
sal, and programswhether universal or notoften miss the highest-risk
parents. In terms of producing significant child outcomes that reduce the
need for additional services, only a few programs have demonstrated cost-
effectiveness. This could, in part, be because these home visiting programs
are not embedded in a larger framework that allows for longer-term and
more varied ongoing services that help address a wide array of parenting
situations.
As discussed in Chapter 4, the U.S. Department of Health and H uman
Services (HHS) currently is sponsoring a national evaluation of various
home visiting models (Michalopoulos et al., 2013), while at the same
time working with states to improve the programs through a Collabora-
tive Improvement and Innovation Network focused on a range of specific
outcomes and processes (Arbour, 2015). The existing research supports at-
tempting to expand the programs with the most evidence while continuing
to improve and study them, as the Health Resources and Services Admin-
istration and Office of Planning, Research, and Evaluation are doing. In
terms of priorities for expansion, universal programs such as Durham Con-
nects and Child First in C onnecticut may warrant consideration because
they capture parents often missed by other programs, including middle-class
parents. They also incorporate screening for special parental needs and con-
nect these parents to needed services. In addition, as discussed in Chapter 4,
two specific p rogramsPlay and Learning Strategies-Infant and My Baby
and Mehave been found to have positive impacts on several important
parent behaviors, including increasing contingent responsiveness, verbal
stimulation, and warmth among socially disadvantaged mothers. Longitu-
dinal follow-ups found later improvements in childrens receptive and/or
expressive language skills and complexity of play, as well as more prosocial
play with their mothers and fewer behavior problems. Such programs might
be especially appropriate for more targeted efforts.
Efforts at expansion would require careful consideration. It is not clear
how transportable these models are and what it would take to implement
them in other places. The most successful programs often were launched
in university-connected settings with access to highly skilled workers. Such
programs have proven difficult to replicate. Using tools developed by imple-
mentation science would be important to support adaptation from one
community to another as evidence-based programs were scaled up (Metz
and Bartley, 2012; Supplee and Metz, 2015).
By carefully evaluating the results from established home visiting pro-

grams (Michalopoulos et al., 2013), incorporating the training and techni-

cal assistance needed to support continuous improvement of these models
(Arbour, 2015), and expanding programs based on evaluations, states and
communities could build more effective home visiting systems that would
best utilize available resources. If a model were selected for implementa-
tion that was not evidence based for a specific community or was new, a
rigorous evaluation once key milestones had been met would be important.
In terms of parenting knowledge, attitudes, and practices, these pro-
grams could focus on attachment, sensitivity to cues and responsiveness,
household organization and routines, and language development through
creation of a stimulating home literacy environment.
Other general parenting education and support programs As discussed in

Chapters 2 and 4, beyond well-baby care and home visitation, a number
of parenting programs developed in recent years provide education and
support on specific aspects of parenting, particularly behaviors that are
associated with furthering childrens academic preparedness, such as use
of language and regular reading to children. These programs are generally
run by nonprofits and supported by a combination of government funds,
foundation support, and fees. Many are designed to serve particular cul-
tural groups, are offered in the native languages of many parents, and are
designed to suit the service networks and needs of local communities. These
programs fill an important niche in a system of parenting education and
support, warranting continued support by government and foundations. As
with other components of the framework, significant additional, carefully
designed research would be needed before the evidence would warrant
taking these efforts to scale. The field would be improved if the relevant
federal and state agencies continued to provide these organizations with
information on the factors that have proven effective in parenting programs
(see, e.g., National Center for Parent Family and Community Engagement,
2015), as well as economic support.
Providing Support in Selecting Child Care

Many parents returning to work will seek infant care in the first year
of their childs life, and by the time most children are ages 5-8, they have
been in some form of nonparental care. Helping parents identify and obtain
quality child care is a key support element in any framework. Low-income
families qualify for child care subsidies under the Child Care Development
Block Grant (discussed in Chapter 3), administered by the states, and one
of the many things states do with those funds is support local child care
resource and referral (CCR&R) agencies. Parents can call such agencies or
go online to find lists of licensed child care providers in their area, includ-

ing providers that participate in the state subsidy system, as a first step in
locating care. In the past 15 years, states also have used their child care
funds for early care and education quality rating and improvement systems
(QRIS), which help consumers know whether a child care setting is meet-
ing state standards in a range of areas; this information also is available
on CCR&R agency Websites. Some states have tried to incentivize families
using subsidies to select care that is of higher quality according to the QRIS
ratings. Given that the subsidy system and CCR&R agencies provide near-
universal access for parents seeking a specific parenting supportchild
care informationthis platform would appear to be a potential lever for
providing additional information about parenting knowledge, attitudes,
and practices, as well as for checking on family well-being. The committee
is not aware of examples of these two specific child care programs being
used for these purposes, and doing so would require developing and testing
new information or program models.
Parenting Programs in Connection with Early Childhood Education

In addition to home visiting, the most widespread parenting programs,
especially for parents of children under 5, are found in in the context of
an early childhood care or education setting (Brooks-Gunn et al., 2000;
Chase-Lansdale and Brooks-Gunn, 2014). As discussed in Chapter 4, these
programs can be categorized as (1) primarily classroom-based services for
children with some parenting education services, (2) primarily classroom-
based services for children with some parent self-sufficiency services, and
(3) comprehensive two-generation programs (such as Educare) that include
multipronged, intensive classroom-based services for children, parenting
education, and parent self-sufficiency programming.
The most widespread and extensive programs are those delivered in
Head Start and Early Head Start; both of these federal programs were cre-
ated to serve low-income children in a manner that includes parent involve-
ment. Most programs focus on helping parents use several of the parenting
practices discussed in Chapter 2, including those related to safety, d
iscipline,
and reading to children. Many of these programs also offer services for
parents designed to strengthen their parenting ability. These services may
include both English language and literacy and parenting classes. As noted
in Chapter 4, however, the nature of the parenting component is highly
variable in these programs, especially in Head Start.
Given the large number of families served by these programs (even
though Early Head Start is available to only a small proportion of eligible
families), the extensive technical assistance and oversight associated with
the programs, the broad community support they command, the potential
benefits of involving parents in their childrens schooling and helping par-

ents carry out reading and other educational activities at home, and the
enrollment of especially disadvantaged children in Early Head Start, these
programs are an important component of any framework. The evidence on
the effectiveness of these programs in changing parenting behavior, usually
maternal behavior, is mixed, especially with respect to Head Start (Love et
al., 2002, 2005; Puma et al., 2012). Nonetheless, as detailed in Chapter 4,
several programs focused on parent training and parent engagement in
school have proven effective for changing both parent behavior and child
outcomes, and much of this effectiveness has been demonstrated with
Head Start children, a population commonly targeted in these intervention
designs. Careful integration of proven parenting programs with Head Start
and other early care and education programs serving low-income families
is needed.
In 2011, HHS released the research-based Head Start Parent, Family,
and Community Engagement Framework, which is intended to improve ser-
vices, with the ultimate goal of having a greater impact on school readiness
(U.S. Department of Health and Human Services, 2011). If these programs
are to play a central role in providing high-quality early care and education
with parenting components, continued quality improvement efforts and
high-quality research on program effectiveness, including investigation of
how to improve the parenting interventions and parent engagement, will
be needed. Of particular benefit might be more experimentation with such
programs as the Research-Based Developmentally Informed Parent Pro-
gram and Parent Corps, which have shown success in enhancing parental
activities that improve childrens learning skills and school performance
(Bierman et al., 2015; Brotman et al., 2013). It would be equally benefi-
cial to examine programs, such as Head Start-based Educare, that are at-
tempting to address the quality gap found in Head Start programs and to
provide targeted, engaging activities and approaches with parents. Some
technology-based add-on interventions also appear promising but would
require close scrutiny and further consideration as enhancements to the
parenting components of Head Start and Early Head Start.
In addition to Head Start and Early Head Start, there are a number
of other two-generation approaches to helping children and improving
parenting. As noted in Chapter 4, extensive evidence indicates that the
Child-Parent Centers Program in Chicago improved outcomes for children,
both through direct work with the children and by enhancing parenting,
as well as by furthering the well-being of the parents (Reynolds, 1997,
2000). Several new models, described in Chapter 4, that focus on building
both the parents human capital and the childs cognitive and emotional
development are being evaluated in a number of sites. Given the critical
importance of helping parents build their own human capital while pro-
viding high-quality care and early education to their children, support for

such programs by government agencies, philanthropies, and the business

community is warranted.
Parent Engagement in Elementary Schools

As discussed in earlier chapters, the transition to kindergarten and
the early years of school are key times for childrens cognitive and social
development (National Research Council and Institute of Medicine, 2000).
Support and information help parents respond to developmental changes in
their children as well as the new demands and rules of the school system.
Parents interactions with their children and with teachers can facilitate
successful transition and contribute to a childs academic success.
As discussed in Chapter 6, education and family support policy has
increasingly emphasized the central role of parent and family engagement in
young childrens learning and development. The Elementary and Secondary
Education Act (reauthorized in 2015 as the Every Student Succeeds Act) re-
quires that schools and districts have a written policy for engaging families
and that families be included in joint decision making on the development
of these policies. Moreover, recent frameworks for parent engagement and
family-school partnerships have been promulgated by federal agencies.
In 2013, the U.S. Department of Education released the evidence-based
Dual Capacity-Building Framework for Family-School Partnerships, which
places a central focus on relational and collaborative approaches to effec-
tive partnering of schools with parents and families (U.S. Department of
Education, 2013). This framework also details present capacity challenges
to family-school partnerships, necessary conditions for successful programs
and policies for promoting such family-school partnerships, and recom-
mendations for intermediate capacity goals and critical outcomes for these
programs and policies.
As outlined in a recent policy statement from HHS and the U.S. Depart-
ment of Education (U.S. Department of Health and Human Services and
U.S. Department of Education, 2016), several obstacles presently impede
the implementation and sustained use of best practices in parent engage-
ment. These obstacles include enduring perceptions that parent engagement
is a supplement to rather than a core element of high-quality early educa-
tion; a dearth of official requirements or guidance at the local, state, and
federal levels to ensure and incentivize the implementation of these best
practices; a lack of attention to cultural and linguistic moderators of ef-
fective practices; and an early education workforce that lacks professional
preparation in implementing these practices. These issues would need to be
addressed in developing this aspect of a system for enhancing the role of
parents in promoting the educational success of their children.

Targeted Programs
In addition to the universal and near-universal programs just discussed,
a comprehensive set of parenting programs would include a variety of pro-
grams offering education and support to selected populations of families
with children ages 0-8. These would include programs serving parents of
children at special educational risk; parents requesting help in parenting
children with special needs or evidencing severe behavioral problems; par-
ents with chronic conditions, such as mental health or substance use prob-
lems that can negatively affect parenting; and families experiencing crises,
such as intimate partner violence or divorce. As discussed in Chapter 5, a
number of programs serving specific populations of parents and children
have been widely studied and proven highly effective and cost efficient, at
least for parents who seek these services. In providing targeted services,
communities can choose among a number of evidence-based programs de-
pending on the needs of the communitys families. In the absence of these
programs, many parents would experience great difficulty in helping their
children attain the outcomes identified in Chapter 2.
Parents with Children with Special Needs or Behavioral Problems

As discussed in Chapter 5, there is strong evidence for the value of par-
enting programs that help parents meet the special needs of their children,
including programs for parents who seek advice on parenting children with
disabilities and children with behavioral problems.
Most training and support for parents of children with special needs is
provided in connection with the Individuals with the Disabilities Education
Act (IDEA) (Public Law No. 94-142). As discussed in Chapter 5, a number
of effective program approaches are designed to meet the special needs of
children with various disabilities. The basic issue is that these services are
not available to all families who need them. Expanding the availability of
parent-oriented services through IDEA could greatly enhance the effective-
ness of a national system for supporting parenting.
With respect to helping parents work with children with behavioral
problems, several well-researched programs, including the Incredible Years,
Parent-Child Interaction Therapy, Triple P, and child-parent psychotherapy,
described in Chapter 5, clearly produce good outcomes when parents are
voluntarily engaged in participation. Providing access to one or more of these
programs for all children and parents who need them could be expected to in-
crease the number of children achieving the outcomes for child development
described in Chapter 2 and also help avoid the need for more costly services.
Critical to serving many of these children and their parents is more sup-
port for childrens mental health services. A strong childrens mental health

department or unit within local health departments or programs (e.g.,

federally qualified health centers) could provide the direction, oversight,
and technical assistance needed to ensure that these services are adequate.
Consistent, high-quality mental health consultation offered to primary
care providers and nutrition and education programs such as WIC and
Early Head Start also could be tested and, if found effective at diminishing
developmental disruptions caused by child conduct problems, expanded.
Parents Needing Support for Their Special Needs

As discussed in Chapter 5, a significant number of parents struggle
with conditions or circumstances that may impair their ability to engage in
the positive parenting practices discussed in Chapter 2. These adversities
include mental illness, substance use, and intimate partner violence.
The components of a system for supporting parents experiencing one or
more of these adversities and protecting the development of their children
would include quality care focused on the parents or family conditions and
the addition or expansion of services designed to help these parents provide
adequate parenting. Adequate treatment could be available to help these
parents overcome or cope with mental illness or substance abuse problems.
Provision of a comprehensive set of services for mothers and fathers expe-
riencing intimate partner violence would also be important.
As discussed in Chapter 5, providers of treatment services for mental
illness and substance abuse often do not determine whether individuals
seeking treatment are parents, thereby missing an opportunity to provide
them with parenting support. Offering these parents such support is likely
to be beneficial not only for their children but also for the success of treat-
ment. Evidence-based approaches for providing this support are discussed
in Chapter 5. In addition, parents experiencing these problems would ben-
efit if home visitors and staff in universal and near-universal programs like
Early Head Start, WIC, and other early childhood programs were trained in
identifying such parents and connecting them with treatment and parenting
training services.
Support for Parenting Following Divorce

About one-half of children will experience a parental divorce, and one-
half of those children will experience a second divorce (Centers for Disease
Control and Prevention, 2015). Divorcing parents are, on average, 30 years
old at the time of divorce, often having one or more children younger than
age 8 (Centers for Disease Control and Prevention, 2015). Whereas most
divorces do not entail a high level of conflict between the parents, many
do, both during the divorce proceedings and thereafter (Fabricus et al.,

2012). Such conflict can be extremely harmful to children (Amato and

Keith, 1991).
As noted in Chapter 5, a number of courts have introduced programs
designed to minimize conflict and to improve parenting following divorce.
A small number of states currently mandate that all divorcing parents par-
ticipate in court-affiliated parenting education programs, with the goals of
preventing future parental conflict and helping to minimize negative effects
of the divorce on children (Sandler et al., 2015). Even though research has
found that several high-quality programs can, to a modest degree, reduce
conflict and improve parenting after divorce (Pruett and Barker, 2010;
Sandler et al., 2015), these programs have not been successfully taken to
scale. Given the potential for highly negative consequences from divorce,
at least in cases of high conflict, states might want to develop and assess
programs focused on these divorces. In situations involving intimate partner
violence, however, safety needs to be a priority since continued contact with
an abusive parent can harm both the nonabusive parent and the children.
Families with Persistent Adversities

The above framework is comprised largely of a set of separate pro-
grams that generally are not integrated, and many are short term. For many
parents, participation in a single evidence-based program may be sufficient
to help them acquire and effectively use the particular knowledge and skills
they need to help their children achieve the desired outcomes discussed in
Chapter 2, especially if they have access to ongoing support through well-
child care providers, family, and community.
Some parents, however, would benefit from more intensive, longer-
term, and more integrated services designed to strengthen and support their
parenting. These are typically parents experiencing persistent adversities
that often prevent them from providing parenting that is more than mini-
mally sufficient, and, at times, even minimally sufficient care.
A variety of indicators led the committee to estimate that from 10 to
20 percent of all children reside in families that need considerable ongo-
ing support if parents are to provide consistently sufficient parenting. One
strong indicator is the number of parents reported to child welfare services.
As noted in Chapter 5, approximately 12 percent of children experience a
substantiated instance of maltreatment by the time they are age 18; nearly
6 percent do so by age 5 (Wildeman et al., 2014). The percentages are con-
siderably higher for some subgroups of children. Several studies have found
that the majority of these families are reported to child welfare services
more than once in a 5-year period (Lohman et al., 2004; Putnam-Hornstein
et al., 2015). Other evidence indicates that an additional 5 to 10 percent

of parents need this support but are not reported to child welfare services
(Wald, 2013).
As described in Chapter 5, the threats to children posed by the be-
haviors of some parents may require intervention through child welfare
services to ensure childrens basic safety. But as discussed in Chapter 5,
child welfare services represent a residual system that is instituted when the
parents already are evidencing highly problematic behavior that falls within
a states definition of child maltreatment or that constitutes a substantial
risk of child maltreatment. These services are typically short term and are,
primarily, invoked to make a decision about whether there is a sufficient
safety concern to warrant court intervention. As discussed in Chapter 5,
even when there is a finding of child maltreatment, child welfare services
are not well designed to work with families experiencing chronic adversi-
ties and are often not successful in helping themhence the high level of
re-reporting to child welfare services.
Child welfare services experience considerable difficulty in responding
to the needs of these families and children, beyond protecting the children
from immediate harm. Child welfare services are not organized, or au-
thorized, to provide ongoing, integrated services beyond a limited p eriod
of time, usually no more than 6-12 months (see Chapter 5 and Wald,
2013). One national study of parents receiving in-home services follow-
ing a child abuse investigation found that the parent skills training lasted
only 5 months (Casanueva et al., 2012). These parenting programs are
focused primarily on the narrow challenge of helping parents interact more
effectively with their children. There are no evidence-based practices for
these children and families that last more than 1 year on average; only one
programchild-parent psychotherapycomes close to providing services
of this duration. Most cases in which child welfare services are involved are
responded to episodically and briefly. Rarely are children separated from
their families and placed with foster parents, in guardianship, or in adop-
tion (Wulczyn et al., 2005).
Further, many parents experiencing persistent adversities do not maltreat
their children but could benefit from ongoing access to intensive services that
would help them to address problems related to mental illness, substance
abuse, intimate partner violence, and persistent poverty and homelessness.
In addition to the need for longer-lasting support, many of these families
need more coordinated support to maximize the benefit they receive from
a variety of service providers, given their personal issues and the challenges
entailed in navigating the current fragmented system of services. In general,
parenting programs are designed to help well-resourced families change just
one or a few of their childrens problematic behaviors (especially external-
izing behavior), not to assist children who may have developed multiple
problems of their own and are living in exceptionally troubled families.

A system of servicesone that facilitates ongoing access to needed

services and encourages their utilizationis needed to support parents fac-
ing multiple adversities. Such a system is needed both for families that do
not require intervention by child welfare services and to supplement the
limited services offered to parents under the supervision of child welfare
services. Such a system could facilitate the receipt of multiple interventions
by parents and young children that are informed by screening, linked by
personal care coordination and information technology, and provided in a
timely way to reduce the burden of exceptional adversities.
The committee recognizes that there currently exist no available exam-
ples of a system at scale that uses screening to identify high-risk families and
then provides continuous engagement, monitoring, and services. There are,
however, elements of existing approaches that can provide the beginnings
for the creation of such a system. In addition, as discussed in Chapter 5, a
system of services is in place to help parents with children who have spe-
cial needs. IDEA and other legislation require the establishment of a broad
system, albeit not fully funded, that provides for screening and connection
to services for these families. This structure might serve as a model for the
development of a system for parents with special needs. Another promising
model discussed earlier is health care for families who have children with
chronic health conditions that require intensive monitoring and assistance.
How these family well-being services might be configured could depend
on state differences, but maternal and child health, well-child care, and early
and elementary education programs would all need to have a significant role.
Such a system could begin with screening for significant adversities
during pregnancy and at birth within prenatal and obstetric care, WIC,
well-child visits, and home visiting programs, much like existing screening
for children with disabilities. The goal would be to identify parents need-
ing more intensive services and help them access these services. Linkages
would be made to the universal or targeted parenting programs and types
of support discussed above. Providers also would need sufficient time to
perform this screening and linkage to other services. As discussed in Chap-
ters 4 and 5, several programs, including Healthy Steps, Durham Connects,
and Family Check-Up, currently perform such screening, and studies have
found their approaches to be effective in helping parents and children (e.g.,
Dishion et al., 2014; Koniak-Griffin et al., 2003; Piotrowski et al., 2009).
In addition, continued efforts to improve parenting interventions in Early
Head Start, Head Start, and early childhood special educationand to have
an available plan for ongoing receipt of services for families that have too
many interfering experiences to be able to benefit from these parent training
programswould be necessary.
While the exact set of services offered to these parents and children
would need to be individually tailored, many parents would need ongoing

access to treatment for mental illness, substance use, or other problems,

while their children would need to be enrolled in quality child care and
early education services that include strong parenting programs. Recently
there have been investments in programs aimed at providing high-quality
education, job training, and career-building services for low-income par-
ents, along with instruction in parenting skills (Chao et al., 2014). Several
efforts to evaluate some of these programs are now under way (Haskins
et al., 2014). Some evidence suggests that when parents with a history of
maltreatment and their preschoolers participate in both Head Start and
Incredible Years, the parents make significant improvements in their parent-
ing practices (Hurlburt et al., 2013). Given that strong evidence on their
impacts is currently unavailable, it is impossible to determine whether this
new generation of programs will change parenting knowledge, attitudes,
and practices or improve child well-being. The importance of serving these
populations warrants continued support for conducting and evaluating
these experiments, but it is unclear whether and how they might be incor-
porated into a national framework for supporting parenting.
Another important element of such a system might be having a method
for periodic check-in with parents. Recent advances in information tech-
nology might enable staff of a neutral source, such as a health department
or school-based program, to monitor the progress of children in these
families, and to determine whether the children are experiencing devel-
opmental problems and whether they and their parents are receiving the
supportive services they need. The monitoring entity could then reach out
to families who needed services but with which the service system had
lost contact. Another approach might be to use a care coordinator who
would remain in contact with parents on an ongoing basis, help parents
monitor their childrens progress, encourage those who would benefit from
additional services to seek those services out and help them do so, and
collaborate with parent support professionals and relevant institutions
(e.g., schools and mental health services) to implement effective parent-
ing interventions. In addition, a number of organizations are establishing
peer-to-peer support networks that help perform these functions. Such net-
works can serve to reduce the isolation often found among families facing
chronic adversities and may be very attractive to parents, enhancing their
engagement and retention in network activities. As discussed in Chapter 6,
an important feature of all these approaches is that they be co-designed
with parent representatives and communities so as to achieve the greatest
potential for appealing to parents and not being viewed as threatening. At
the same time, these support networks would need to be very clear with
parents about the professionals responsibility for making reports to child
welfare services, as needed, if the risk to their childs well-being reached
the mandated reporting threshold.

Information technologies and tools also could be used to assist in com-

municating across professional settings to facilitate continuous and coor-
dinated parenting support mechanisms. Such an information infrastructure
might have features characteristic of Facebook (voluntary and allowing
multiple parties to communicate with a network of individuals concerned
about a single individual) and combined with a linked information system
that would capture information across health, human service, financial as-
sistance, and correctional agencies. It might be hoped that parents would
see the advantage of not needing to repeat information that had previ-
ously been gathered and the benefit of having better coordination between
themselves and people trying to help them. As these tools were developed,
parent support professionals could be trained to use them in an ethical and
effective manner.
While the system outlined above entails attempting to connect with
high-risk parents as early as possible, the system would be designed to
engage parents whenever there were indications that more intensive and
coordinated services might be needed. Children and families with such
needs could be identified by health care providers, child care and early
education personnel, and even family members. While earlier is better,
research is clear that even when at-risk children are entering elementary
school, it is not too late for effective programs to provide significant ben-
efit. For example, children recruited into the Fast Track intervention during
kindergarten because of their high level of problem behaviors were able to
benefit from this school- and family-focused program (Conduct Problems
Prevention Research Group, 2011). Although the advantages of the services
were not evident at every follow-up period, important benefits with respect
to decreased drug use, crime, and risky sexual behavior and increased well-
being outcomes were seen even at age 25 (Conduct Problems Prevention
Research Group, 2015).
CONCLUDING THOUGHTS
Governments at all levels currently invest substantial resources with the
goal of helping children attain the outcomes identified in Chapter 2. Yet
large numbers of children still do not attain one or more of the outcomes.
As discussed in this and many other reports (Center on the Developing
Child at Harvard University, 2016; National Research Council and Insti-
tute of Medicine, 2000, 2009), enhancing the ability of parents is a key
component of a national strategy for promoting the well-being of children
and families. Implementation of the framework outlined in this chapter
could reduce the burden on parents seeking out the services they need and
help programs focus on delivering services rather than filling their slots.
By building on and improving existing service platforms, this framework

could serve as an engine for enhancing parenting knowledge, attitudes, and

practices associated with healthy child development and ultimately improv-
ing child and family well-being by helping all families, as well as providing
access to more intensive services to those families that need them most.
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Conclusions and Recommendations
This chapter presents the committees conclusions and recommenda-

tions. As directed in the statement of task for this study (Box 1-2 in Chap-
ter 1), the recommendations focus on promoting the wide-scale adoption
of parenting knowledge, attitudes, and practices associated with healthy
child development and effective intervention strategies, as well as identify-
ing priorities for future research.
SCALING EFFECTIVE INTERVENTIONS
Using Existing Platforms to Promote Parent Support

As described in Chapters 4 and 5, a number of intervention strategies
currently have strong evidence of effectiveness for supporting parents well-
being and their use of practices associated with positive child outcomes.
The committee was unable to identify a single intervention that supports
all of the knowledge, attitudes, and practices identified in Chapter 2 for all
groups of parents. However, intervention research has identified a number of
strategies with robust evidence for supporting particular parenting practices
in specific settings or among specific population groups. Yet many families
who could benefit from these interventions neither seek out nor are referred
to them. To better support parents and children, then, improved referral
mechanisms are needed. Millions of parents interact with health care (e.g.,
well-child and mental and behavioral health care), education (e.g., early care
and education and formal prekindergarten to grade 3), and other commu-
nity services each year. Along with improvements in workforce preparation
381

(see Recommendations 3 and 4 below), better leveraging the services with

which many parents already have ongoing connections as points of interven-
tion and referral would help improve the reach of effective strategies.

vices, the U.S. Department of Education, state and local agencies, and
community-based organizations responsible for the implementation of
services that reach large numbers of families (e.g., health care, early care
and education, community programs) should form a working group to
identify points in the delivery of these services at which evidence-based
strategies for supporting parents can be implemented and referral of
parents to needed resources can be enhanced. Based on its findings, the
working group should issue guidance to service delivery organizations
on increasing parents access to evidence-based interventions.
Strengthening Evidence on How to Scale Parenting Programs

Research on how to bring effective parenting programs to scale is lim-
ited. Although a number of programs are effective in supporting parents,
their potential for helping large numbers of families often depends on factors
specific to the families served and to the organizations and communities in
which they will be implemented (Axford et al., 2012; Katz et al., 2007).
Additional evidence is needed to inform the creation of a system for effi-
ciently disseminating evidence-based programs and services to the field and
for ensuring that a wide range of communities learn about them, are able
to assess their fit with community needs, develop needed adaptations, and
monitor fidelity and progress toward targeted outcomes.
Recommendation 2:1 The U.S. Department of Health and Human

Services, the Institute of Education Sciences, the Patient-Centered Out-
comes Research Institute, and private philanthropies should fund re-
search focused on developing guidance for policy makers and program
administrators and managers on how to scale effective parenting pro-
grams as widely and rapidly as possible. This research should take into
account organization-, program-, and system-level factors, as well as
quality improvement. Supports for scaling efforts developed through
this research might include cost tools, measurement toolkits, and imple-
mentation guidelines.
1This recommendation, along with Recommendations 4, 6, and 10 were modified following
the transmittal of the report to the study sponsors. In particular, the U.S. Department of Health
and Human Services (HHS) was inserted to replace the names of specific agencies within HHS
to allow HHS to decide the most appropriate agencies to carry out the recommendations.

CONCLUSIONS AND RECOMMENDATIONS 383
Implementation of this recommendation should not delay or preclude

implementation of Recommendation 1. Rather, findings from this research
could be used in an ongoing way to inform the integration of evidence-
based interventions into widely used service platforms.
Enhancing Workforce Competence in Delivering

Evidence-Based Parenting Interventions
A professional workforce with knowledge about and competencies for
implementing evidence-based interventions to support parents is essential to
the successful scale-up of effective approaches. The committee found that
evidence-based parenting interventions often are not available as part of
either routine services for parents or services, such as treatments for mental
illness and substance abuse, not designed specifically for parents but with
the potential to benefit many parents (Barth et al., 2005; Garland et al.,
2010; Institute of Medicine, 2015). One reason for this is that providers
of these services often lack knowledge and competencies in evidence-based
parenting interventions. Graduate training for providers of childrens ser-
vices and behavioral health care (e.g., in schools of social work and nursing)
generally includes limited or no coursework on evidence-based parenting
programs or their core elements. A viable way to increase the availability
of evidence-based parenting interventions is to build on the commonality
of specific and nonspecific elements across interventions (Institute of Medi-
cine, 2015). Although further research in this area is needed, the common
elements approach has been shown to outperform usual care in at least one
randomized clinical trial addressing children with mental health problems
(Chorpita et al., 2013).
Recommendation 3: The U.S. Department of Health and Human Services

should continue to promote the use of evidence-based parenting inter
ventions. In so doing, it should support research designed to further op-
erationalize the common elements of effective parenting interventions and
to comparethe benefits of interventions based on the common elements
of effective parenting programs with the specific evidence-based programs
from which the elements originated. These efforts also should encom-
pass (1) development of a common terminology for describing common
elements and creation and testing of corresponding training materials;
(2) development of an open-source curriculum, fidelity-checking strate-
gies, and sustainability strategies for use in educating health and human
service professionals in the delivery of evidence-based parenting interven-
tions; and (3) creation of a variety of incentives and training programs to
ensure knowledge of effective parenting interventions among professional
groups working with young children and their families.

Enhancing Workforce Knowledge and Competence in Parent Engagement

Parents engagement in young childrens learning is associated with im-
provements in childrens literacy, behavior, and socioemotional well-being
(Dearing et al., 2006; Fan and Chen, 2001; Fantuzzo et al., 2004; Gadsden,
2014; Jeynes, 2012; Sheridan et al., 2010). Engagement is a process that can
be facilitated by provider skills in communication and joint decision m
aking
with diverse families about their childrens education (U.S. Department of
Health and Human Services and U.S. Department of Education, 2016).
The Institute of Medicine and National Research Council (2015) report
Transforming the Workforce for Children Birth through Age 8 identifies as
important competencies for all professionals providing direct, regular care
for young children the ability to connect with families in a way that is mu-
tually respectful and reciprocal, set goals with families, and prepare them
to engage in behaviors and activities that enhance childrens development
and early learning. However, the committee found that programs designed
to prepare individuals to work with young children do not always include
evidence-informed strategies for creating successful partnerships with fami-
lies. Despite growing recognition that partnerships with families contribute
to the success of early childhood programs and schools in preparing chil-
dren for academic success, as well as an emphasis on family engagement in
statutes and policies, programs designed to prepare teachers and providers
often do not include professional development related to working with par-
ents (U.S. Department of Health and Human Services and U.S. Department
of Education, 2016). Moreover, courses on interacting with diverse families
show substantial variation. The committees review of state/territory/tribal
credentials for early education professionals revealed that only 12 states
require a course or workshop on families, and just 5 states require a course
on addressing the needs of culturally and ethnically diverse families.

vices and the U.S. Department of Education should convene a group of
experts in teaching and research and representatives of relevant practice
organizations and research associations to review and improve profes-
sional development for providers who work with families of young
children across sectors (e.g., education, child welfare, health). Profes-
sional development should be evaluated as to whether its core elements
include best practices in engagement of and joint decision making
with parents, across diverse family structures with other parental care
givers, as well as evidence-informed programs that support parents.
The expert group should identify appropriate courses to address issues
of parents and develop appropriate course plans and frameworks for
professional development where they are lacking. Courses and course-

work on parent engagement for educators of young children should

be aligned with the knowledge and competencies outlined in the 2015
Institute of Medicine and National Research Council report Transform-
ing the Workforce for Children Birth through Age 8.
Developing and Disseminating Best Practices in Parent Engagement

Studies have documented the effectiveness of joint decision making
(parents as partners) and other approaches to parent-teacher collabora-
tion in education (Dearing et al., 2015; Gadsden, 2014; Henderson and
Mapp, 2002; Sheridan et al., 2010, 2014). Accordingly, the Elementary and
Secondary Education Act requires that school districts develop and imple-
ment parent engagement policies designed to bolster student outcomes. Yet
despite the availability of evidence-based approaches for increasing parent
engagement in childrens learning and thereby improving child develop-
ment outcomes, limited official guidance is available on how to do so (U.S.
Department of Health and Human Services and U.S. Department of Educa-
tion, 2016). In addition to obstacles related to workforce preparation, the
implementation and sustained use of best practices in parent engagement
are limited by a dearth of official guidance at the local, state, and federal
levels, as well as a lack of attention to how families culture and language
may moderate the effectiveness of school districts engagement plans (U.S.
Department of Health and Human Services and U.S. Department of Educa-
tion, 2016).

vices and the U.S. Department of Education should convene experts
in parent engagement to create a toolbox of evidence-informed en-
gagement and joint decision-making models, programs, and practices
for implementation in early education settings. The U.S. Department
of Health and Human Services and U.S. Department of Education
should disseminate this toolbox to support state and district adher-
ence to requirements for parent engagement such as those described
in the Elementary and Secondary Education Act, as well as to sup-
port the effective use of parenting interventions by health, behav-
ioral health, and community programs with which parents and their
children often have sustained and important connections. Toolbox
development and disseminationefforts should include parents from
diverse language and cultural backgrounds.

COMMUNICATING EVIDENCE-BASED
PARENTING INFORMATION
Parents with knowledge of child development compared with parents
without such knowledge have higher-quality interactions with their young
children and are more likely to engage in parenting practices associated
with childrens healthy development (Benasich and Brooks-Gunn, 1996;
Hess et al., 2004; Huang et al., 2005). Moreover, parents with versus those
without knowledge of parenting practices that lead to healthy outcomes
in children, particularly practices that facilitate childrens physical health
and safety, have been found to be more likely to implement those practices
(Bryanton et al., 2013; Chung-Park, 2012; Corrarino et al., 2001; Katz et
al., 2011). Although simply knowing about parenting practices that pro-
mote child development or the benefits of a particular parenting practice
does not necessarily translate into the use of such practices, awareness is
foundational for behavior that supports children.
When designed and executed carefully in accordance with rigorous
scientific evidence, public health campaigns are a potentially effective low-
cost way to reach large and heterogeneous groups of parents. Exemplar
public health campaigns have addressed tobacco control, seat belt use,
sudden infant death syndrome, and illicit drug use (Hornik, 2012). More-
over, information and communication technologies now offer promising
opportunities to tailor information to the needs of parents based on their
background and social circumstances.
Several important ongoing efforts by the federal government and private
organizations (e.g., Centers for Disease Control and Prevention, 2016; ZERO
TO THREE, 2016) communicate information to parents on developmental
milestones and parenting practices grounded in evidence. Yet communication
inequalities exist in how such information is generated, manipulated, and dis-
tributed among social groups and also at the individual level in the ability to
access and take advantage of the information (Viswanath, 2006). Parenting
information that is delivered via the Internet, for example, is more difficult
to access for some parents, including linguistic minorities, families in rural
areas, and parents with less education (File and Ryan, 2014).

vices and the U.S. Department of Education, working with state and
local departments of health and education and private partners, in-
cluding businesses and employers, should lead an effort to expand and
improve the communication to parents of up-to-date information on
childrens developmental milestones and parenting practices associated
with healthy child development. This effort should place particular
emphasis on communication to subpopulations that are often under-

served, such as immigrant families; linguistic, racial, and ethnic minori-

ties; families in rural areas; parents of low socioeconomic status; and
fathers. Given the potential of public health campaigns to promote
positive parenting practices, this effort should draw on the latest state
of the science of such campaigns. The effectiveness of communication
efforts also should be evaluated to enhance their success and to inform
future efforts.
ADDRESSING GAPS IN THE

RESEARCH-TO-PRACTICE/PRACTICE-TO-RESEARCH PIPELINE
The committee identified a number of interventions that show promise
in supporting the parenting knowledge, attitudes, and practices described
in Chapter 2 for specific groups of parents and children. Further research is
needed to understand whether and how these interventions should be scaled
up to serve all parents who would benefit from them.
To best guide policy and practice, it is important that such research
focus on major gaps in current knowledge and that it use those method-
ologies most likely to produce evidence that can inform policy or practice.
These gaps include interventions previously subjected to rigorous evalua-
tion but not tested in diverse populations; interventions that may have been
limited by their mother-only focus; and the lack of interventions focused on
parents needing services for personal issues, such as mental illness.
More research also is needed on cases in which parenting interventions
have been layered onto another intervention and (1) their unique benefit
(separate from that of the primary intervention) has not been adequately
assessed or (2) the parenting component was found to have no impact. Ex-
amples of parenting interventions that fall into one or both of these catego-
ries are enhanced anticipatory guidance, which can be provided as part of
well-child care; parenting interventions delivered in conjunction with treat-
ment for parents who have mental illness or substance abuse or are experi-
encing interpersonal violence; parenting interventions delivered using new
information and communication technologies; and parenting components
in Head Start, Early Head Start, and the Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC). Although evaluation of
these layered parenting interventions has been limited, many of them have
shown promising initial findings and been supported by sizable public and
private investment; thus it is important for both research and practice to
optimize opportunities to learn from these investments and build on this
existing work. Each of the above examples offers multiple opportunities
for researchers to learn from practitioners and for practitioners to work
with researchers to identify possibilities for improving both research and
interventions and engaging parents.

To generate research that would produce policy-relevant findings, the

federal government could sponsor a relatively small number of studies
involving large and diverse samples. Most likely to produce findings that
would be cumulative and translatable into policy and practice would be a
research agenda based on three to five parenting behaviors clearly related to
child outcomes, entailing studies that would utilize the same small number
of measures and instruments. This research also could focus on evaluating
the cost of programs and avenues through which evidence-based programs
could be funded.
The evidence-based process used by the Department of Health and
Human Services to design, fund, and implement the Maternal, Infant,
and Early Childhood Home Visitation (MIECHV) Program (Health Re-
sources and Services Administration, 2016), described in Chapter 4, could
serve as a model for future research and practice aimed at improving pro-
grams designed to support parents and parenting knowledge, attitudes, and
practices associated with positive child outcomes. MIECHV began with a
systematic review of the evidence, followed by a state competition for fund-
ing that required the use of a consistent set of performance measures, rigor-
ous local evaluation, and participation in a national evaluation. The Health
Resources and Services Administration also has implemented collaborative
improvement and innovation networks to facilitate ongoing learning and
improve models for supporting parenting knowledge, attitudes, and prac-
tices in the areas of home visiting and infant mortality prevention (Arbour,
2015) that could inform the refinement and implementation of other types
of parenting supports.
Recommendation 7: The secretary of the U.S. Department of Health

and Human Services and the secretary of the U.S. Department of Edu-
cation should launch a national effort to address major gaps in the
research-to-practice/practice-to-research pipeline related to parenting.
This effort should be based on an assessment aimed at identifying the
gaps in knowledge that if filled would most advance parenting-related
policy and practice. The effort should include (1) systematic review of
the evidence for the selected areas; (2) further development and testing
of the most promising interventions; (3) research on newly developed
and existing interventions conducted through collaborative improve-
ment and innovation networks; and (4) rigorous efficacy, effectiveness,
and implementation studies of promising programs and policies. In
funding decisions, priority should be given to examining interventions
delivered in the context of services that reach large numbers of families,
such as prenatal care, well-child care, Head Start and Early Head Start,
and parent engagement in the early grades.

Three important areas of need for additional research are described

in Recommendations 8, 9, and 10 below, all of which address popu-
lations of parents on which relatively little evidence-based research has
been conducted and for which few evidence-based interventions have been
developed.
STRENGTHENING THE EVIDENCE ON STRATEGIES

FOR SUPPORTING PARENTS WITH SPECIAL NEEDS
Many parents in the United States cope with personal challenges, such
as mental illness, substance abuse, and intimate partner violence, as well
as the stigma that is often associated with these challenges, that can re-
duce their ability to use effective parenting practices and their access to
and participation in evidence-based parenting interventions. As reviewed
in Chapter 5, relatively little is known about how best to support parents
and parenting practices grounded in evidence for families with such special
needs. Research is needed to realize the potential of available interventions
that show promise for parents with special needs, as well as to develop
new interventions that reflect emerging knowledge of how to support these
parents. The strengths of evidenced-based training in parenting skills o ffer
a foundation for improving existing and developing new interventions that
can serve greater numbers of families with special needs, including by pro-
viding a setting of trust in which parents can reveal their needs.

vices and the U.S. Department of Education, in coordination with pri-
vate philanthropies, should fund research aimed at evaluating existing
interventions that have shown promise with and designing and evaluat-
ing new interventions for parents with special needs. The design of new
interventions should be informed by elements of successful programs,
which include treating parents as equal partners, tailoring interventions
to meet families needs, making programs culturally relevant, ensuring
service integration and collaboration for families with multiple needs,
providing opportunities for peer support, addressing trauma, and tar-
geting both mothers and fathers. Funders should incentivize the use of
state and local data to support this research.
STRENGTHENING THE EVIDENCE ON FATHERS

Childrens development is shaped by the independent and combined
effects of myriad influences, especially their mothers and fathers and the
interactions between them. During the early years, parents are the most
proximaland most importantinfluence on childrens development.

Substantial evidence shows that young children have optimal devel-

opmental outcomes when they experience nurturing relationships with
both fathers and mothers (Cabrera et al., 2006; Lamb, 2004; Pruett, 2000;
Ramchandani et al., 2013; Rosenberg and Wilcox, 2006). Research also
demonstrates that children benefit when parents who are living in the same
household are supportive of each other and are generally consistent in their
expectations for the child and in their parenting behaviors. Further, there
is evidence that when parents live apart, children generally benefit if they
have supportive relationships with each parent, at least in those cases in
which the parents do not have negative relationships with each other. In
contrast, children are placed at risk when their parents experience conflict
or when they have very different expectations for the child, regardless of
whether the parents are living together or apart. Yet despite the importance
of the father-child relationship, fathers continue to be underrepresented in
research on parenting and parenting support (Fabiano, 2007; Panter-Brick
et al., 2014; Smith et al., 2012). Moreover, very few interventions aimed
at improving mother-child relationships also target father-child or mother-
father-child relationships, whether the parents are living together or apart.
When parents are living apart, fatherhood programs typically focus on
building fathers economic capacity to parent, such as through employment
or counseling, rather than on fostering father-child relationships that can
support childrens development.
More research is needed on how to design parenting programs so
they better engage fathers and enhance the parenting of both parents. Few
studies have evaluated how the dyadic and reciprocal interactions between
parents and between fathers and their children affect childrens develop-
ment. Research is needed to identify promising interventions for parents
both in their individual relationships with their children and in their co-
parenting role.
Research also is needed to understand how nonresident fathers can
establish long-lasting warm and nurturing relationships with their children.
Although steps have been taken to increase evidence-based and empirically
rigorous evaluations of fathering programs serving noncustodial fathers
(e.g., the federally funded Fatherhood Research and Practice Network)
(Fatherhood Research and Practice Network, 2016), these studies are still
in their early stages and may be minimally focused on changes in child
outcomes.

vices, in coordination with the U.S. Department of Education and
other relevant federal agencies, private philanthropies and foundations,
researchers, and research associations focused on children and families,
should increase support for studies that can inform the development

and improvement of parenting interventions focused on building par-

ents capacity to parent both individually and together. Such studies
should be designed to identify strategies that can improve fathers
knowledge and use of parenting practices associated with positive child
outcomes, and should examine the unique and combined effects of
individual and co-parenting practices, with special attention to build-
ing strong relationships between parents and within diverse parenting
relationships. The research should focus not only on adult but also on
child outcomes, and should be designed to shed light on the specific
ways in which greater investments in co-parenting can lead to better
outcomes for children. Existing efforts to provide parenting support for
both mothers and fathers should be reinforced and expanded in such
programs as the Maternal, Infant, and Early Childhood Home Visita-
tion program, Head Start, and Early Head Start.
STRENGTHENING THE EVIDENCE FOR DIVERSE POPULATIONS

The U.S. population of young children and their parents is demographi-
cally, culturally, linguistically, and socially diverse. Although research sug-
gests that some parenting knowledge, attitudes, and practices vary across
groups (Brooks-Gunn and Markman, 2005; Brooks et al., 2013; B urchinal
et al., 2010; Leyendecker et al., 2002; Rowe, 2008), little is known about
whether and how these differences matter for childrens development. More-
over, relatively little is known about how engagement with, acceptance
of, retention in, and the efficacy of interventions for parents vary across
culturally and linguistically diverse subgroups. Finally, despite increasing
diversity in family structure, data are lacking on how parenting, engagement
in interventions and services, and efficacy of services may vary for diverse
family forms (e.g., same-sex parents), kinship providers (e.g., grandparents),
stepparents, and other adults assuming parental roles (e.g., foster or adop-
tive parents). Filling these gaps would improve the ability of evidence-based
programs and policies to support the needs of the range of families and
children while addressing the needs of parents from historically marginalized
and underrepresented populations.
Recommendation 10: The U.S. Department of Health and Human

Services and the U.S. Department of Education should launch a multi
pronged effort to support basic research on parenting and applied
research on parenting interventions across diverse populations and
family forms. Basic research should include the identification of (1) key
constructs and measures related to successful parenting among different
populations; (2) important gaps in knowledge of how parenting prac-
tices and parent-child interactions affect child outcomes in culturally,

ethnically, and socially diverse groups; and (3) constraints that produce
disparities in access to and utilization of resources that support parent-
ing across groups and contribute to negative outcomes for parents and
children. Applied intervention research should include the formation of
a collaborative improvement and innovation network to develop new
and adapt existing interventions for diverse groups, and support for
rigorous efficacy, effectiveness, and implementation studies of the most
promising programs and policies conducted in a manner consistent
with Recommendation 7 above.
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Appendix A
Public Session Agendas
PUBLIC INFORMATION-GATHERING SESSION AGENDA
MEETING 1
January 29, 2015
Room 120
National Academy of Sciences Building
2101 Constitution Ave, NW, Washington, DC
1:00 p.m. Welcome and Opening Remarks

Vivian L. Gadsden, Ed.D., William T. Carter Professor of
Child Development and Education, School of Education,
University of Pennsylvania; Committee Chair
1:05 p.m. Remarks on Study Statement of Task from Sponsors

(5 minutes each)
Linda Smith, Administration for Children and Families
Bernadette Sangalang, David and Lucile Packard Foundation
Steven Hicks, Department of Education (Office of
Elementary and Secondary Education)
Carlos Martinez, Department of Education (Office of
English Language Acquisition)
Jacqueline Jones, Foundation for Child Development
395

David Willis, Health Resources and Services Administration

Holly Kreider, Heising-Simons Foundation
Larke Huang, Substance Abuse and Mental Health Services
Administration
By phone:
Megan Wyatt, Bezos Family Foundation
Sarah Weber, Bill & Melinda Gates Foundation
Jennifer Kaminski, Centers for Disease Control and Prevention
2:00 p.m. Committee Discussion with Sponsors
2:40 p.m. Public Comment
3:10 p.m. Concluding Remarks

Vivian L. Gadsden
3:15 p.m. Adjourn Open Session
MEETING 2
April 9, 2015
Room 120
National Academy of Sciences Building
2101 Constitution Ave, NW, Washington, DC
9:00 a.m. Welcome and Introductory Remarks

Vivian L. Gadsden, Ed.D., William T. Carter Professor of
Child Development and Education, School of Education,
9:05 a.m. General and Specific Positive Parenting: Effects on Child

Development
Marc Bornstein, Ph.D., Senior Investigator, Section on Child
and Family Research, National Institute of Child Health
and Human Development (20 minutes)
Discussion and Q & A
Facilitated by: William R. Beardslee, M.D., Gardner/Monks
Professor of Child Psychiatry, Harvard Medical School;
Committee Member

APPENDIX A 397
9:45 a.m. Effect of Changes in U.S. Policy on Parents and Parenting

Kathryn Edin, Ph.D., Bloomberg Distinguished Professor,
Department of Sociology, Zanvyl Krieger School;
Department of Population, Family, and Reproductive
Health, Bloomberg School of Public Health, Johns
Hopkins University (20 minutes)
Facilitated by: Iheoma Iruka, Ph.D., Director of Research
and Evaluation, Buffet Early Childhood Institute,
University of Nebraska; Committee Member
10:25 a.m. Break
10:40 a.m. Panel: Addressing the Needs of Specific Populations

Moderator: Selcuk R. Sirin, Ph.D., Associate Professor of
Applied Psychology, New York University; Committee
Member
Supporting Parents of Young Children in Native American

Communities: Cultural Contexts, Evidence Gaps, and the
Way Forward
Nancy Rumbaugh Whitesell, Ph.D., Associate Professor of
Community and Behavioral Health; Associate Director,
Tribal Early Childhood Research Center; Colorado
School of Public Health, University of Colorado
Anschutz Medical Campus (20 minutes)
Fragility in Affluent Families and Implications for Parenting

Research and Practice
Suniya Luthar, Ph.D., Foundation Professor of Psychology,
Arizona State University; Professor Emerita, Teachers
College, Columbia University (20 minutes)
Strategies for Supporting Low-Income and Welfare-

Dependent Parents of Young Children
Aurora Jackson, Ph.D., Professor of Social Welfare, Lustin
School of Public Affairs, University of California, Los
Angeles (20 minutes)

12:10 p.m. Implementing Evidence-Based Parenting Programs at Scale

Kenneth Dodge, Ph.D., Founding Director, Center for
Child and Family Policy; William McDougall Professor
of Public Policy and Professor of Psychology and
Neuroscience, Duke University (20 minutes)
Facilitated by: Michael Wald, J.D., M.A., Jackson Eli
Reynolds Professor of Law, Emeritus, School of Law,
Stanford University; Committee Member
12:50 p.m. Public Comment (as needed)

Facilitated by: Vivian L. Gadsden, Ed.D., William T. Carter
Professor of Child Development and Education, School
of Education, University of Pennsylvania; Committee
Chair
1:10 p.m. Concluding Remarks

Vivian L. Gadsden
1:15 p.m. Adjourn Open Session
MEETING 3
June 29, 2015
Huntington Room
Arnold & Mabel Beckman Center
100 Academy Drive, Irvine, CA
8:30 a.m. Welcome and Introductory Remarks

Vivian L. Gadsden, William T. Carter Professor of Child
Development and Education, School of Education,
8:35 a.m. Panel 1: Perspectives from Practitioners
Panelists will discuss their perspectives on how parents

and families use supports and services across various
organizations to meet diverse needs; how policies and
programs relevant to families may affect parenting

APPENDIX A 399
practices, with a particular focus on hard-to-reach

families; and the trajectory of policies and programs in
the near future and possible implications for families.
Moderator: Kim Boller, Senior Fellow, Mathematica Policy

Research; Committee Member
Tammy Mann, President and Chief Executive Officer, The

Campagna Center (via WebEx)
Albert Pooley, Founder and President, Native American
Fatherhood and Families Association
Alyce Mastrianni, Director of Health Policy and Programs,
Children and Families Commission of Orange County
Charles Avila, Executive Director, Yes2Kids; Founder,
MENFOLK
9:35 a.m. Behavioral Insights and Parenting Knowledge, Attitudes,

and Practices
Ariel Kalil, Professor and Director of the Center for Human
Potential and Public Policy, Harris School of Public
Policy Studies, University of Chicago (15 minutes)
Discussion with Committee
Moderator: Clare Anderson, Policy Fellow, Chapin Hall;
Committee Member
10:10 a.m. Break
10:20 a.m. Panel 2: Perspectives from Parents
Panelists will discuss their perspectives on the challenges

that parents of young children experience, the types of
services for parents of young children that should receive
more support, and how services can be improved for
families and parents.

Moderator: Elena Fuentes-Afflick, Professor and Vice Chair
of Pediatrics; University of California, San Francisco;
Committee Member
Clarissa Doutherd, Executive Director, Parent Voices Oakland

Sergio Hinojosa, Jr., Parent with Native Dads Network
(NDN)

Maria Rosales, National Trainer for Abriendo Puertas/

Opening Doors
Stacy Williamson, State President, Missouri State Teachers
Association (MSTA)
11:35 a.m. Lessons on Home Visiting Program Implementation from a

Collaborative Improvement and Innovation Network
Mary Catherine Arbour, Associate Physician for Research,
Division of Global Health Equity, Brigham and Womens
Hospital; Senior Research Associate, Center on the
Developing Child, Harvard Medical School (15 minutes)
Moderator: William R. Beardslee, Gardner/Monks Professor
of Child Psychiatry, Harvard Medical School; Committee
Member
12:10 p.m. Parenting in the Context of Culture: Insights from Health

Research
Marjorie Kagawa-Singer, Professor, Department of
Community Health Sciences and Department of Asian
American Studies, University of California, Los Angeles
(15 minutes)
Moderator: Vish Viswanath., Professor of Health
Communications, Harvard School of Public Health;
Director, Health Communication Core, Dana-Farber/
Harvard Cancer Center; Committee Member
12:45 p.m. Public Comment Session

Moderator: Vivian L. Gadsden, William T. Carter Professor
of Child Development and Education, School of
Education, University of Pennsylvania; Committee Chair
1:00 p.m. Final Remarks and Adjourn

Vivian L. Gadsden

Appendix B
Clearinghouses Used to
Identify Interventions with
Evidence of Effectiveness
THE SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATIONS NATIONAL REGISTRY
OF EVIDENCE-BASED PROGRAMS AND PRACTICES1
The National Registry of Evidence-based Programs and Practices
(NREPP) provides publicly available electronic access to information on
more than 350 substance abuse and mental health interventions. NREPPs
registry and review system was established to provide information to the
public about evidence-based programs and practices that are available for
implementation. NREPPs registry, run by the Substance Abuse and Mental
Health Services Administration (SAMHSA), includes only interventions that
undergo NREPPs review process, which provides information on research
quality and impacts on individual outcomes. However, it should be noted
that some, but not all, of the evidence presented online has been reviewed.
Therefore, NREPPs registry is not fully comprehensive, and specific inter-
ventions are not recommended or supported. Instead, the registry is intended
to be a tool for use in designing an intervention to meet specific needs.
The information provided by NREPP includes a program profile that
gives
a description of the program, the population(s) served, and the

programs major components and goals;
1This section was compiled from information on SAMHSAs Website (http://nrepp.samhsa.
gov) and NREPPs database (http://nrepp.samhsa.gov/AllPrograms.aspx) [October 2016].
401

key study findings and ratings for outcomes (both positive and
negative);
a compilation of evaluations of the effectiveness of the program;
dissemination and implementation information; and
references.
The information is updated over time.

Typically, interventions that are candidates for inclusion in the registry
are submitted by developers or other interested parties or found through
environmental scans, such as literature searches by staff, or through agency
nominations. NREPP then screens the interventions to determine whether
they are eligible for review. To be eligible, an intervention must meet three
minimum requirements:
1. The interventions research or evaluation must either measure

mental health or substance abuse outcomes or behavioral health-
related outcomes for those with or at risk of mental health issues
or substance use problems.
2. Evidence of outcomes must have been found in a minimum of one
experimental or quasi-experimental study.
3. Results of the study/studies must have been published in a profes-
sional publication such as a peer-reviewed journal or included in
an eligible comprehensive evaluation report.
NREPP recently revised its review criteria and ratings. The new review
process is intended to improve the quality of the reviews themselves as well
as the information they yield. Programs that are eligible for review are rated
as effective, promising, or ineffective. These new ratings are intended to
make it easier for users to find evidence-based programs that can address
their specific needs. From September 2015 through June 2019, NREPP will
be re-reviewing all programs currently in the registry.
Previously, programs were given a rating for the quality of research for
each outcome assessed, as well as for the programs overall readiness for
dissemination, on a scale of 0 to 4, with 4 being the highest rating. Higher
scores indicated stronger, more persuasive evidence. Outcomes were rated
individually since programs could aim to achieve more than one outcome
(e.g., decreased substance use and improvement of parent-child relation-
ships), and the evidence for each outcome could differ. A brief description
of the criteria used to rate programs is provided in Box B-1, as until the
updated reviews have been completed, the results of the previous review
process will be the only information available.
Now, new interventions that qualify for the registry undergo a review
process that begins with information gathering and a literature search for

APPENDIX B 403
BOX B-1
Previous National Registry of Evidence-based Programs and
Practices (NREPP) Criteria for Rating Programs
All programs were previously reviewed using the following six criteria:
1. Reliability of measures: Outcome measures should have acceptable reliability

to be interpretable. Acceptable here means reliability at a level that is con-
ventionally accepted by experts in the field.
2. Validity of measures: Outcome measures should have acceptable validity to be

interpretable. Acceptable here means validity at a level that is conventionally
accepted by experts in the field.
3. Intervention fidelity: The experimental intervention implemented in a study

should have fidelity to the intervention proposed by the applicant. Instruments
that have tested acceptable psychometric properties (e.g., inter-rater reliability,
validity as shown by positive association with outcomes) provide the highest
level of evidence.
4. Missing data and attrition: Study results can be biased by participant attrition
and other forms of missing data. Statistical methods as supported by theory
and research can be employed to control for missing data and attrition that
would bias results, but studies with no attrition or missing data needing adjust-
ment provide the strongest evidence that results are not biased.
5. Potential confounding variables: Often variables other than the intervention

may account for the reported outcomes. The degree to which confounds are
accounted for affects the strength of causal inference.
6. Appropriateness of analysis: Appropriate analysis is necessary to make an

inference that an intervention caused reported outcomes.
SOURCE: SAMHSAs National Registry of Evidence-based Programs and Practices (2016).

Available: http://nrepp.samhsa.gov/04a_review_process.aspx [August 2016].
relevant evaluation studies and eligible outcomes that meet minimum cri-
teria. Eligible outcomes presently include mental health, substance abuse,
and wellness. Next, an expert review performed by two certified reviewers
measures the rigor of the study and the impact on outcomes. The outcomes
are reviewed using an NREPP outcome rating instrument and are judged
on the basis of four dimensions: rigor, effect size, program fidelity, and
conceptual framework (see Box B-2).
After all eligible measures or effects have been rated, the scores for each
outcome are calculated, an evidence class for each measure is determined,
and an outcome rating is determined (see Figure B-1).

BOX B-2
Four Dimensions Used to Review Outcomes in the
National Registry of Evidence-based Programs and Practices
(NREPP)
1.
Rigor: A calculation of the study methodology strength, which consists of
design/assessment; intent-to-treat original group assignment; statistical preci-
sion; pretest equivalence, pretest adjustment; analysis method; other threats
to internal validity; measurement reliability; measurement validity; and attrition.
2. Effect size: A measurement of possible program impact and the impact on

participants.
3. Program fidelity: A review of if the program was provided as anticipated to the

target population, including service utilization and delivery.
4. Conceptual framework: A review of how well program components are ex-

pressed, consisting of program goals and components and utilization of a
theory of change.
SOURCE: Excerpted from SAMHSAs National Registry of Evidence-based Programs and

Practices (2016). Available: http://www.nrepp.samhsa.gov/02c_faq.aspx#12 [August 2016].
First, the evidence class is determined based on the evidence score (a

combination of the rigor and fidelity dimensions) and the effect class (based
on the confidence interval of the effect size). The evidence classes are as
follows:
Class A: highest-quality evidence with confidence interval com-

pletely within the favorable range
Class B: sufficient evidence with confidence interval completely
within the favorable range
Class C: sufficient or highest-quality evidence with confidence in-
terval spanning both the favorable and trivial ranges
Class D: sufficient or highest-quality evidence with confidence in-
terval completely within the trivial range
Class E: sufficient or highest-quality evidence with confidence in-
terval spanning both the harmful and trivial ranges
Class F: sufficient or highest-quality evidence with confidence inter-
val completely within the harmful range
Class G: limitations in the study design preclude reporting further
on the outcome

APPENDIX B 405
FIGURE B-1 Diagram of how the final outcome rating is determined for the National Registry
of Evidence-based Programs and Practices.
SOURCE: SAMHSAs National Registry of Evidence-based Programs and Practices (2016).
Available: http://nrepp.samhsa.gov/04a_review_process.aspx [August 2016].
Next, the outcome rating is determined on the basis of the outcome

scores and the conceptual framework. The outcome scores are calculated
from the evidence classes of each component measure, and the rating of the
conceptual framework is a determination of whether a program has clear
goals, activities, and a theory of change. The possible outcome ratings are
Effective: strong evidence of a favorable effect

Promising: sufficient evidence of a favorable effect
Ineffective: sufficient evidence of a negligible effect OR sufficient
evidence of a possibly harmful effect
Inconclusive: study design limitations or a lack of effect size infor-
mation precludes reporting further on the effect
BLUEPRINTS FOR HEALTHY YOUTH DEVELOPMENT2

Blueprints for Healthy Youth Development is a registry of evidence-
based programs for positive youth development created by the Center for
the Study and Prevention of Violence at the University of Colorado Boulder.
The registry is intended to be a source of information for decision makers
investing in programs with a goal of promoting positive youth develop-
ment. Positive youth development includes academic performance and suc-
cess, health and well-being, and positive relationships. Programs can be
family-, school-, or community-based and can have a variety of different
goals (e.g., violence prevention, reduced school delinquency, reduced sub-
2This section was compiled from information on the Blueprints Website. Available: http://
www.blueprintsprograms.com/ [October 2016].

stance use, improved mental and physical health, improved self-regulation,

higher educational achievement). The registry is intended to provide users
with information on evidence-based programs with high standards. Thus
far, more than 1,300 programs have been reviewed, with less than 5 percent
having been found to meet the review criteria. For programs that have met
the criteria, users can find a program description as well as information on
outcomes, target population, risk and protective factors, training and tech-
BOX B-3
Basic Criteria for Inclusion in the Blueprints Registry
1. Evaluation Quality: The evaluation produces valid and reliable findings from a
minimum of one high-quality randomized control trial (RCT) or two high-quality
quasi-experimental (QED) evaluations. The evaluation also meets the follow-
ing criteria:
Assignment to the intervention is at a level appropriate to the intervention

Valid and reliable measures that are appropriate for the intervention population
of focus and desired outcomes are used
Analysis is based on intent-to-treat
Appropriate statistical methods are used to analyze results
Additional requirements include the following:
A clear statement of the demographic characteristics of the targeted interven-

tion population
Documentation of what participants actually received in the intervention
condition/s and description of any significant departures from the interven-
tion as designed and the nature of the control condition
No evidence of significant differential attrition
Outcome measures must be independent of the content of the intervention
Outcome measures cannot be rated solely by the individual(s) delivering the
intervention
2. Intervention Impact: Evidence from high-quality evaluations indicates signifi-

cant positive change in intended outcomes that are attributed to the program
with no evidence of harmful effects. There must be
Evidence of a consistent and statistically significant positive impact on a Blue-

prints outcome in a preponderance of studies that meet the Evaluation Quality
criteria above
An absence of iatrogenic effects for intervention participants, including all
subgroups and Blueprints outcomes
3. Intervention Specificity: The program identifies intended program outcomes,

risks and protective factors linked to this change in outcome, target population

APPENDIX B 407
nical assistance, evaluation methodology, program costs, funding strategies,

benefits and costs, and references.
Program reviews are conducted by staff and then an advisory board of
seven youth development experts to determine whether a program meets the
criteria of (1) evaluation quality, (2) intervention impact, (3) intervention
specificity, and (4) dissemination readiness. (See Box B-3 for more detail.)
Programs meeting these criteria have demonstrated at least some effective-
and how intervention components work to produce this change. Specifically

the program
Identifies the intended subjects or clients to receive the intervention

Specifies the outcomes of the intervention which must be one of the Blueprints
outcomes
Identifies the risk and protective factors that the program seeks to change
along with the programs theoretical rationale or logic model explaining how the
intervention is expected to have a positive effect on these factors and how this
change in risk or protection will affect the specified outcome(s).
Documents the intended intervention structure, content and delivery process,
and includes a description of the planned intervention, including what service,
activity or treatment is provided, to whom, by whom, over what period, with
what intensity and frequency, and in what setting.
4. Dissemination Readiness: The program is available for dissemination with

the appropriate organizational capability, manuals, training, technical assis-
tance, and support necessary for implementation with fidelity. This includes
having
explicit processes for insuring the program gets to the right persons.
training materials, protocols and explicit implementation procedures which
specify the program content and guide the implementation of the intervention.
This includes materials specifying in detail what the intervention comprises;
levels of formal training or qualifications for those delivering the intervention;
and typically includes training and technical assistance
specifications on the financial resources required to deliver the intervention
including a description of costs associated with implementing the program
(start-up costs; intervention implementation costs; intervention implementation
support costs, costs associated with fidelity monitoring and evaluation).
information on the human resources required to deliver the intervention (staff
resources, qualifications and skill requirements for staff, and staff time required
to cover delivery, training, supervision, preparation and travel)
a program that is still available for sites wishing to implement it with up-to-date
materials
SOURCE: Excerpted from Blueprints for Health Youth Development (2016). Available: http://
www.blueprintsprograms.com/criteria [August 2016].

ness at changing targeted behavior and developmental outcomes. These

programs are then added to the registry with a rating of Model or Promising.
Model Programs
Model programs meet higher standards than those met by Promising
programs and offer greater confidence in the programs ability to modify be-
havior and developmental outcomes. These programs are suggested for use
in large-scale implementation, such as at the national or state level. Model
programs meet the four criteria above and two additional requirements:
1. Evaluation Quality: Evidence is required from two high-quality

randomized controlled trials (RCTs) or one RCT and one quasi-
experimental evaluation.
2. Intervention Impact: A minimum of one long-term follow-up (at
least 12 months after the intervention has ended) on at least one
outcome measure must indicate that results have been sustained
following the intervention. Data on sustainability are required for
both program and control groups. For interventions designed to
extend over many years, evidence is required that effects have been
sustained after several years of participation in the program even
though participation is continuing and will be accepted as evidence
of sustainability.
Programs rated as Model that also have been independently replicated

in a high-quality manner are designated Model Plus.
Promising Programs
Promising programs meet the four criteria elaborated in Box B-3 and
are recommended for local community and system adoption. Promising
programs do not have to meet the additional evaluation quality and inter-
vention impact requirements for Model programs listed above.
THE CALIFORNIA EVIDENCE-BASED

CLEARINGHOUSE FOR CHILD WELFARE3
The California Evidence-Based Clearinghouse for Child Welfare
(CEBC), funded by the California Department of Social Services Office of
Child Abuse Prevention, is a database of child welfare-related programs in-
3This section was compiled from information on CEBCs Website. Available: http://www.
cebc4cw.org/ [October 2016].

APPENDIX B 409
tended to provide information and resources for child welfare professionals.

The mission of the clearinghouse is to advance the effective implementation
of evidence-based practices for children and families involved in the child
welfare system. CEBC provides descriptions of and information on research
evidence for specific programs, as well as implementation guidance. All pro-
grams are categorized by topic area. Assignment to topic areas is based on
clear definitions and requirements that programs must meet. Requirements
also are specified for which program outcomes the research evidence must
demonstrate for programs to be rated within each topic area.
The CEBC review process starts with the selection of topic areas,
which is performed annually by an advisory committee. A list of possible
programs to be included in each topic area is then generated based on infor-
mation from topic experts and literature searches conducted by staff. Each
of these programs is then contacted with a list of screening questions. If the
program passes the screening, it receives a questionnaire to complete, and
a literature search is conducted for any relevant published peer-reviewed
research literature. A program outline is then created, and study outcomes
are summarized from the research literature. Outcomes of focus relate to
child welfare and include safety, permanency, and child/family well-being.
Program outlines that meet one of the five categories of the CEBC Scientific
Rating Scale (see Figure B-2) are then sent to raters (usually the topic expert
and two staff). The scales purpose is to assess each program based on the
available research evidence.
Scientific Rating Scale

The Scientific Rating Scale is a 1 to 5 rating of the strength of the re-
search evidence supporting a program. A scientific rating of 1 represents a
program with the strongest research evidence, while a 5 represents a con-
FIGURE B-2Scientific Rating Scale for the California Evidence-Based Clearinghouse for
Child Welfare.
SOURCE: California Evidence-Based Clearing House for Child Welfare (2016).

cerning practice that appears to pose substantial risk to children and fami-
lies. A rating of 2 indicates the program is supported by research evidence,
3 indicates promising research evidence, and 4 indicates that the evidence
fails to demonstrate effect. Specific criteria for each rating are presented in
Box B-4. Some programs currently lack strong enough research evidence to
be rated on the Scientific Rating Scale and are classified as NR (Not Able
to Be Rated). A rating of NR does not mean a program is not effective.
Program ratings are evaluated on an ongoing basis as new research is
published, and programs are rerated if necessary. Intermittent re-reviews are
conducted to look for new published, peer-reviewed research on programs
already rated. Program representatives also can submit new published, peer-
reviewed studies to initiate the re-review process at any time.
Child Welfare System Relevance Levels

In addition to its assigned rating, each program included in the da-
tabase is reviewed to determine how child outcomes are addressed in the
programs research evidence. The topic expert and staff review the target
population and goals of the program to determine a Child Welfare System
Relevance Level of high, medium, or low. Programs rated high are designed
or commonly used to meet the needs of children and families receiving child
welfare services. Those rated medium are designed or commonly used to
serve children and families similar to child welfare populations and likely
include current and former child welfare participants. Finally, programs
rated low serve children and families with little or no apparent similarity
to child welfare participants.
BOX B-4
Specific Criteria for Each CEBC Classification System Category
1 = Well-Supported by Research Evidence

A minimum of two rigorous randomized controlled trials (RCTs) in published,
peer-reviewed literature have found the practice to be superior to an appropri-
ate comparison practice, and at least one RCT has found a sustained effect
at minimum one year after treatment ended.
Reliable and valid outcome measures are administered consistently and accu
rately across all subjects.
If multiple outcome studies have been published, the total weight of the evi-
dence must support the value of the practice.
continued

APPENDIX B 411
BOX B-4 Continued
No data suggest a risk of harm that (a) was probably caused by the treatment
and (b) the harm was severe or frequent.
There is no legal or empirical basis suggesting that, compared to its likely
benefits, the practice constitutes a risk of harm to those receiving it.
The practice has a book, manual, and/or other available writings that specify
components of the service and describe how to administer it.
2 = Supported by Research Evidence

A minimum of one rigorous randomized controlled trials (RCTs) in published,
peer-reviewed literature have found the practice to be superior to an appropri-
ate comparison practice, and at least one RCT has found a sustained effect
at minimum 6 months after treatment ended.
3 = Promising Research Evidence

A minimum of one study in published, peer-reviewed literature utilizing some
form of control have found the practice to have a benefit over the control, or
found it comparable to a practice rated 1, 2, or 3, or superior to an appropriate
comparison practice.
4 = Evidence Fails to Demonstrate Effect

A minimum of two randomized controlled trials (RCTs) in published, peer-
reviewed literature have found the practice has not resulted in improved
outcomes, when compared to usual care.
continued

BOX B-4 Continued
If multiple outcome studies have been conducted, the total weight of evidence
(based on published peer-reviewed studies, not a systematic review or meta-
analysis) does not support the benefit of the practice.
5 = Concerning Practice
If multiple outcome studies have been conducted, the total weight of evidence
suggests the intervention has a negative effect upon clients served; and/or
there are data suggesting a risk of harm that (a) was probably caused by the
treatment and (b) the harm was severe or frequent.
There is a legal or empirical basis suggesting that, compared to its likely ben-
efits, the practice constitutes a risk of harm to those receiving it.
the components of the practice protocol and describe how to administer it.
NR = Not Able to Be Rated

The practice does not have any published, peer-reviewed study utilizing some
form of control that has established the practices benefit over the placebo or
found it to be comparable to or better than an appropriate comparison practice.
The practice is generally accepted in clinical practice as appropriate for use
with children receiving services from child welfare or related systems and their
parents/caregivers.
Practice does not meet criteria for any other level on the CEBC Scientific
Rating Scale.
There are no case data suggesting a risk of harm that (a) was probably caused
by the treatment and (b) the harm was severe or frequent.
the components of the practice protocol and describe how to administer it.
SOURCE: Excerpted from The California Evidence-Based Clearinghouse for Child Welfare
(2016). Available: http://www.cebc4cw.org/ratings/scientific-rating-scale/ [August 2016].

Appendix C
Table of Parenting Interventions
The committee used the National Registry of Evidence-based Programs

and Practices (NREPP), the Blueprints for Youth Development registry, and
the California Evidence-Based Clearinghouse for Child Welfare (CEBC) to
identify parenting programs with strong evidence of effectiveness for sup-
porting parenting knowledge, attitudes, or practices1 for parents of children
ages 0-8. The following table draws on those sources to present information
on the parenting support interventions that are discussed in this report.
Some of the programs the committee determined to be important to include
in the table, such as Adult-Focused Family Behavior Therapy and Child and
Family Traumatic Stress Intervention, are not included in the report text.
See Appendix B for a description of the criteria used by the clearinghouses
for reviewing programs.
1This appendix was compiled from information on the National Registry of Evidence-
based Programs and Practices (NREPP) (http://nrepp.samhsa.gov/AllPrograms.aspx), Blue-

prints for Youth Development registry (http://www.blueprintsprograms.com/programs), and
the California Evidence-Based Clearinghouse for Child Welfare (CEBC) (http://www.cebc4cw.
org/home/). Some of the information provided in the table is used verbatim from the above
Websites.
413

TABLE C-1 Evidence-Based Interventions That Support Parenting
Program Name Target Population Intervention Description

1-2-3 Magic: Parents, Group-format discipline program that divides
Effective Discipline grandparents, parenting responsibilities into three straightforward
for Children 2-12 teachers, babysitters, tasks: controlling negative behavior, encouraging
and other good behavior, and strengthening the child-parent
caretakers working relationship. The program seeks to encourage
with children gentle, but firm, discipline without arguing, yelling,
approximately ages or spanking. By effectively addressing behavior
2-12 with behavior problems, the program also attempts to improve
problems involving the adult-child relationship.
compliance and
oppositional issues One or two sessions per week for 4-8 weeks, each
1.5 hours

APPENDIX C 415
Targeted Knowledge, Attitudes, Qualifications

and Practices of Staff Cost Rating
The program defines two basic kinds Mental health None noted CEBC: 3
of problems that children present professionals or CEBC:
to adultsStop Behavior and Start teachers Medium
Behavior. When adults are frustrated Child
with their children, the children are Welfare
either (1) doing something the adults
want them to Stop or (2) not doing
something the adults want them to
Start. Start behavior tactics (behavioral
management techniques) include using
positive verbal feedback, a kitchen
timer method, a docking system, natural
consequences, and charting.
Three simple steps:

(1) Control Obnoxious Behavior
Parents learn a simple technique for
getting their children to Stop doing what
they do not want them to do (whining,
arguing, tantrums, sibling rivalry, etc.).
(2) Encourage Good BehaviorParents
learn several effective methods for
getting their children to start doing what
they do want them to do (cleaning their
room, going to bed, homework, etc.).
(3) Strengthen RelationshipsParents
learn powerful techniques that reinforce
their bond with their children.
1-2-3 Magic utilizes a counting

technique that is clearly understood by
children so they know the consequences
of their actions. The secret is not just in
the counting, however. The real secret
or magic comes from parents learning
when to keep quiet.
The Little Adult Assumption explores

the notion that children are not little
adults and do not have the same
reasoning capacity as an adult.
Parents also learn about managing the

Six Kinds of Testing and Manipulation:
badgering, intimidation, threats,
martyrdom, butter-up, and physical.


Adolescent First-time pregnant Support to first-time pregnant and parenting teens
Parenting Program and parenting youth through intensive home visiting and peer group
(APP) ages 12-19 who education
must be enrolled
in school or a Monthly home visits, along with 24 hours of group
GED completion education
program, and their
children ages 0-5

APPENDIX C 417

The program supports adolescent Staff must have Not provided CEBC: 3
parents to prevent a repeat pregnancy, a history of CEBC:
complete their high school education, working with Medium
acquire job skills, and improve their at-risk youth Child
parenting skills, helping them become and must be Welfare
self-sufficient and better able to support trained in either
themselves and their families. It also the Partners
establishes a strong, stable foundation for a Healthy
upon which their children will be raised. Baby or Parents
as Teachers
The program is designed to increase home visiting
the self-sufficiency outcomes for curriculum.
participants by increasing the time to Staff must also
a subsequent pregnancy; increasing complete at
rates of graduation from high school least 18 hours
with a diploma or completion of of professional
GED; increasing successful transition development
to adulthood, including enrollment in training
postsecondary education, vocational annually, aimed
training, or employment at a livable at improving
wage; and living in safe and stable program
housing after graduation from the outcomes.
program. The program also aims to
improve developmental outcomes
for the children of participants by
increasing healthy births; increasing
the incidence of appropriate discipline,
of nurturing behavior, and of children
who are well cared for; and increasing
age-appropriate physical, emotional,
cognitive, and social development,
including readiness for school success.


Adult-Focused Adults with More than a dozen treatments, including
Family Behavior drug abuse and management of emergencies, treatment planning,
Therapy (Adult- dependence, as well home safety tours, behavioral goals and rewards,
Focused FBT)* as other coexisting contingency management skills training,
problems, such as communication skills training, child management
depression, family skills training, job-getting skills training, financial
dysfunction, trauma, management, self-control, environmental control,
child maltreatment, home safety and aesthetics tours, and teletherapy to
noncompliance, improve session attendance
employment, HIV/
sexually transmitted Starts with 1- to 2-hour initial outpatient or home-
infection risk based sessions once or twice in the first week,
behavior, and poor then declines in frequency depending on multiple
communication factors that are determined among the client, the
skills clients family, and the treatment provider (e.g.,
population, setting, intensity of treatment plan,
effort)
Typically lasts 6 months to 1 year. The length

varies depending on multiple factors (e.g.,
population, setting, intensity of treatment plan,
effort) that are determined by the client, clients
family, and treatment provider

APPENDIX C 419

Goals are to decrease alcohol and drug Supervisors must None noted CEBC: 2
use, depression, conduct problems, be state-licensed CEBC:
family dysfunction, and days absent mental health High
from work/school. professionals Child
with an interest Welfare
Treatment components: program in supervising
orientation; behavioral goals and the intervention.
rewards through establishing family They should
support systems; treatment planning; ideally have
communication skills training; child experience in
management skills training, where conducting
parents learn to discipline their children evidence-based
by catching them being good, engaging therapies,
in positive practice learning exercises, particularly
and when necessary, providing firm cognitive-
directives and undesired consequences; behavioral
training in job-getting skills, financial therapies, and
management; self-control intervention; should have
assurance of basic necessities, home professional
safety and aesthetics tour, environmental therapeutic
control. experience
serving the
Addresses the following: alcohol population that
and drug misuse, depression, school/ is being targeted
work attendance problems, parenting for treatment.
stress, poor child management
and communication skills, family Therapists
dysfunction, HIV prevention, child should be
abuse and neglect, home hazards, state-licensed
management of emergencies, and mental health
conduct problems in children. professionals.
They should
ideally have
experience
serving the
population that
is being targeted
for treatment,
and must have
an interest in
conducting
therapy utilizing
the intervention.


Attachment and Caregivers of infants Targets several key issues that have been identified
Biobehavioral ages 6 months to as problematic among children who have
Catch-up (ABC)* 2 years who have experienced early maltreatment and/or disruptions
experienced early in care. The first intervention component helps
adversity caregivers reinterpret childrens behavioral signals
so that they provide nurturance even when it is
not elicited. Second, many children who have
experienced early adversity are dysregulated
behaviorally and biologically. The second
intervention component helps caregivers provide a
responsive, predictable environment that enhances
young childrens behavioral and regulatory
capabilities. The third intervention component
helps caregivers decrease behaviors that could be
overwhelming or frightening to a young child.
10 weekly 1-hour sessions

APPENDIX C 421

Goals: increase caregiver nurturance, There is no None noted CEBC: 1
sensitivity, and delight; decrease educational CEBC:
caregiver frightening behaviors; increase requirement for High
child attachment security and decrease parent coaches. Child
disorganized attachment; increase child Potential Welfare
behavioral and biological regulation. parent coaches
participate in a
Targets several key issues: Child screening prior
behaves in ways that push caregiver to training. If
awaycaregiver is helped to override they pass the
tendencies to respond in kind and short screening,
to provide nurturance regardless. coaches attend
Child is dysregulated at behavioral and a 2- to 3-day
biological levelscaregiver is helped to training and are
provide an environment that helps the subject to a year
child develop regulatory capabilities. of supervision.
This includes the parent following the
childs lead and showing delight in the
child. Caregiver is helped to decrease
behaviors that may be frightening or
overwhelming to the child.
Provides services to parents/caregivers

and addresses the following: Has
child that pushes caregivers away
or has difficulty being soothed; has
child with behavioral and biological
dysregulation; has difficulty in providing
parental nurturance, following the
lead, or delighting; has tendency to be
frightening or overwhelming; has own
history of care that may interfere with
parenting.
The child is involved in the home visits

to show the parents new skills, and the
parents are expected to observe and
note the childs behavior and practice
new skills between sessions.


Behavioral Couples Substance-abusing Components include a recovery or sobriety contract
Therapy for patient together between the partners and therapist
Alcoholism and with the spouse
Drug Abuse* or live-in partner 15-20 hour-long sessions over 5-6 months
seeking help for
alcoholism or drug
abuse
Caring Dads: Fathers (including Combines elements of parenting, fathering, and

Helping Fathers biological, step, child protection practice to address the needs of
Value Their and common-law) maltreating fathers
Children who have physically
abused, emotionally 17 2-hour weekly sessions
abused, or neglected
their children,
have exposed their
children to domestic
violence, or are
deemed to be at
high risk for these
behaviors

APPENDIX C 423

Activities and assignments are Providers must Behavioral NREPP:
designed to increase positive feelings, be therapists Couples Therapy 3.54
shared activities, and constructive in outpatient for Alcoholism
communication; relapse prevention facilities. and Drug Abuse
planning. guidebook, $38
each
Average per-couple
cost estimated
in 1997 to be
about $1,400;
included clinician
training, staff
salaries, overhead,
workbooks, etc.
Combination of motivation No specific None provided CEBC:

enhancement, parent education formal NR
(including skills training and behavioral qualifications CEBC:
practice), and cognitive-behavioral needed, although High
therapy. Aims are to improve mens as a group, the Child
recognition and prioritization of cofacilitation Welfare
childrens needs; improve mens team needs
understanding of developmental stages; training and
improve mens respect and support experience in
for childrens relationships with their working with
mothers; improve mens listening and men (particularly
using praise; improve mens empathy for men who are
childrens experiences of maltreatment, resistant to
and identify and counter the distortions intervention),
underlying mens past, and potentially a firm
ongoing, abuse of their children and/or understanding
childrens mothers. of the dynamics
of abuse
against women,
knowledge
of child
development,
and experience
in cognitive-
behavioral
therapy.


Chicago Parent Parents of children Parenting-skills training program designed to
Program (CPP) ages 2-5 originally improve parenting self-efficacy and promote
for low-income positive parenting behavior and child discipline
African American strategies. Uses video vignettes to depict parent-
and Latino child interactions at home and in various
parents in urban community settings
communities
Eleven 2-hour group sessions, followed by a
booster session 4-8 weeks later

APPENDIX C 425

The vignettes present challenging Sessions are Group leader set NREPP:
situations parents typically face with facilitated by costs $699 each; 3.43
their children and stimulate discussion two trained 2-day, onsite group
and problem solving related to child group leaders leader training
behavior and parenting skills. Sessions who must have in the Chicago
focus on building positive relationships a minimum of metropolitan area
with children (e.g., having child- a high school costs $2,500 for up
centered time, maintaining family degree or to 20 participants,
routines and traditions, using praise equivalent and plus travel
and encouragement), child behavior must successfully expenses; in other
management skills (e.g., following complete a 2-day cities, $3,000 for up
through with consequences, using CPP group to 20 participants,
effective forms of discipline), stress leader training. plus travel expenses
management, and problem-solving skills.


Child and Family Families with Aims to reduce early posttraumatic stress
Traumatic Stress children ages 7-18 symptoms, to decrease the likelihood of
Intervention who have either traumatized children developing long-term
(CFTSI)* recently experienced posttraumatic psychiatric disorders, and to assess
a potentially childrens need for longer-term treatment. The
traumatic event or intervention focuses on increasing communication
recently disclosed between the caregiver and child about the childs
the trauma of traumatic stress reactions and on providing skills
physical or sexual to the family to help cope with traumatic stress
abuse reactions
Four to eight weekly sessions lasting 45-60 minutes

each

APPENDIX C 427

In session 1, the clinician provides Providers must CFTSI CEBC: 3
education about trauma and childrens be trained implementation CEBC:
typical reactions to traumatic exposure clinicians guide for providers: High
and explains the protective role of (masters, Ph.D., free electronic copy Child
communication and family support. In or M.D. level). or $15 for hard Welfare
session 2, the clinician first meets with copy; 2-day training
the child alone to provide education costs $3,000 per NREPP:
about trauma and childrens typical day for up to 30 3.0
reactions to traumatic exposure and to participants, plus
use standardized assessment instruments travel expenses; 6
to obtain the childs assessment of his months of biweekly
or her traumatic stress reactions. Next, consultation
the clinician meets with the caregiver calls: $200 per
and the child together. In this session, hour for up to 15
the clinician uses the childs and participants per call
caregivers responses to the standardized
assessment instruments as a basis for
discussion. The discussion focuses on
ways of improving communication,
including encouraging greater awareness
of when traumatic stress reactions are
occurring; helping the child to better
communicate with and inform his or
her caregiver about feelings, symptoms,
and behaviors; and helping the caregiver
to be more aware, receptive, and
supportive of the child. The clinician
works with the child and caregiver
collaboratively to identify specific
traumatic stress reactions as the areas
of focus, which are based on symptom
clusters identified by the child and
caregiver as being the most problematic
(e.g., anxiety, sleep disturbance,
depressive withdrawal, intrusive
thoughts, oppositionality, tantrums,
aggressive behaviors). The clinician
then introduces skills, techniques, and
behavioral interventions for the child
and caregiver to practice to help the
child cope with and master traumatic
stress reactions. Sessions 3 and 4
are held with the child and caregiver
together, and the clinician focuses on
continuing to improve communication
between the child and caregiver and
on practicing the skills introduced in
session 2. Sessions 5-8 are provided on
an as-needed basis and may be used for
additional meetings with the child and
caregiver together or with the caregiver
or child alone.


Child-Parent Children ages Aims to support and strengthen the relationship
Psychotherapy 0-5 who have between a child and his or her parent (or caregiver)
(CPP) experienced at least as a vehicle for restoring the childs sense of safety,
one traumatic event attachment, and appropriate affect and improving
and are experiencing the childs cognitive, behavioral, and social
behavior, functioning
attachment, and/
or mental health Weekly 1- to 1.5-hour sessions for approximately
problems a year

APPENDIX C 429

(1) Focus on safety: focus on safety The therapist Psychotherapy with CEBC: 2
issues in the environment as needed; must be a Infants and Young CEBC:
promote safe behavior; legitimize masters- or Children: Repairing High
feelings while highlighting the doctoral-level the Effects of Stress Child
need for safe/appropriate behavior; psychologist, a and Trauma on Welfare
foster appropriate limit setting; help masters-level Early Attachment
establish appropriate parent-child social worker (manual) costs
roles. (2) Affect regulation: provide or counselor, $35.79 for
developmental guidance regarding or a supervised hardcover, $28
how children regulate affect and trainee. for paperback, or
emotional reactions; support and $21.95 for Kindle
label affective experiences; foster version; Dont
parents ability to respond in helpful, Hit My Mommy!:
soothing ways when child is upset; A Manual for
foster childs ability to use parent as a Child-Parent
secure base; develop/foster strategies Psychotherapy with
for regulating affect. (3) Reciprocity Young Witnesses
in relationships: highlight parents and of Family Violence
childs love and understanding for each costs $24.95 each.
other; support expression of positive One training option
and negative feelings for important is required: free
people; foster ability to understand the 1-year full-time
others perspective; talk about ways internship at
that parent and child are different and specialized National
autonomous; develop interventions Child Traumatic
to change maladaptive patterns of Stress Network
interactions. (4) Focus on the traumatic (NCTSN) sites,
event: help parent acknowledge what or free (except
child has witnessed and remembered; travel) 1.5-year
help parent and child understand training through the
each others reality with regard to the NCTSN Learning
trauma; provide developmental guidance Collaborative
acknowledging response to trauma; Model, or 1.5-year
make linkages between past experiences training for a
and current thoughts, feelings, and learning community
behaviors; help parent understand or an individual
link between her own experiences and agency at a cost
current feelings and parenting practices; of $1,500-$3,000
highlight the difference between past per day of training
and present circumstances; support for up to 30
parent and child in creating a joint participants, plus
narrative; reinforce behaviors that help travel expenses
parent and child master the trauma and
gain a new perspective. (5) Continuity
of daily living: foster prosocial,
adaptive behavior; foster efforts to
engage in appropriate activities; foster
development of a daily predictable
routine. (6) Reflective supervision.
[continued]


Child-Parent
Psychotherapy
(CPP)
continued
Clinician-Based Families with Based on public health models. Core elements

Cognitive parents with of the intervention are (1) an assessment of all
Psychoeducational significant mood family members, (2) teaching information about
Intervention for disorders affective disorders and risks and resilience in
Families (Family children, (3) linking information to the familys
Talk) life experience, (4) decreasing feelings of guilt
and blame in children, and (5) helping children to
develop relationships within and outside the family
to facilitate their independent functioning in school
and in activities outside the home.
6-11 modules that include separate meetings

with parents and children, family meetings, and
telephone contacts or refresher meetings at 6- to
9-month intervals

APPENDIX C 431

Provides services to children/adolescents
and addresses exposure to trauma,
internalizing and externalizing
symptoms, and/or symptoms of
posttraumatic stress disorder (PTSD).

to address negative attributions about
the child, problems in the parent-
child relationship, and maladaptive
parenting strategies. In addition, when
appropriate, the program targets
parental symptoms of PTSD (avoidance,
intrusion, and hyperarousal), depression,
and anxiety.
Designed to provide information Sessions are Implementation NREPP:

about mood disorders to parents, conducted manual: free; online 3.5
equip parents with skills they need to by trained training: free; 2-day
communicate this information to their psychologists, initial training:
children, and open dialogue in families social workers, $500 per day;
about the effects of parental depression. and nurses. ongoing biweekly
supervision and
consultation: $100
per hour
Delivery of the
intervention
requires 7-10 hours
of clinician time per
family, including
parent, child, and
family sessions


Cognitive- Primarily children School-based group and individual intervention
Behavioral in grades 3 designed to reduce symptoms of PTSD, depression,
Intervention for through 8 who and behavioral problems; improve peer and
Trauma in Schools screened positive parent support; and enhance coping skills among
(CBITS)* for exposure to a students exposed to traumatic life events, such as
traumatic event and community and school violence, physical abuse,
symptoms of PTSD domestic violence, accidents, and natural disasters
related to that event
10 45-minute group sessions and 1-3 30-minute
individual sessions for students, 2 parent
psychoeducational sessions, and a teacher
educational session

APPENDIX C 433

Relies on cognitive and behavioral Delivered in the Manual costs $40 Blueprints:
theories of adjustment to traumatic school setting Promising
events and uses cognitive-behavioral by mental health One professional
techniques such as psychoeducation, professionals can screen students CEBC: 3
relaxation, social problem solving, (with a masters and select those CEBC:
cognitive restructuring, imaginal or doctoral with elevated Medium
exposure, exposure to trauma degree in a symptoms, Child
reminders, and development of a trauma clinical field) serving up to 30 Welfare
narrative. Uses a mixture of didactic working in close CBITS groups per
presentation, examples, and games to collaboration academic year (6-8 NREPP:
solidify concepts. Components of the with school students per group, 3.17
program include relaxation training, personnel. for about 210
combating negative thoughts, reducing students). Assuming
avoidance, developing a trauma an approximate
narrative, and building social problem- staffing cost of
solving skills. $90,000 per year
for a full-time
This program involves the family or social worker, the
other support systems in the individuals estimated cost per
treatment. The program includes participant is $430.
extensive outreach to parents and two
parent sessions to keep them informed Cost for
about what is happening in the groups, implementation
as well as to teach them some of the in 10 schools in
same skills the child is learning. year 1: $5,000 for
training, $500 for
manuals, $900,000
for 10 mental
health professional
salaries; so at a
ratio of 30 groups
serving 6-8 children
per mental health
professional, the
above costs would
support CBITS
for 2,100 children
and youth at a per
youth cost of $431
for year 1.


Computer-Assisted Pregnant and/ Aims to increase motivation among adolescent
Motivational or parenting mothers to use condoms and contraception
Intervention adolescents ages 18 consistently, with the long-term goal of reducing
(CAMI) and younger rapid repeat births
60-minute sessions conducted in two parts
Early Head Start Low-income Federally funded early childhood development

(EHS) families program providing comprehensive child
development services in a center-based setting,
supplemented with home visits
Weekly home visits and bimonthly group

socialization experiences
Families and Families Multifamily group intervention designed to build

Schools Together with children relationships between and within families, schools,
(FAST)* transitioning into and communities (particularly in low-income areas)
elementary school to increase all childrens well-being
8 weeks of multifamily group meetings, each about

2.5 hours long; and 2 years of monthly parent-led
group meetings

APPENDIX C 435

During the first part of each session, It is Not specified CEBC: 3
participants use the computer- recommended CEBC:
based CAMI program to answer that agencies Medium
questions about current sexual seek individuals Child
relationships and contraceptive use who possess Welfare
intentions and behaviors. Based empathetic
on the responses generated, CAMI qualities,
counselors conduct a stage-matched excellent
motivational interviewing session communication
to enhance participants motivation skills, experience
to use condoms and contraception working with
consistently in order to reduce the risk adolescents, and
for a repeat pregnancy. familiarity with
the community.
There is no
set minimum
educational
requirement.
Also serves children through locally Teacher and Not specified CEBC: 3
designed family child care options, in other EHS staff CEBC:
which certified child care providers care Medium
for children in their homes. Services Child
include early education both in and Welfare
out of the home, parenting education,
comprehensive health and mental health
services for mothers and children,
nutrition education, and family support
services.
Objectives: (1) enhance parent-child Sessions are led Licensing fee is NREPP:
bonding and family functioning by a trained $550 per site; 3.7
while reducing family conflict and team that training package
isolation and child neglect; (2) enhance includes at least costs $4,295
school success through more parent one member of per site (serving
involvement and family engagement the school staff approximately 1 to
at school, improved school climate, in addition to 10 families), plus
and reduced school mobility; (3) parents and travel expenses;
prevent substance use by both adults professionals ongoing technical
and children by building protective from local assistance costs
factors and referring appropriately for social service $200 per site;
treatment; and (4) reduce the stress that agencies in the evaluation package
children and parents experience in daily community. costs $1,100 per
life situations in their communities by FAST teams site
empowering parents, building social must be
capital, and increasing social inclusion. culturally
representative
of the families
served.


Family Check-Up Families with Strengths-based, family-centered intervention that
(FCU) for Children children ages 2-17 motivates parents to use parenting practices in
support of child competence, mental health, and
reduced risk for substance use; can be integrated
into a variety of service settings, including schools,
primary care, and community mental health
Phase 1 involves 3 1-hour sessions. Phase 2 can be

limited to 1 to 3 Everyday Parenting sessions; as a
treatment approach, Phase 2 can range from 3 to
15 Everyday Parenting sessions.
Family Check-Up Families with Strengths-based, family-centered intervention that

(FCU) for Toddlers children ages 17 motivates parents to use parenting practices in
months-2 support of child competence, mental health, and
reduced risk for substance use; can be integrated
into a variety of service settings, including schools,
primary care, and community mental health
Phase 1 involves 3 1-hour sessions. Phase 2 can be

limited to 1 to 3 Everyday Parenting sessions; as a
treatment approach, Phase 2 can range from 3 to
15 Everyday Parenting sessions.

APPENDIX C 437

Two phases: (1) initial interview, Providers with a Manual costs $21; NREPP:
assessment, and feedback; and (2) masters degree training manual 3.1
Everyday Parenting as a follow-up in education, costs $104.25 per
service that builds parents skills in social work, provider; 2-day
positive behavior support, healthy limit counseling, or FCU training costs
setting, and relationship building. related areas $4,194 + trainer
generally travel costs for 1
implement trainer and up to
the program; approximately 8-10
however, trainees; 2-day
bachelors- and Everyday Parenting
paraprofessional/ training costs
nonbachelors- $4,194 + trainer
level providers, travel costs for 1
with the trainer and up to
appropriate approximately 8-10
consultation trainees; additional
and supervisory costs incurred if the
support, may site wants providers
also implement to become certified.
the program.
Two phases: (1) initial interview, Providers Example cost: For Blueprints:
assessment, and feedback; and (2) must have a one community Promising
Everyday Parenting as a follow-up masters degree agency serving
service that builds parents skills in in education, 400 families, the
positive behavior support, healthy limit social work, first-year expense
setting, and relationship building. counseling, or would be $476 per
related areas. family. The costs
would decrease
significantly in
subsequent years as
the initial readiness,
training, and
certification costs
are start-up costs
that would not be
incurred beyond
year 1.


Family Connections Families at risk for Multifaceted, community-based service program
(FC) child maltreatment that works with families in their homes and in the
context of their neighborhoods to help them meet
the basic needs of their children and prevent child
maltreatment
A minimum of 1 hour of face-to-face contact

between the social worker and clients weekly for
3-4 months, with an optional 90-day extension if
needed
Family Adult couples Aims to help establish positive parenting skills and
Foundations* expecting their adjustment to the physical, social, and emotional
first child challenges of parenthood. Program topics include
coping with postpartum depression and stress,
creating a caring environment, and developing the
childs social and emotional competence.
Delivered to groups of couples through four

prenatal and four postnatal classes of 2 hours each.
Prenatal classes are started during the fifth or sixth
month of pregnancy, and postnatal classes end
when children are 6 months old.

APPENDIX C 439

Nine practice principles guide FC Masters-level or None provided CEBC: 3
interventions: ecological developmental bachelors-level CEBC:
framework, community outreach, workers are High
individualized family assessment supervised by Child
and tailored interventions, helping a staff member Welfare
alliance, empowerment principles, with a masters
strengths-based practice, cultural degree or higher.
competence, outcome-driven service
plans with SMART goals, and a focus
on the competence of the practitioner.
Individualized family intervention is
geared to increase protective factors;
decrease risk factors; and target child
safety, well-being, and permanency
outcomes.
Addresses the following: Poor household

conditions, financial stress, inadequate
social support, parenting stress and
poor parenting attitudes, unsafe
caregiver/child interactions, poor family
functioning, poor adult functioning
(e.g., mental health problems/substance
abuse) that impacts parenting, poor
family resources.
Foster and enhance the coparenting Delivered in Facilitator NREPP:

relationship through conflict a community manual (includes 3.65
resolution strategies, information setting by PowerPoint slides,
and communication exercises to help childbirth facilitator DVDs,
parents develop realistic and positive educators who and participant
expectations about parenthood, and have received 3 feedback forms)
videos presenting couples discussing the days of training costs $325 each;
family and personal stresses they have from Family pre- and postnatal
experienced as well as the successful Foundations parent handbooks
strategies they have employed. Key staff. It is (include DVDs) cost
aspects of parenting addressed include recommended, $300 for materials
fostering child emotional security, but not required, for 10 couples
attending to infant cues, and promoting that classes be
infant sleep. codelivered by
a male and a
female. The
female leader
is a childbirth
educator, and
male leaders are
from various
backgrounds,
but experienced
in working with
families and
leading groups.


Family Spirit American Indian Culturally tailored home visiting intervention with
teenage mothers, lessons designed to correspond to the changing
who generally developmental needs of the mother and child
experience high during this period, addressing such topics as
rates of substance prenatal care, infant care, child development,
use, school dropout, family planning, and healthy living
and residential
instability, 63 structured lessons delivered one on one by
receive services health educators in participants homes, starting at
from pregnancy about 28 weeks of gestation and continuing to 36
through 36 months months postpartum. Each home visit lasts about
postpartum an hour and includes a warm-up conversation,
lesson content, a question-and-answer period, and
review of summary handouts. The 63 lessons can
be delivered in 52 home visits, which occur weekly
through 3 months postpartum and gradually
become less frequent thereafter.

APPENDIX C 441

Designed to increase parenting Health educators 1-week, on- or NREPP:
competence (e.g., parenting knowledge are trained off-site training in 3.22
and self-efficacy), reduce maternal American Indian curriculum content
psychosocial and behavioral risks paraprofessionals and implementation
that could interfere with effective costs $3,000 per
parenting (e.g., drug and alcohol use, person for up to 30
depression, externalizing problems), participants, plus
and promote healthy infant and toddler travel expenses;
emotional and social adjustment (i.e., tailored training
avoid internalizing and externalizing development and
behaviors). The program also aims implementation
to prepare toddlers for early school affiliation fee
success, promote parents coping (includes access
and life skills, and link families to to all training
appropriate community services. resources; 3-year
membership to
the Web-based
FS Connect; and
consultation and
technical assistance
before training to
establish needs and
after training to
support program
implementation,
sustainability, and
data collection)
is $9,600 per
program, plus travel
expenses.


Head Start REDI Enrichment intervention that can be integrated into
the existing framework of Head Start programs
that are already using the High/Scope or Creative
Curriculum. The intervention is delivered by
classroom teachers and integrated into their
ongoing classroom programs.

APPENDIX C 443

Includes curriculum-based lessons, Prerequisites: Example cost: With Blueprints:
center-based extension activities, Attendance at three classrooms of Promising
and training and weekly classroom a Preschool 17 students each,
coaching in teaching strategies to PATHS the REDI program
use throughout the day. It is focused Workshop/ would serve 51
primarily on social-emotional skill REDI Workshop; students in the first
enrichment using the Preschool PATHS high-quality year. The year 1
curriculum and language/emergent performance for cost per student
literacy skill enrichment. Parents also at least 2 years would be $599.55.
receive take-home materials describing as a Preschool
the importance of positive support, PATHS/REDI
emotion coaching, and interactive teacher or
reading, with parenting tips and learning PATHS/REDI
activities to use at home. coach; masters
degree (or
comparable
credentials);
classroom
experience
with students
in a learner
role (teaching,
administration,
and school
counseling
preferred);
training
experience with
educators


Healthy Families Overburdened Home visiting program model offering services
America (Home families who voluntarily, intensively, and over the long term (3
Visiting for Child are at risk for to 5 years after the birth of the baby)
Well-Being) (HFA) child abuse and
neglect and other Families are to be offered weekly home visits for a
adverse childhood minimum of 6 months after the birth of the baby.
experiences. Home visits typically last 50-60 minutes. Once
Families are the defined criteria for family functioning have
determined eligible been met, visit frequency is reduced to biweekly,
for services once monthly, and quarterly, and services are tapered off
they have been over time. Typically, families receive two to four
screened and/ visits per month during pregnancy. During times
or assessed for of crisis, families may be seen two or more times
the presence of per week. Services are offered prenatally or at birth
factors that could until the child is at least age 3 and can be offered
contribute to until he/she is age 5.
increased risk for
child maltreatment
or other poor
childhood outcomes
(e.g., social
isolation, substance
abuse, mental
illness, parental
history of abuse in
childhood). Home
visiting services
must be initiated
either prenatally or
within 3 months
after the birth of the
baby.

APPENDIX C 445

Goals: Build and sustain community Direct service None noted CEBC: 1
partnerships to systematically engage staff should have CEBC:
overburdened families in home visiting qualifications Medium
services prenatally or at birth. Cultivate including, but Child
and strengthen nurturing parent- not limited to, Welfare
child relationships. Promote healthy experience in
childhood growth and development. working with
Enhance family functioning by reducing or providing
risk and building protective factors. services to
children and
Parent Survey (formerly Kempe Family families, an
Stress Checklist) is administered to ability to
identify the family strengths as well as establish trusting
family history and/or issues related to relationships,
higher risk of child maltreatment and/ acceptance
or poor childhood outcomes. Services of individual
focus on supporting the parent as differences,
well as parent-child interaction and experience and
child development. All families are willingness to
linked to a medical provider to ensure work with the
optimal health and development (e.g., culturally diverse
timely immunizations, well-child care). populations
Depending on the familys needs, that are present
the program may also be linked to among the
additional services, such as financial, programs target
food, and housing assistance programs; population; and
school readiness programs; child care; knowledge of
job training programs; family support infant and child
centers; substance abuse treatment development.
programs; and domestic violence
shelters. Training is
provided in
Provides services to expectant or new person either
parents screened and/or assessed as in state or
at moderate to high risk for child regionally: 4
maltreatment and/or poor early days for direct
childhood outcomes (e.g., mental health service staff.
issues, domestic violence, substance
abuse, poverty, housing, lack of
education, lack of social support).
[continued]


Healthy Families
America (Home
Visiting for Child
Well-Being) (HFA)
(continued)

APPENDIX C 447

Involves the family or other support
systems in the individuals treatment.
Given that children develop within the
context of a relationship, relationship-
based early intervention focuses on
strengthening the parent (or caregiver)-
child relationship. HFA takes advantage
of teachable moments to encourage the
healthy parent-child relationship. Three
key aspects of building a relationship
must be present to grow a mentally and
emotionally healthy child: parents or
caregivers must touch the child, have
eye contact, and give quality time to
the child. Children must experience,
regulate, and express emotions to
form close and secure interpersonal
relationships and to explore their
environment and learn. The end result
is formation of a strong attachment to
the parent or caregiver. It is critical that
early caregivers know how to promote
healthy social and emotional well-
being through nurturing and consistent
relationships.


Highscope Preschool students Educational approach aims to promote active
Preschool* from disadvantaged learning by providing many opportunities for
families and at children to initiate their own activities and take
high risk of school responsibility for completing them.
problems
Classroom program meets for half-days (2.5 hours
per day), 5 days a week for 7 months of the year,
with 90-minute weekly home visits by preschool
teachers.

APPENDIX C 449

Program aims to enhance childrens Delivered by Three steps, each Blueprints:
cognitive, social-emotional, and physical preschool with training Promising
development, imparting skills that teachers. The options. Initial
will help them succeed in school and staff-to-child onsite training NREPP:
be more productive and responsible ratio is one adult averages $1,930 3.55
throughout their lives. for every five or per participant for
six children. groups of more
than 30. Each of
the implementation
steps requires
the purchase of
materials for each
classroom. The
curriculum costs
approximately $800
per classroom.
Estimated cost
for consumable is
$500-$1,000 per
classroom per year.
Each student is
evaluated using the
HighScope Child
Observation Record
at an annual cost of
$10.95-19.95 per
student.
Program example:
Cost for a preschool
program with 10
teachers in five
classrooms of 20
children would be
$295.50 per student
in year1.


Home Instruction Parents with young Home-based and parent-involved school readiness
for Parents children ages 3-5 program that helps parents prepare their children
of Preschool and with limited for success in school and beyond. The parent is
Youngsters formal education provided with carefully developed curriculum,
(HIPPY) and resources books, and materials designed to strengthen the
childs cognitive and early literacy skills, as well as
social, emotional, and physical development.
Home visitors engage their assigned parents on a

weekly basis. Service delivery is primarily through
home visits. A home visit consists of a 1-hour,
one-on-one interaction between the home visitor
and the assigned parents. Parents then engage
their children in educational activities for 5 days
per week for 30 weeks. At least six times per year,
one or more cohorts of parents meet in a group
setting with the coordinator and their assigned
home visitor(s). Group meetings feature enrichment
activities for parents and their children and last
approximately 2 hours.
A minimum of 30 weeks of interaction with the

home visitor; curriculum available for up to 3 years
of home visiting services

APPENDIX C 451

In the developmentally appropriate The home None noted CEBC: 2
curriculum, role play is the method visitors live in CEBC:
of instruction. Staff consisting of the community Medium
coordinators and home visitors engage they serve and Child
parents through home visits and group work with the Welfare
meetings. Parent-child educational same group
interactions are encouraged through of parents for
the use of the HIPPY curriculum. The 3 years. They
scripted curriculum serves as a lesson receive weekly
plan for parents and is designed to comprehensive
support parents with limited formal training to
education. The curriculum is based on equip them
exposure to skills, rather than mastery. to serve their
assigned families
Provides services to children/adolescents effectively. The
that address limited exposure to reading training also
readiness skills. encourages them
to seek further
Provides services to parents/caregivers education. Many
that address low literacy level and home visitors
limited English proficiency. earn degrees in
early childhood
education.
Educational
requirements are
established by
the implementing
agency and are
usually a high
school diploma
or GED. Home
visitors must be
able to read in
and speak the
language of the
families they
serve.
The coordinator,
who trains the
home visitors
and oversees the
local program,
is required to
have a minimum
of a bachelors
degree.


Homebuilders Families with one Home-based intensive family preservation services
or more children program designed to improve family functioning
(up to age 18) who and childrens behavior and to prevent out-of-home
are at imminent placement of children into foster or group care,
risk of out-of-home psychiatric hospitals, or correctional facilities.
placement or who
have been placed 4 to 6 weeks; extensions are offered, and two
out of the home booster sessions are offered in the 6 months after
and need intensive services end.
services to reunify
with their family.
Family is usually
experiencing such
problems as child
abuse and neglect,
other family
violence, juvenile
delinquency, mental
illness, and/or
substance abuse.

APPENDIX C 453

Drawing on social learning and crisis Families are Site development NREPP:
intervention theories, the program typically referred and implementation 3.05
is structured to reduce barriers to by protective readiness
family support services and maximize services, consultation for
opportunities for family members to foster care all training costs
learn new personal and social skills. and adoption $1,250 (up to 15
Services provided by therapists include agencies, participants) or
social support (e.g., transportation, community $2,500 (up to 30
budgeting, household maintenance mental health participants), plus
and home repair services), counseling, professionals, travel expenses.
modeling of parenting skills, extensive probate courts,
interagency treatment planning, and or domestic Core Curriculum
family advocacy within the community violence shelters. training costs $120
context. Within 24 hours per participant
of referral, for materials.
families begin Goal-Setting
receiving services and Paperwork
from masters- training costs $20
level therapists per participant.
who meet with Motivational
them in their Interviewing
homes and training costs $40
neighborhoods per participant.
during sessions Relapse Prevention
that are training costs $20
scheduled on a per participant.
flexible basis. Utilizing Behavioral
Each therapist Principles and
serves two or Strategies with
three families at Families costs $20
a time, typically per participant.
spending 40 Teaching Skills to
or more hours Families costs $15
in face-to-face per participant.
contact with Improving Decision
family members. Making through
In addition, Critical Thinking
therapists are on costs $25 per
call for families participant.
24 hours per Fundamentals
day, 7 days per of Supervising
week. Homebuilders:
Intensive Family
Preservation
costs $275 per
participant.
[continued]


Homebuilders
(continued)

APPENDIX C 455

Program
Consultation
and Quality
Assurance Skills
for Homebuilders
Supervisors costs
$75 per participant.
Online Data
Manager training
costs $15 per
participant. Phone
consultations
(held weekly in
the first 2 years of
implementation,
monthly in year
3, and quarterly
thereafter) cost
$100 per hour.
3- to 4-day onsite
visits (twice per
year) cost $1,250
per day, plus travel
expenses. Access
to the Online Data
Manager: $4,900
activation fee (year
1 only); $350
monthly fee; $980
annual upgrade fee.


Incredible Years Young children and Child, parent, and teacher developmentally based
(IY) their parents and programs designed to promote emotional and
teachers social competence and to prevent, reduce, and
treat behavioral and emotional problems in young
Programs for children.
parents target key
developmental The Dinosaur School Program consists of more
stages: IY Babies than 60 classroom lesson plans (approximately
Program (0-9 45 minutes each) for three age levels, beginning
months); IY in preschool through second grade (ages 3-8).
Toddlers Program Lesson plans are delivered by the teacher at least
(ages 1-3); IY twice weekly over consecutive years. The small-
Preschool Program group treatment program consists of 18-22 weekly
(ages 3-5); IY sessions (2 hours each) offered in conjunction with
School Age Program the training programs for parents of preschoolers
(ages 6-12) or school-age children.
There are two Social Lengths of the parent and child programs vary
and Emotional from 12 to 20 weekly group sessions (2-3 hours
Skills Programs for each).
Children (Dinosaur
School Program): Teacher sessions can be completed in 5-6 full-day
IY Classroom Child workshops or 18 to 21 2-hour sessions.
Program (ages
3-8); IY Treatment The Basic Parent Training Program is 14 weeks
Small Group Child for prevention populations, and 18-20 weeks for
Program (ages 4-8) treatment. The Child Training Program is 18-22
weeks. For the treatment version, the Advance
One Classroom Parent Program is recommended as a supplemental
Management program. Basic plus Advance takes 26-30 weeks.
Program for The Child Prevention Program is 20-30 weeks and
Teachers (early may be spaced over 2 years. The Teachers Program
childhood and is 5-6 full-day workshops spaced over 6-8 months.
elementary school,
ages 3-8)

APPENDIX C 457

The child program aims to strengthen Trained Program materials CEBC: 1
childrens social and emotional facilitators with cost $1,150-$1,895, CEBC:
competencies, such as understanding a masters degree depending on the Medium
and communicating feelings, using (or equivalent) series selected. Child
effective problem-solving strategies, use videotaped Welfare
managing anger, practicing friendship vignettes to Ongoing costs
and conversational skills, and behaving structure the include $476 for NREPP:
appropriately in the classroom. content and each parent in 3.5
stimulate group parent groups,
The parent programs focus on discussions, $775 for each child
strengthening parent-child interactions problem solving, in child treatment
and relationships; reducing harsh and practices groups, $15 for
discipline; and fostering parents ability related to each child receiving
to promote childrens social, emotional, participants the Dinosaur
and language development. In the goals. curriculum in
programs for parents of preschoolers school, and $30
and school-age children, participants for each teacher
also learn how to promote school receiving the
readiness skills; in addition, these teacher training.
parents are encouraged to partner These costs vary by
with teachers and become involved in location.
their childrens school experiences to
promote childrens academic and social
skills and emotional self-regulation
and to reduce conduct problems.
Each program includes protocols for
use as a prevention program or as a
treatment program for children with
conduct problems and attention deficit
hyperactivity disorder (ADHD).
The teacher program focuses on

strengthening teachers classroom
management strategies; promoting
childrens prosocial behavior, emotional
self-regulation, and school readiness;
and reducing childrens classroom
aggression and noncooperation with
peers and teachers. The training also
helps teachers collaborate with parents
to support parents school involvement
and promote consistency between home
and school.


Incredible Years Families of Small-group treatment program designed
(IY)-Child children ages 4-8 to enhance social competence, positive peer
Treatment with conduct interactions, conflict management strategies,
problems, ADHD, emotional literacy, and anger management.
and internalizing
problems 18-22 weekly 2-hour sessions

APPENDIX C 459

Emphasizes training children in such Trained Initial workshop Blueprints:
skills as emotional literacy, empathy facilitators use training costs Promising
or perspective taking, friendship skills, videotaped typically include
anger management, interpersonal scenes to a 3-day training
problem solving, school rules, and how encourage group for approximately
to be successful at school. The child discussion, $1,100-$2,000.
program is organized to dovetail with problem solving, A set of program
the IY parent training programs. and sharing of DVDs and materials
ideas. costs $1,150 for
the Small-Group
Treatment version
of the Dinosaur
Child Program.
With 18 children
participating,
the initial cost
of the program
is approximately
$2,150.60/child for
the Small-Group
Treatment version;
however, after one-
time up-front costs
have been paid,
subsequent groups
in future years cost
less: $1,117.95.


Incredible Years Families and Three BASIC parent training programs target key
(IY)-Parent teachers of children developmental stages: Baby and Toddler Program,
ages 2-8 with Preschool Program, and School Age Program.
behavioral and
emotional problems Program length varies, but generally lasts between
3-5 months: Baby and Toddler Program (0-2.5
years; 9-13 sessions), Preschool Program (3-5 years;
18-20 sessions), and School Age Program (6-12
years; 12-16+ sessions).

APPENDIX C 461

Programs emphasize developmentally Trained Initial training Blueprints:
appropriate parenting skills known to facilitators use and technical Promising
promote childrens social competence, video scenes to assistance costs
emotional regulation, and academic encourage group typically include
skills and to reduce behavior problems. discussion, a 3-day training
The BASIC parent program is the self-reflection, for group leaders
core of the parenting programs and modeling for approximately
must be implemented, as Blueprints and practice $1,100-$2,000.
recognition is based on evaluations rehearsals, A set of program
of this program. This BASIC parent problem solving, DVDs costs $1,595
training component emphasizes such sharing of ideas, for Preschool
parenting skills as child-directed play and support BASIC ($1,895
with children; academic, persistence, networks. for dual-language
social, and emotional coaching methods; English/
use of effective praise and incentives; Spanish). With
establishment of predictable routines 108 parents
and rules and effective limit setting; participating,
handling misbehavior with proactive the initial cost
discipline; and teaching children to of the program
problem solve. is approximately
$643/parent;
however, after one-
time up-front costs
have been paid,
subsequent groups
in future years cost
less.


Kids Club Children ages 6-12 Preventive intervention program that targets
& Moms and their mothers childrens knowledge about family violence, their
Empowerment* exposed to intimate attitudes and beliefs about families and family
partner violence in violence, their emotional adjustment, and their
the last year social behavior in the small group. Later sessions
address responsibility for violence, managing
emotions, family relationship paradigms, and
conflict and its resolution.
10 weeks of 1-hour sessions where groups of

mothers and children meet concurrently

APPENDIX C 463

Provides support to mothers by Therapists have None noted CEBC: 3
empowering them to discuss the a masters in CEBC:
impact of the violence on their childs social work Medium
development, building parenting (MSW), are Child
competence, providing a safe place to licensed clinical Welfare
discuss parenting fears and worries, and social workers,
building connections for the mother in or have a
the context of a supportive group. masters or Ph.D.
in psychology.
Goals of Kids Club are reducing Therapists
childrens internalizing and externalizing also can be
behavioral adjustment problems, in training
reducing childrens harmful attitudes to receive a
and beliefs about the acceptability of professional
violence, enhancing childrens ability to degree, in which
cope with violence by learning safety case they are
skills and additional conflict resolution subject to regular
skills, and enhancing childrens ability supervision
to identify and regulate emotions related by a licensed
to violence. professional.
The goals of Moms Empowerment are

reducing the level of mothers traumatic
stress and violence exposure, enhancing
mothers safety and ability to parent
under stress, and providing support and
resources in a group setting.


Nurse-Family First-time, low- Prenatal and infancy home visiting by nurses
Partnership (NFP) income mothers (no beginning during pregnancy and continuing
previous live births) through the childs second birthday. Designed
to link families with needed health and human
services, promote good decision making about
personal development, assist families in making
healthy choices during pregnancy and providing
proper care to their children, and help women
build supportive relationships with families and
friends.
Weekly home visits for the first month after

enrollment and then every other week until the
baby is born. Visits are weekly for the first 6
weeks after the baby is born and then every other
week until the baby is 20 months old. The last four
visits are monthly until the child is 2 years old.
Visits typically last 60-75 minutes.

APPENDIX C 465

Goals are to improve pregnancy Nurse home The cost to CEBC: 1
outcomes by promoting health- visitors must prepare one team CEBC:
related behaviors; to improve child be registered to begin offering Medium
health, development, and safety by nurses with a the program is Child
promoting competent caregiving; bachelors degree approximately Welfare
and to enhance parent life-course in nursing, as $77,000.
development by promoting pregnancy a minimum NREPP:
planning, educational achievement, and qualification. Estimated annual 3.38
employment. The program also has two salary and benefit
secondary goals: to enhance families Nurse costs for a team of Blueprints:
material support by providing links with supervisors must eight nurses and Model
needed health and social services, and to be registered one supervisor
promote supportive relationships among nurses with a serving 200 families
family and friends. bachelors degree total $711,000 but
in nursing as costs vary based on
Objectives include improving womens a minimum local salary levels.
diets; helping women monitor their qualification,
weight gain and eliminate the use with a masters Travel is a
of cigarettes, alcohol, and drugs; degree in nursing significant expense,
teaching parents to identify the signs of preferred. estimated at
pregnancy complication; encouraging $21,000 for a
regular rest, appropriate exercise, Implemented by nursing team
and good personal hygiene related to teams of eight annually. Ongoing
obstetric health; and preparing parents nurse home training is estimated
for labor, delivery, and early care of the visitors with one at $1,526 annually
newborn. supervisor. for a nursing team,
and replacement
training as a
result of turnover
is $7,750 per
supervisor and
$6,000 per nurse.
Annual quality
improvement and
technical assistance
services total
$8,816 per nursing
team.
With 8 nurses and

a caseload of 25
families per nurse,
200 families would
be served at a
cost of $5,074 per
family for 1 year of
services.
[continued]


Nurse-Family
Partnership (NFP)
(continued)
Nurturing Families who have Instruction-based program for the prevention

Parenting Program been identified and treatment of child abuse and neglect is
(NPP) by child welfare based on psychoeducational and cognitive-
agencies for past behavioral approaches to learning and focuses
child abuse and on reparenting, or helping parents learn new
neglect or who are patterns of parenting to replace their existing,
at high risk for child learned abusive patterns.
abuse and neglect;
includes families of Participating families attend sessions either at home
children ages 0-12 or in a group format with other families. Group
sessions combine concurrent separate experiences
for parents and children with shared family
nurturing time. In home-based sessions, parents
and children meet separately and jointly during a
90-minute lesson once per week for 15 weeks.

APPENDIX C 467

NFP costs
approximately
$4,500 per family
per year, with a
range of $2,914 to
$6,463 per family
per year.
By completing questionnaires and Two group Materials set NREPP:

participating in discussion, role play, facilitators are (includes all 3.05
and audiovisual exercises, participants recommended materials needed for
learn how to nurture themselves and in for every implementation and
turn build their nurturing family and seven adults quality assurance)
parenting skills as dads, moms, sons, participating in costs $300-$2,000,
and daughters. Participants develop the program. depending on the
awareness, knowledge, and skills in five Two additional program selected;
areas: age-appropriate expectations; group 3-day, on- or
empathy, bonding, and attachment; facilitators are off-site facilitator
nonviolent nurturing discipline; recommended training costs
self-awareness and self-worth; and for every $250-$325 per
empowerment, autonomy, and healthy 10 children participant.
independence. Multiple NPPs have been participating.
developed for various age groups and NPP can be The cost of running
family circumstances. implemented by a high-quality NPP
professionals or varies based on the
paraprofessionals program format
in such fields and number of
as social work, sessions provided.
education, The initial set of
recreation, and materials can be
psychology who used to implement
have undergone the program for
NPP facilitator approximately
training and 15 families.
have related The majority of
experience. program materials
are reusable.


Parent Recently separated Group- or individual-based parent training
Management single mothers of program that teaches effective family management
Training-Oregon children ages 2-18 strategies and parenting skills, including skill
Model (PMT-O)* with disruptive encouragement, setting limits/positive discipline,
behaviors, such as monitoring, problem solving, and positive
conduct disorder, involvement, aimed at reducing antisocial and
oppositional defiant behavior problems in children.
disorder, and
antisocial behaviors Delivered in group and individual family formats,
in diverse settings (e.g., clinics, homes, schools,
community centers, homeless shelters), over varied
lengths of time depending on families needs. Can
be tailored for specific clinical problems, such as
antisocial behavior, conduct problems, substance
abuse, and child neglect and abuse.
1.5- to 2-hour weekly parent group sessions and

60-minute weekly individual/family sessions;
14 group sessions and 20-25 individual/family
sessions, depending on severity; individual family
treatment is not typically provided together with
group treatment. The time frame can be 5-6
months or longer, depending on circumstances.

APPENDIX C 469

Teach and coach parents in the use Providers Estimated cost Blueprints:
of effective parenting strategies: skill must have a is $1,000 per Model
encouragement, setting limits or bachelors degree participant,
effective discipline, monitoring, problem with 5 years based on 10-15 CEBC: 1
solving, and positive involvement. In of appropriate participants per CEBC:
addition to the core parenting practices, clinical group, with 2 group Medium
PMT-O incorporates the supporting experience or facilitators and 14 Child
parenting components of identifying masters degree sessions. Welfare
and regulating emotions, enhancing in a relevant
communication, giving clear directions, field. During Estimated total NREPP:
and tracking behavior. PMT-O also the first phase, training and 3.56
includes strategies designed to help therapists are technical assistance
parents decrease coercive exchanges trained and cost for Phase 1
with their children and use contingent certified over a for 16 clinicians is
positive reinforcements (e.g., praise, period of 18-24 $515,000 in year
incentives) to promote prosocial months. 1 and $310,000 in
behavior. Promoting school success is year 2.
woven into the program throughout
relevant components. Beyond Phase 3
costs an estimated
Goals include improving parenting $12,000 yearly.
practices; reducing family coercion;
reducing and preventing in youth Estimated cost
internalizing and externalizing over 3 years to
behaviors, substance use and abuse, become a qualified
delinquency and police arrests, out- independent Fidelity
of-home placements, and deviant of Implementation
peer associations; and improving in Rating System
youth academic performance, social (FIMP) team is
competency, and peer relations. $11,780 (Phase4).
$2,500-$4,000
will be needed
for testing before
independent
operation starts.
An organization
with 16 clinicians
could expect to
incur estimated
costs of $1,170,000
in year 1.


Parent-Child Parents of children Didactic and coaching sessions
Interaction ages 2-7 with focus on decreasing externalizing child behaviors
Therapy (PCIT) behavior and (e.g., defiance, aggression), increasing child
parent-child social skills and cooperation, and improving the
relationship parent-child attachment. Parents learn to use
problems traditional play-therapy skills as social reinforcers
of positive child behavior and traditional behavior
management skills to decrease negative child
behavior. Parents learn and practice these skills
with their child in a playroom while coached
by a therapist. The coaching provides parents
with immediate feedback on their use of the new
parenting skills, which enables them to apply the
skills correctly and master them rapidly.
Typically one or two 1-hour sessions per week with

the therapist. The average number of sessions is
14, but varies from 10 to 20. Treatment continues
until the parent masters the interaction skills to
meet preset criteria and the childs behavior has
improved to within normal limits.

APPENDIX C 471

Parents are taught specific skills to Generally Treatment materials NREPP:
establish or strengthen a nurturing and administered in cost $1,000 per 3.375
secure relationship with their child an outpatient set; 1-week, offsite
while encouraging prosocial behavior clinic by training plus 100 CEBC: 1
and discouraging negative behavior. a licensed hours of additional CEBC:
This treatment has two phases, each mental health training/ Medium
focusing on a different parent-child professional consultation over Child
interaction: child-directed interaction with experience 12 months costs Welfare
(CDI) and parent-directed interaction working with $3,000-$4,000 per
(PDI). In each phase, parents attend children and person; certification Blueprints:
one didactic session to learn interaction families. costs $200 per Promising
skills and then attend a series of organization.
coaching sessions with the child in
which they apply these skills. During the The model
CDI phase, parents learn nondirective often requires
play skills similar to those used in play modification
therapy and engage their child in a play of space at an
situation with the goal of strengthening estimated cost of
the parent-child relationship. During $1,000-$1,500.
the PDI phase, parents learn to direct
the childs behavior with clear, age- An Eyberg Child
appropriate instructions and consistent Behavior Inventory
consequences, with the aim of increasing is administered
child compliance. weekly to each
parent at a cost of
Teaches parents traditional play- $40 for 25 forms.
therapy skills to improve parent-child Each therapist
interactions and problem-solving receives weekly
skills that can be used to manage consultation from
new problem behaviors. Parents are the purveyor for
taught and practice communication the first year at a
skills and behavior management with cost of $1,000 per
their children in a playroom while therapist for the
coached by therapists. Most parenting year.
programs for abusive parents treat
parents separately from their children A study of high-risk
and use an instructive approach, but families involved
PCIT treats parents with their children. in the child welfare
Skills are behaviorally defined, directly system estimated
coached, and practiced in parent-child the cost for each
sessions. Parents are shown directly how parent-child
to implement specific behavioral skills pair completing
with their children. Therapists observe the program at
parent-child interactions through a one- $2,208-$3,638.
way mirror and coach. Live coaching
and monitoring of skill acquisition are [continued]
cornerstones of PCIT.
[continued]


Parent-Child
Interaction
Therapy (PCIT)
(continued)

APPENDIX C 473

Child goals include building close If each therapist
relationships with parents using positive had a caseload of
attention strategies; helping children feel 20 families for an
safe and calm by fostering warmth and average of 15 weeks
security between parents and children; per family, 280
increasing childrens organizational families could be
and play skills; decreasing childrens served in the first
frustration and anger; educating year at a cost of
parents about ways to teach their child $1,210 per family.
without frustration for parent and
child; enhancing childrens self-esteem;
improving childrens social skills,
such as sharing and cooperation; and
teaching parents how to communicate
with young children who have limited
attention spans.
Parent goals include teaching parents

specific discipline techniques that help
children listen to instructions and follow
directions, decreasing problematic child
behaviors by teaching parents to be
consistent and predictable, and helping
parents develop confidence in managing
their childrens behaviors at home and
in public.

that address noncompliance, aggression,
rule breaking, disruptive behavior,
dysfunctional attachment with parents,
and internalizing symptoms.

that address ineffective parenting styles
(e.g., permissive, authoritarian, and
overly harsh parenting).


ParentCorps Parents and their Family-centered preventive intervention designed to
young children ages foster healthy development and school success of
3-6 living in low- young children
income communities
Weekly series of 14 2-hour group sessions that
occur concurrently for parents and children

APPENDIX C 475

Parent groups present a specific set Delivered in ParentCorps NREPP:
of parenting strategies: establishing parent and child training and 3.36
structure and routines for children, groups facilitated start-up materials
providing opportunities for positive by trained (include leaders
parent-child interactions during professionals. manuals and
nondirective play, using positive Groups include resource guides for
reinforcement to encourage compliance approximately use with the child
and social and behavioral competence, 15 participants and parent groups;
selectively ignoring mild misbehaviors, and are held in props, puppet,
and using effective forms of discipline early childhood and music CD for
for misbehavior (e.g., time-outs, loss education use with the child
of privileges). Parenting strategies or child care group; and DVD
are introduced through group settings. Parent for use with the
discussions, role plays, an animated groups are parent group) cost
video series, and a photography-based facilitated $2,000 (for up to 4
book of ParentCorps family stories by trained child group leaders
and homework. In a manner that is mental health and 1 parent group
sensitive to and respectful of parents professionals. leader). Family
readiness for change, facilitators help Child groups are group materials
parents anticipate barriers and generate led by trained (include parent
solutions so that families can implement classroom workbooks,
the strategies successfully. teachers. parent toolkit, and
wordless picture
Child groups focus on promoting social, book) cost $30 per
emotional, and self-regulatory skills family. ParentCorps
through interactive lessons, experiential 101 Web-based
activities, and play. In support of training costs $50
individualized goals that parents set for per user. 5-day
children, teachers promote skills and training at New
shape behaviors using strategies that York University
complement the parenting strategies costs $5,000 per
being introduced to parents. site (for up to 4
participants). 2-day,
onsite consultation
costs $5,000 plus
travel expenses.
Group leader
coaching (14 hours
during the first cycle
of implementation)
costs $2,000.
Quality assurance
measures are
included in the cost
of implementation
materials.


Parenting Wisely Parents of children A set of self-instructional interactive, computer-
ages 3-18 at risk for based training programs based on social learning,
or with behavior cognitive-behavioral, and family systems
problems, substance theories, the program aims to increase parental
abuse problems, or communication and disciplinary skills.
delinquency
All nine sessions can be completed in 2-3 hours.

APPENDIX C 477

Parents use this self-instructional None required Program kit CEBC: 3
program on an agencys personal (includes service CEBC:
computer or laptop, either onsite providers guide and Medium
or at home, using the CD-ROM or program integrity Child
online format. The program utilizes a guide) costs $659 Welfare
DVD for group administration or an each. Additional
interactive online program for individual parent workbooks NREPP:
administration, with 10 video scenarios cost $6.75-$9.00 2.73
depicting common challenges with each, depending
adolescents. Parents choose from among on the quantity
three solutions to these challenges and purchased.
are able to view the scenarios enacted
while receiving feedback about each
choice. Parents are quizzed periodically
throughout the program and receive
feedback. The program operates as a
supportive tutor, pointing out typical
errors parents make and highlighting
new skills that will help them resolve
problems.


Parents as Teachers Parents of children Early childhood family support and parent
(PAT) ages 0-5 education home visiting program includes optional
group connection formats with family activities,
presentations, community events, parent cafes, and
ongoing groups. Annual health, hearing, vision,
and developmental screenings, beginning within 90
days of enrollment, are a third component of the
model.
Home visits of approximately 60 minutes delivered

weekly, every 2 weeks, or monthly, depending on
family needs; optional monthly or more frequent
group connections

APPENDIX C 479

Parent educators work with parents to Parent educators 5-day, offsite NREPP:
strengthen protective factors and ensure ideally hold parent educator 3.175
that young children are healthy, safe, a bachelors foundational
and ready to learn. The goals of the degree in an and model
model are to increase parent knowledge area, such as implementation
of early childhood development, early childhood training (includes all
improve parenting practices, provide education, program materials
early detection of developmental delays human services, and 1-year access
and health issues, prevent child abuse or a related field; to online materials
and neglect, and increase childrens however, a high for serving families
school readiness and school success. school diploma prenatally to age
Parent-child interaction focuses on and 2 years of 3) costs about
promoting positive parenting behaviors supervised work $800 per parent
and child development through parent- experience with educator, but varies
child activities. Development-centered young children by location. 2-day,
parenting focuses on the link between and/or parents offsite parent
child development and parenting and is acceptable. educator training
on key developmental topics (i.e., Different for the 3 Years to
attachment, discipline, health, nutrition, curriculum Kindergarten Entry
safety, sleep, transitions/routines, materials are curriculum (includes
healthy births). Family well-being used for those printed curriculum)
includes a focus on family strengths, working with costs about $225-
capabilities, skills, and building of families of $450. Annual
protective factors. children up recertification and
to age 3 and online access fee
those working is $75 per parent
with families educator.
of children
from age 3 to After initial start-up
kindergarten. expenses have
been paid, the cost
to provide PAT
services to families
is estimated to
be approximately
$2,500 per family
for twice-monthly
visits. PAT provides
resources to help
new affiliates build
a realistic and
comprehensive
budget.


Period of PURPLE All mothers Shaken baby syndrome prevention program
Crying and fathers of educates parents and caretakers on normal infant
new infants and crying, the most common trigger for shaking an
society in general infant. The program was designed to be used
with respect to primarily in universal, primary prevention settings,
understanding early but is applicable to secondary prevention as well.
increased infant
crying and shaken Three 3- to 10-minute doses: (1) in the maternity
baby syndrome ward, provided separately from other materials;
(2) either pre- or postbirth as a second dose
(e.g., in prenatal classes and in the first pediatric
office visit); (3) via media and social networking
campaigns. With these three doses, the duration
of the program is at least a week and can be much
longer since the infant crying period lasts up to
4-5 months, and a key element of the program is
that each parent receives a copy of the DVD and
booklet to take home.
Play and Learning Children ages 5-15 Preventive intervention program to strengthen the
Strategies-Infant months and their bond between parent and baby and to stimulate
Program (PALS I) families early language, cognitive, and social development
The program consists of 90-minute individual

sessions in the familys home and lasts about 11
weeks.

APPENDIX C 481

Goals include supporting caregivers in There are no Not specified CEBC: 3
their understanding of early increased educational CEBC:
infant crying and reducing the incidence requirements, Medium
of shaken baby syndrome/abusive head but providers Child
trauma. must take the Welfare
training online
or in person and
be in a position
where they have
the authority
to provide the
program to
new parents.
Providers should
protect the
fidelity of the
program by
complying with
the protocol
required.
The aim is to facilitate parents mastery It is Not specified CEBC: 3

of specific skills for interacting with recommended CEBC:
their young children, including paying that a trained Medium
attention to and correctly interpreting PALS I home Child
babies signals, responding contingently visitor have Welfare
to signals, and using rich language. at least an
associates
Goals include increasing parents degree in early
contingent responsiveness behaviors, childhood (or a
rich language input, emotional/affective related field) or
support, and ability to maintain their work experience
childs focus of attention, and improving commensurate
childrens language, cognitive, and social with that
outcomes. education. PALS
I home visitors
are supervised by
a person with at
least a bachelors
degree in early
childhood
education or
a related field
with 3-5 years
experience
in parent
education.


Play and Learning Children ages 18 Preventive intervention program designed to
Strategies-Toddler/ months to 4 years strengthen the bond between parent and child and
Preschool Program and their families to stimulate early language, cognitive, and social
(PALS II) development through positive language input, use
of language and activities to encourage childrens
problem-solving skills, and positive discipline
strategies.
The program consists of 90-minute individual

sessions in the familys home and lasts about 14
weeks.
SafeCare Parents at risk for In-home parenting program that targets risk factors
or with a history of for child neglect and physical abuse. Parents are
child neglect and/or taught (1) how to interact in a positive manner
abuse with their children, plan activities, and respond
appropriately to challenging child behaviors; (2)
how to recognize hazards in the home to improve
the home environment; and (3) how to recognize
and respond to childrens symptoms of illness and
injury, in addition to keeping good health records.
18-20 weekly sessions of approximately 1-1.5

hours each

APPENDIX C 483

Facilitate parents mastery of specific It is Not specified CEBC: 3
skills for interacting with their young recommended CEBC:
children, such as understanding that a trained Medium
childrens signals, responding PALS II home Child
contingently, guiding childrens behavior, visitor have Welfare
and using rich language. at least an
associates degree
Goals include increasing parents or higher in early
contingent responsiveness behaviors, childhood (or a
rich language input, emotional/affective related field) or
support, and ability to maintain the work experience
childs focus of attention, and improving commensurate
the childs language, cognitive, and with that
social outcomes. education. PALS
II home visitors
are supervised by
a person with at
least a bachelors
degree in early
childhood
education or
a related field
with 3-5 years
experience
in parent
education.
Goals are to reduce future incidents of A college Not specified SafeCare

child maltreatment, increase positive education is CEBC: 2
parent-child interaction, improve how preferred, CEBC:
parents care for their childrens health, but the most High
and enhance home safety and parent important Child
supervision. qualification Welfare
is that staff
be trained to SafeCare
performance [Home
criteria. Visiting
for Child
Well-
Being]
CEBC: 3
CEBC:
High
Child
Welfare


Strengthening Children ages 3-16 Family skills training program designed to increase
Families Program resilience and reduce risk factors for behavioral,
(SFP) emotional, academic, and social problems
14 weekly 2-hour sessions

APPENDIX C 485

Comprises three life-skills courses. Not specified CD containing NREPP:
The Parenting Skills sessions are materials for one 3.1
designed to help parents learn to age group (3-5,
increase desired behaviors in children 6-11, 7-17, or 12-
by using attention and rewards, clear 16) costs $450 each
communication, effective discipline, (or is included in
substance use education, problem training fee).
solving, and limit setting. The Childrens
Life Skills sessions are designed to help Small agencies may
children learn effective communication, find it economical
understand their feelings, improve social to attend a
and problem-solving skills, resist peer training hosted by
pressure, understand the consequences a nearby agency.
of substance use, and comply with Lutra Group,
parental rules. In the Family Life Skills Inc., the entity
sessions, families engage in structured that coordinates
family activities, practice therapeutic SFP training and
child play, conduct family meetings, technical assistance,
learn communication skills, practice can help in locating
effective discipline, reinforce positive other trainings.
behaviors in each other, and plan Training in the
family activities together. Participation United States is
in ongoing family support groups available in English
and booster sessions is encouraged to and Spanish.
increase generalization and use of skills Implementation
learned. requires a minimum
of five trained staff:
two group leaders
for the parents, two
group leaders for
the children, and a
site coordinator.


Systematic Training Parents dealing Skills training that promotes a more participatory
for Effective with frequently family structure by fostering responsibility,
Parenting (STEP)* encountered independence, and competence in children;
challenges with their improving communication between parents and
children (ages 0-12) children; and helping children learn from the
that often result natural and logical consequences of their own
from autocratic choices. Presented in a group format, with optimal
parenting styles. group sizes ranging from 6 to 14 parents.
Designed for use
with parents facing Typically taught in 8 or 9 weekly 1.5-hour study
typical parenting groups
challenges;
however, all the
studies reviewed
for this summary
targeted families
with an abusive
parent, families at
risk for parenting
problems and child
maltreatment, or
families with a child
receiving mental
health treatment.

APPENDIX C 487

Four current versions of STEP: Early Facilitated by STEP kit costs $345 NREPP:
Childhood STEP for parents of a counselor, each. 2.86
children up to age 6; STEP for parents social worker, or
of children ages 6-12; STEP/Teen for individual who Parents handbook
parents of teens; and Spanish STEP, has participated costs $16.99
a complete translation of the STEP in a STEP per participant
program for parents of children ages workshop. (quantity discounts
6-12. Using the STEP multimedia kit, are available).
lessons are taught to parents on how
to understand child behavior and
misbehavior, practice positive listening,
give encouragement (rather than praise),
explore alternative parenting behaviors
and express ideas and feelings, develop
their childs responsibilities, apply
natural and logical consequences,
convene family meetings, and develop
their childs confidence.


Trauma-Focused Children with a Psychosocial treatment model designed to address
Cognitive- known trauma traumatic experiences. Initially provides parallel
Behavioral Therapy history who are individual sessions with children and their parents
(TF-CBT)* experiencing (or guardians), with conjoint parent-child sessions
significant PTSD increasingly incorporated over the course of
symptoms, whether treatment.
or not they meet full
diagnostic criteria. Sessions are conducted once a week. Each session is
In addition, children 30-45 minutes for the child, 30-45 minutes for the
with depression, parent. The conjoint child-parent sessions toward
anxiety, and/or the end of treatment last approximately 30-45
shame related to minutes. Treatment lasts 12-18 sessions.
their traumatic
exposure. Children
experiencing
childhood traumatic
grief can also benefit
from the treatment.

APPENDIX C 489

Goals include improving child PTSD, Masters 10-hour online CEBC: 1
depressive, and anxiety symptoms; degree and introductory CEBC:
improving child externalizing behavior training in the training is free. High
problems (including sexual behavior treatment model; 2- to 3-day onsite Child
problems if related to trauma); experience full clinical training Welfare
improving parenting skills and parental working with (introductory and
support of the child and reducing children and advanced training) NREPP:
parental distress; enhancing parent-child families varies depending 3.72
communication, attachment, and ability on site needs.
to maintain safety; improving childs Consultation call
adaptive functioning; and reducing twice a month for
shame and embarrassment related to the at least 6 months
traumatic experiences. costs $200-$260
per hour.
Components include psychoeducation
and parenting skills, relaxation
techniques, affective expression and
regulation, cognitive coping, trauma
narrative and processing, in vivo
exposure, conjoint parent-child sessions,
and enhancing personal safety and
future growth.

that address feelings of shame, distorted
beliefs about self and others, acting-
out behavior problems, and PTSD and
related symptoms.

that address inappropriate parenting
practices and parental trauma-related
emotional distress.


Treatment Foster Preschool foster Foster care treatment model effective at promoting
Care Oregon children ages 3-6 secure attachment in foster care and facilitating
for Preschoolers who exhibit a high successful permanent placements. TFCO-P is
(TFCO-P) level of disruptive delivered through a treatment team approach in
and antisocial which foster parents receive training and ongoing
behavior and cannot consultation and support.
be maintained
in regular foster For foster parent(s), the program typically entails a
care or may be minimum of seven contacts per week that include
considered for five 10-minute contacts, one 2-hour group session,
residential treatment and additional contacts based on the amount of
support or consultation required. For the child
in treatment, the program includes two contacts
per week that comprise a 2-hour therapeutic
playgroup and a 2-hour skills training session. For
the biological family or other long-term placement
resource, the program includes one contact per
week in the form of a 1-hour skill-building session.
Designed with an overall treatment duration of 6-9
months.

APPENDIX C 491

Children receive individual skills Program None noted CEBC: 2
training and participate in a therapeutic supervisors must CEBC:
playgroup, and birth parents (or other have a masters- High
permanent placement caregivers) receive level education Child
family therapy. TFCO-P emphasizes and relevant Welfare
the use of concrete encouragement experience
for prosocial behavior; consistent, in behavior
nonabusive limit setting to address management
disruptive behavior; and close approaches.
supervision of the child. In addition,
the TFCO-P intervention employs a Foster parent
developmental framework in which the consultants/
challenges of foster preschoolers are recruiters/
viewed from the perspective of delayed trainers must
maturation. have knowledge
of foster parents
Goals include eliminating or reducing and a clear
child problem behaviors; increasing understanding of
developmentally appropriate normative the model. Prior
and prosocial behavior in children; experience as a
transitioning children to a birth family, foster/adoptive
adoptive family, or lower-level aftercare parent is strongly
resource; improving childrens peer desirable.
associations; improving parent-child
interaction and communication; and Family therapists
improving childrens coping and social must have a
skills. masters-level
education.
Knowledge
of parent
management
training
or related
behaviorally
based parenting
techniques is
highly desirable.
Playgroup
leaders and
skills trainers
must have a
bachelors-level
education.


Triple P-Positive Families with Triple P is a multitiered system of five levels of
Parenting children ages 0-12, education and support for parents and caregivers
Program System with extensions of children and adolescents. Although Triple P can
(Triple P) to families with be used in parts (e.g., using only one level of the
teenagers ages 13-16 five or a group version versus the standard version),
this entry on the CEBC reviews Triple P as a whole
(i.e., using all five levels) in its standard version and
includes only evidence from research that evaluated
the whole system.
As a prevention program, Triple P helps parents

learn strategies that promote social competence
and self-regulation in children. Parents become
better equipped to handle the stress of everyday
childrearing, and children become better able to
respond positively to their individual developmental
challenges. As an early intervention, Triple P can
assist families in greater distress by working with
parents of children who are experiencing moderate
to severe behavior problems. Throughout the
program, parents are encouraged to develop a
parenting plan that makes use of a variety of Triple
P strategies and tools. Triple P practitioners are
trained, therefore, to work with parents strengths
and to provide a supportive, nonjudgmental
environment in which parents can continually
improve their parenting skills.
Level 1, Universal/Stay Positive, uses variable

outreach strategies (Websites, parent newspaper,
brochures, posters, and radio/TV spots) that are
designed to reach the entire population at planned
intervals.
Level 2, Selected Seminars/Selected Seminars Teen,

includes three 2-hour seminars that may be offered
as standalone events or together in a series, and
brief primary care, which consists of one to two
brief consultations lasting up to 30 minutes.
Level 3, Primary Care/Primary Care Teen/Primary

Care Stepping Stones, consists of one to four brief
consultations lasting approximately 30 minutes
each and four 2-hour discussion groups that may
be offered as standalone events or together in a
series.
{continued]

APPENDIX C 493

The overall goal of Triple P is to Formal training Parent workbooks CEBC: 2
prevent development or worsening on each of the cost $20-$32 CEBC:
of severe behavioral, emotional, and five program per participant. Medium
developmental problems in children levels is available Positive parenting Child
and adolescents by enhancing the to organizations booklets cost $6.50 Welfare
knowledge, skills, and confidence of implementing per participant.
parents. Practitioners are trained to this program. Parenting tip sheets NREPP:
create a supportive learning environment cost $8-$11 for a 2.93
in which parents receive and discuss Provider training set of 10.
practical information about parenting courses are Blueprints:
skills that they can incorporate into usually offered 2- to 3-day on- Promising
everyday interactions with their to practitioners site training and
children. Specific expected outcomes with a post- half-day follow-up
include increasing parents competence high school training (includes
in promoting healthy development and degree in health, session fidelity
managing common behavior problems education, checklists and
and developmental issues; reducing child care, or pre-and post-
parents use of coercive and punitive social services. test assessment
methods of disciplining children; In exceptional measures) costs
increasing parents use of positive circumstances, $21,415-$26,195
parenting strategies in managing their this requirement per site for up to
childrens behavior; increasing parents is relaxed when 20 practitioners,
confidence in raising their children; the prospective depending on their
decreasing child behavior problems practitioners are level of training.
(for families experiencing difficult child actively involved
behavior); improving parenting partners in hands-on Costs are based
communication about parenting issues; roles dealing on preparing a site
and reducing parenting stress associated with the targeted to serve 100,000
with raising children. parents, children, families: Level 2,
and teenagers. $160,300; Level
Level 1 is a comprehensive media These particular 3, $537,900
campaign and distribution strategy for practitioners (includes $66,800
delivering positive parenting information have developed, for preaccreditation
to all families within a given community. through their cost); Level 4,
workplace $301,000 (includes
Level 2 interventions are delivered to experience, some $33,400 for
parents through low-intensity seminars knowledge of preaccreditation
or single-session meetings. child/adolescent cost); Level
development 4 (Standard),
Level 3 interventions are brief in and/or have $210,700 (includes
duration (one to four sessions) and experience $23,380 for
focus on identifying and resolving working with preaccreditation
commonly encountered behavior families. cost); Level 4
problems in childhood. Level 3 (Standard Stepping
interventions may be offered in a variety {continued] Stones), $32,155
of settings that parents naturally visit. (includes $3,340
for preaccreditation
{continued] cost);
{continued]


Triple P-Positive Level 4 can consist of a variety of options: (1)
Parenting Group/Group Teen/Group Stepping Stones, which
Program System includes five 2-hour group sessions and three
(Triple P) 20-minute individual telephone consultations for
(continued) each family, offered over 8 consecutive weeks; (2)
Triple P Online, which comprises eight self-paced
online modules; (3) a self-directed workbook,
which is self-paced; or (4) Standard/Standard Teen/
Standard Stepping Stones, which comprises ten
1-hour sessions that occur weekly.
Level 5 can consist of a variety of options: (1)

Enhanced, which consists of three to ten 60- to
90-minute sessions; (2) Pathways, which includes
four sessions lasting 60-90 minutes each when
offered individually or 2 hours each when offered
in group format; (3) Family Transitions, which
consists of ten 2-hour group sessions plus two
individual telephone consultations for each family
lasting 30 minutes; or (4) Group Lifestyle, which
consists of ten 90-minute group sessions plus four
individual telephone consultations for each family
lasting 30 minutes.
Level 1 may be planned for intermittent

distribution of materials throughout the course of
Levels 2-5. Level 1 is typically planned as a 3-year
intervention; Levels 2-3 may include one to four
encounters that take place over 1-6 weeks;
Levels 4-5 typically take place over 4-5 months.
If accommodations are needed (e.g., low-literacy
clients), the duration may be longer.

APPENDIX C 495

Level 4 interventions are delivered in Trainers are Level 5,
eight to ten sessions and offer parents masters- or $81,740. Total
a more comprehensive set of strategies doctorate-level for training and
for improving family functioning professionals preaccreditation
and parent-child relationships in any (mainly clinical workshops is
situation. The interventions have or educational $1,323,795.
sufficient impact to address moderate to psychologists) Implementation
severe behavior problems in children. who are resources cost
Level 5 interventions offer further practitioners $723,598 (including
support for parents with specific risk (Triple P freight and
factors (e.g., families at high risk for providers) handling).
child maltreatment, families going trained to
through a divorce or separation, or implement Triple To summarize
families with overweight or obese P programs the above costs,
children) or for parents with continuing with the parents which represent the
needs following a Level 4 intervention. with whom year-1 investment
they work. in a Triple P
Directly provides services to parents/ Professionals program serving
caregivers that address management of invited to 100,000 families:
child behavior problems; management become Triple P training courses,
of stress, mild to moderate depression trainers undergo $1,323,795;
symptoms, anxiety, and anger; an intensive implementation
parenting partner conflict; and negative 2-week training costs, $723,598;
attributional thinking. program. Stay Positive
communications
campaign,
$320,000; total
year-1 cost,
$2,367,393. The
total dollar value
of $2,367,393
represents a cost of
$23.67 per family
in a community
serving 100,000
families.


Triple P-Positive For parents and Level 4 Triple P helps parents learn strategies that
Parenting caregivers of promote social competence and self-regulation
Program Level 4 children and in children as well as decrease problem behavior.
(Level 4 Triple P) adolescents with Parents are encouraged to develop a parenting
moderate to severe plan that makes use of a variety of Level 4 Triple
behavioral and/ P strategies and tools. Parents are then asked to
or emotional practice their parenting plan with their children.
difficulties or for During the course of the program, parents are
parents that are encouraged to keep track of their childrens
motivated to gain behavior, as well as their own behavior, and to
a more in-depth reflect on what is working with their parenting
understanding of plan and what is not working so well. They then
positive parenting. work with their practitioner to fine tune their plan.
Level 4 Triple P Level 4 Triple P practitioners are trained to work
is applicable to with parents strengths and to provide a supportive,
parents of children nonjudgmental environment in which parents can
and adolescents ages continually improve their parenting skills. Level
0-12. 4 Triple P is offered in several different formats
(e.g., individual, group, self-directed, online). The
CEBC evaluated the standard version of Level 4
Triple P as described above and no other variations
(including early teen versions or those for children
with developmental delays).
The program has a variety of delivery options:

(1) three group versions that include five 2-hour
group sessions and three 20-minute individual
telephone consultations for each family offered
over 8 consecutive weeks; (2) an online version that
comprises eight self-paced online modules; (3) a
self-directed workbook, which is self-paced; or (4)
three individual or standard versions consisting of
ten 1-hour weekly sessions.
Program interventions typically take place over 2-3

months. If accommodations are needed (e.g., low-
literacy clients), the duration may be longer.
*Program that is not mentioned in the report text.

APPENDIX C 497

The aim is to prevent worsening of Level 4 Triple P None noted CEBC: 1
severe behavioral, emotional, and provider training CEBC:
developmental problems in children courses are Medium
and adolescents by enhancing the usually offered Child
knowledge, skills, and confidence to practitioners Welfare
of parents. Practitioners are trained with a post-
to create a supportive learning high school
environment in which parents receive degree in health,
and discuss practical information about education,
parenting skills they can incorporate child care, or
into everyday interactions with their social services.
children. Specific expected outcomes In exceptional
include increasing parents competence circumstances,
in promoting healthy development and this requirement
managing common behavior problems is relaxed when
and developmental issues; reducing the prospective
parents use of coercive and punitive practitioners are
methods of disciplining children; actively involved
increasing parents use of positive in hands-on
parenting strategies in managing their roles dealing
childrens behavior; increasing parents with the targeted
confidence in raising their children; parents, children,
decreasing child behavior problems and teenagers.
(for families experiencing difficult child These particular
behavior); improving parenting partners practitioners
communication about parenting issues; have developed,
and reducing parenting stress associated through their
with raising children. workplace
experience, some
Provides services to parents/caregivers knowledge of
that address parents with children with child/adolescent
moderate to severe behavior problems, development
significant difficulty managing these and/or have
behaviors, and lack of positive parenting experience
skills. Typically includes management working with
of stress, mild to moderate depression families.
symptoms, anxiety, and anger;
parenting partner conflict; and negative
attributional thinking.


Appendix D
Biographical Sketches of
Committee Members
Vivian L. Gadsden, Ed.D. (Chair) is William T. Carter professor of child

development and professor of education at the University of Pennsylvania.
She is also on the faculties of Africana Studies and of Gender, Sexuality, and
Womens Studies; serves as director of the National Center on Fathers
and Families; and served as associate director of the National Center on
Adult Literacy. Her research and scholarly interests focus on children and
families across the life course, particularly those at the greatest risk for aca-
demic and social vulnerability by virtue of race, gender, ethnicity, poverty,
and immigrant status. In addition to serving on the Board of the Founda-
tion for Child Development, she has served or serves on various foundation
and congressionally mandated review committees. She has held leadership
roles in the American Educational Research Association, of which she is
a fellow, and the Society for Research in Child Development. She received
her Ed.D. in educational psychology and policy from the University of
Michigan.
Clare Anderson, M.S.W., is a policy fellow at Chapin Hall, University of

Chicago. Her work focuses on using research, policy, and fiscal levers to
improve outcomes for vulnerable children and families. She works with
state child welfare systems to implement evidence-based screening, assess-
ment, and interventions and better integrate the goals of childrens safety,
permanency, and well-being. Prior to joining Chapin Hall, she was deputy
commissioner at the U.S. Department of Health and Human Services
Administration on Children, Youth, and Families (ACYF), responsible for
federal programs addressing child abuse and neglect, runaway and homeless
499

youth, domestic and intimate partner violence, and teen pregnancy preven-
tion. Prior to joining ACYF, she spent a decade at the Center for the Study
of Social Policy, helping states and local jurisdictions change policies and
practices to improve outcomes for vulnerable children and families. She
holds an M.S.W. from the University of Alabama.
Oscar A. Barbarin, III, Ph.D., is Wilson H. Elkins professor and chair of the
African American Studies Department (with a joint faculty appointment in
the Department of Psychology) at the University of Maryland, College Park.
He is former Lila L. and Douglas J. Hertz endowed chair, Department of Psy-
chology, Tulane University. He has served on the faculties of the Universities
of Maryland, Michigan, and North Carolina. His research has focused on
the social and familial determinants of ethnic and gender achievement gaps
beginning in early childhood. He has developed a universal mental health
screening system for children from prekindergarten to age 8. He was prin-
cipal investigator for a national study focused on the socioemotional and
academic development of boys of color. His work on children of African
descent includes a 20-year longitudinal study of the effects of poverty and
violence on child development in South Africa. He served as editor of the
American Journal of Orthopsychiatry, 2009-2014, and on the Governing
Council of the Society for Research in Child Development, 2007-2013. He
earned a Ph.D. in clinical psychology at Rutgers University in 1975.
Richard P. Barth, M.S.W., Ph.D., is dean, School of Social Work, at the Uni-
versity of Maryland. He previously served as Frank A. Daniels distinguished
professor, School of Social Work, University of North Carolina, Chapel
Hill, and as Hutto Patterson professor, School of Social Welfare, University
of California, Berkeley. He was the 1986 winner of the Frank Breul Prize
for Excellence in Child Welfare Scholarship from the University of Chicago;
a Fulbright Scholar in 1990 and 2006; the 1998 recipient of the Presidential
Award for Excellence in Research from the National Association of Social
Workers; the 2005 winner of the Flynn Prize for Research; and the 2007
winner of the Peter Forsythe Award for Child Welfare Leadership from the
American Public Human Services Association. He is a fellow of the Ameri-
can Psychological Association, and was a founding board member and
president of the American Academy of Social Work and Social Welfare. He
served on the Board of the Society for Social Work Research, 2002-2006,
and has also served on the boards of numerous child-serving agencies. His
A.B., M.S.W., and Ph.D. degrees are from Brown University and the Uni-
versity of California, Berkeley.
William R. Beardslee, M.D., directs the Baer Prevention Initiatives at Boston

Childrens Hospital and is senior research scientist at the Judge Baker Chil-

APPENDIX D 501
drens Center; chairman emeritus, Department of Psychiatry, Boston Chil-

drens Hospital; and Distinguished Gardner-Monks professor of child
psychiatry at Harvard Medical School. His long-standing research interest
has centered on the development of children at risk because of p arental
adversities such as mental illness or poverty. He and his colleagues adapted
the principles of his work on public health interventions for families facing
depression in a teacher training and empowerment program for use in Head
Start and Early Head Start called Family Connections. He directed the Bos-
ton site of a multisite study on the prevention of depression in adolescents
that demonstrated prevention of episodes of major depression in high-risk
youth fully 60 months after intervention delivery. He has received numerous
awards, including the Blanche F. Ittleson Award of the American Psychiatric
Association for outstanding published research contributing to the mental
health of children, the Catcher in the Rye Award for Advocacy of the Ameri-
can Academy of Child and Adolescent Psychiatry, the Human Rights Award
from the Department of Mental Health of the Commonwealth of Massa-
chusetts and the Judge Baker Childrens Center World of Children Award.
He received an honorary doctor of science degree from Emory University.
Kimberly Boller, Ph.D., is a senior fellow at Mathematica Policy Research.

She studies the effects of early childhood care and education, parenting
programs, and policy on children and parents. Her expertise includes mea-
surement of program fidelity, implementation, and quality; child outcomes
from infancy through early elementary school; and parent well-being and
self-sufficiency. Her current research in the United States focuses on Early
Head Start, the cost of quality early childhood services, and informal child
care. As director of testing and learning for the Early Learning Lab, she
supports research-informed innovation and improvement of programs for
children and families. She has conducted research on early childhood and
parenting programs and systems in more than 10 countries. A recent project
in Tanzania included an evaluability assessment of a preprimary teacher
training intervention designed to improve grade 2 outcomes. She recently
guest co-edited a special issue of Early Childhood Research Quarterly on
early childhood care and education quality rating and improvement sys-
tems. She received her Ph.D. in developmental and cognitive psychology
from Rutgers University.
Natasha J. Cabrera, Ph.D., is a professor in the Department of Human

Development and Quantitative Methodology, College of Education, Univer-
sity of Maryland, College Park. Previously, she had several years of experi-
ence as an executive branch fellow and expert in child development with
the National Institute of Child Health and Human Development (NICHD).
Her research focuses on father involvement and childrens social develop-

ment, ethnic and cultural variations in fathering and mothering behaviors,

family processes in a social and cultural context, and the mechanisms that
link early experiences to childrens school readiness. In her previous posi-
tion with NICHD, she developed a major initiative called Developing a
Daddy Survey, which coordinated measures of father involvement across
major studies in the field and provided a set of measures for others to use.
She is associate editor of Child Development and Early Childhood Research
Quarterly and recipient of the National Council on Family Relations award
for best research article regarding men in families. She is a 2015-2016 visit-
ing scholar at the Russell Sage Foundation. She holds a Ph.D. from the Uni-
versity of Denver, Colorado, in educational and developmental psychology.
Eric Dearing, Ph.D., is a professor in the Department of Counseling, Devel

opmental, and Educational Psychology at Boston Colleges Lynch School
of Education. He is also a senior researcher at the Norwegian Center for
Child Behavioral Development, University of Oslo. His work is focused on
the consequences of childrens lives outside of school for their performance
in school. He has a special interest in the power of families, early education
and care, and neighborhood supports to bolster achievement and well-being
for children growing up poor. He is currently principal investigator for a
study investigating the importance of parents engagement in their chil-
drens early math learning for childrens long-term achievement. He holds
a Ph.D. in psychology from the University of New Hampshire.
Greg J. Duncan, Ph.D., is distinguished professor of education at the Uni-

versity of California, Irvine. Previously, he was a professor at the Univer-
sity of Michigan and director of the Panel Study of Income Dynamics.
His recent work has focused on understanding the relative importance of
early academic skills, cognitive and emotional self-regulation, and health
in promoting childrens eventual success in school and the labor market.
He has also investigated how families, peers, neighborhoods, and public
policy a ffect the life chances of children and adolescents. He has served
as president of the Population Association of America and of the Society
for Research in Child Development. He received the 2013 Klaus J. Jacobs
Research Prize of the Jacobs Foundation, given for scientific work of high
social relevance to the personality development of children and young
people. He is a member of the National Academy of Sciences and holds a
Ph.D. in economics from the University of Michigan.
Norma Finkelstein, Ph.D., M.S.W., is founder and executive director of

the Institute for Health and Recovery, a Massachusetts statewide services,
policy, program development, training, and research organization. Previ-
ously, she was founder and executive director of the Womens Alcoholism

APPENDIX D 503
Program/CASPAR, Inc., a comprehensive prevention, education, and treat-

ment program for chemically dependent women and their families. Her
work has focused on substance use prevention and treatment, with specific
emphasis on women, children, and families; pregnancy; co-occurring dis-
orders, including integrated care for women with substance use disorders,
mental illness, and histories of violence; trauma-informed services; services
for youth and young adults; tobacco education and cessation; and family-
centered care. She has received numerous awards, including, most recently,
the National Center on Substance Abuse and Child Welfares National Col-
laborative Leadership Award, the National Organization on Fetal Alcohol
Syndromes Erin Frey Advocacy Award, and the Womens Service Networks
and National Association of State Alcohol and Drug Abuse Directors
Womens Services Champion Award. She received her M.S.W. from the
University of Michigan and her Ph.D. from Brandeis University.
Elena Fuentes-Afflick, M.D., M.P.H., is chief of pediatrics at San Francisco

General and professor and vice chair of pediatrics and vice dean for aca-
demic affairs at the University of California, San Francisco (UCSF). Her
research has focused on the broad themes of acculturation and immigrant
health, with specific emphasis on perinatal and neonatal health dispari-
ties. She has served as chair of the UCSF Academic Senate and served on
national committees of the Society for Pediatric Research, the National
Institutes of Health, and the Robert Wood Johnson Foundation. She served
as president of the Society for Pediatric Research, 2008-2009, and has
served or is serving as a member of numerous advisory councils and com-
mittees. In 2010, she was elected to the National Academy of Medicine.
She obtained her undergraduate education and medical degree at the Uni-
versity of Michigan. She completed her residency training at UCSF, where
she served as chief resident, followed by a research fellowship at the Phillip
R. Lee Institute for Health Policy Studies. She also completed an M.P.H. at
the University of California, Berkeley.
Iheoma U. Iruka, Ph.D., is director of research and evaluation, Buffett

Early Childhood Institute, University of Nebraska. Her research focuses
on determining how early experiences impact poor and ethnic minority
young childrens health, learning, and development and the role of the
family and education environments and systems in this process. She is
engaged in projects and initiatives focused on how evidence-informed
policies, systems, and practices in early education can support the optimal
development and experiences of low-income and ethnic minority children,
such as through quality rating and improvement systems, home visiting
programs, and high-quality preschool programming. In addition to being
a former scientist and associate director at the Frank Porter Graham Child

Development Institute, University of North Carolina, Chapel Hill, she

serves on several national committees and boards. She holds a Ph.D. in
applied developmental psychology from the University of Miami, Florida.
Samuel L. Odom, Ph.D., is director of the Frank Porter Graham Child

Development Institute, University of North Carolina, Chapel Hill, and prin-
cipal investigator, National Professional Development Center on A utism
Spectrum Disorders and Center on Secondary Education for Students with
Autism Spectrum Disorders (ASD). His current research is addressing treat-
ment efficacy for children and youth with ASD, early intervention for
toddlers with disabilities and their families, and professional development
for teachers of children and youth with ASD. In 2013, he received the
Arnold Lucius Gesell Prize for career achievement in research on social
inclusion and child development from the Theordor Hellbrugge Founda-
tion, Munich, Germany. He holds a Ph.D. in special education from the
University of Washington.
Barbara Rogoff, Ph.D., is distinguished professor of psychology, Univer-

sity of California, Santa Cruz. She received the 2013 Award for Distin-
guished Lifetime Contributions to Cultural and Contextual Factors in
Child Development from the Society for Research in Child Development.
She is a fellow of the Association for Psychological Science, the American
Anthropological Association, the American Psychological Association, and
the American Educational Research Association. Her research focuses on
cultural aspects of learning, with special emphasis on collaboration and
observation and indigenous-heritage, Mexican, Guatemalan, and other
communities of the Americas. She has held the University of California
Presidential Chair and has been a fellow of the Center for Advanced Study
in the B
ehavioral Sciences, a Kellogg fellow, a Spencer fellow, and an Osher
fellow of the E
xploratorium. She holds a Ph.D. in developmental psychol-
ogy from Harvard University.
Mark A. Schuster, M.D., Ph.D., is William Berenberg professor of p ediatrics,

Harvard Medical School, and chief of general pediatrics and vice chair for
health policy, Department of Medicine, Boston Childrens Hospital. He
conducts research on child, adolescent, and family issues and has studied
the role of parents in influencing and addressing their childrens health.
He has conducted research on health disparities, family leave for parents
with chronically ill children, adolescent sexual health, obesity prevention,
children with HIV-infected parents, parental reports of family experience
of health care, and other aspects of quality of health care. He is an elected
member of the National Academy of Medicine and a recipient of the Society
for Pediatric Researchs Richardson Award for lifetime achievement in peri-

APPENDIX D 505
natal and pediatric health care research, and was president of the Academic
Pediatric Association (2014-2015). He received his B.A. from Yale Univer-
sity, his M.D. and M.P.P. from Harvard University, and his Ph.D. in public
policy analysis from the Pardee RAND Graduate School.
Selcuk R. Sirin, Ph.D., is associate professor of applied psychology, New

York University (NYU). His research focuses primarily on the lives of immi-
grant and minority children and their families and ways to increase profes-
sionals ability to better serve them. He conducted a major meta-analytical
review of research on socioeconomic status and co-produced the Racial
and Ethical Sensitivity Test and accompanying training program for school
professionals. He also served as research coordinator for the Partnership for
Teacher Excellence project at NYU in collaboration with New York City
School of Education. His most recent research focused on immigrant youth
in general and Muslim American children and adolescents in particular.
He is the recipient of a Teaching Excellence Award from Boston College;
a Young Scholar Award from the Foundation for Child Development for
his project on immigrant children; and a Review of Research Award from
the American Educational Research Association, given in recognition of
an outstanding article published in education. He holds a Ph.D. in applied
developmental and educational psychology (minor in methodology) from
Boston College.
Kasisomayajula Vish Viswanath, Ph.D., is professor of health communica-

tion, Department of Social and Behavioral Sciences, Harvard School of Public
Health and McGraw-Patterson Center for Population Sciences, Dana-Farber
Cancer Institute. He is also faculty director of the Health Communication
Core of the Dana-Farber/Harvard Cancer Center (DF/HCC) and leader of
the DF/HCCs Cancer Risk and Disparities Program. He is founding director
of DF/HCCs Enhancing Communications for Health Outcomes Laboratory.
His work focuses on the use of translational communication science to influ-
ence public health policy and practice. His primary research emphasis is on
documenting the relationship among communication inequalities, poverty
and health disparities, and knowledge translation to address health dispari-
ties. He is a member of the U.S. Department of Health and Human Services
National Vaccine Advisory Committee and chairs its Working Group on
Vaccine Acceptance, and is a member of the Board of Scientific Counselors,
Office of Public Health Preparedness, Centers for Disease Control and Pre-
vention. He holds a Ph.D. in mass communications from the University of
Minnesota, Minneapolis.
Michael S. Wald, J.D., M.A., is Jackson Eli Reynolds professor of law,

emeritus, at Stanford University. His teaching and research focus on public

policy concerning children and families. In addition to his teaching and

research, he has extensive experience in designing and implementing public
policy related to parents and children, including holding a number of gov-
ernment positions at the federal, state, and local levels related to social ser-
vices for children and families, and he has helped author legislation related
to child welfare at the federal and state levels. He has served as director of
the San Francisco Human Services Agency, deputy general counsel of the
U.S. Department of Health and Human Services (1993-1995), and member
of the U.S. Advisory Board on Child Abuse and Neglect. He is currently a
member of the San Francisco Our Children Our Families Council, which
develops child and family policy for San Francisco, and has been a member
of the World Economic Forums Global Agenda Council on the Welfare of
Children; the Board of Directors, Chapin Hall Childrens Center, University
of Chicago; and the Carnegie Foundations Commission on Children 0-3.
He received his B.A. from Cornell University, his M.A. in political science
from Yale University Graduate School of Arts and Sciences, and his LL.B
from Yale Law School.

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Committee on Supporting the Parents of Young Children

Vivian L. Gadsden, Morgan Ford, and Heather Breiner, Editors

Board on Children, Youth, and Families

Division of Behavioral and Social Sciences and Education

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

International Standard Book Number-13: 978-0-309-38854-2

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Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine.

Copyright National Academy of Sciences. All rights reserved.

The National Academy of Sciences was established in 1863 by an Act of Con-

The National Academy of Medicine (formerly the Institute of Medicine) was

The three Academies work together as the National Academies of Sciences,

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Reports document the evidence-based consensus of an authoring committee of

Proceedings chronicle the presentations and discussions at a workshop, sym-

Copyright National Academy of Sciences. All rights reserved.

COMMITTEE ON SUPPORTING THE

VIVIAN L. GADSDEN (Chair), School of Education, University of

MORGAN A. FORD, Study Director

Copyright National Academy of Sciences. All rights reserved.

ANTHONY JANIFER, Program Assistant (until December 2015)

Copyright National Academy of Sciences. All rights reserved.

BOARD ON CHILDREN, YOUTH, AND FAMILIES

ANGELA DIAZ (Chair), Departments of Pediatrics and Preventive

NATACHA BLAIN, Director, Board on Children, Youth, and Families

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

Network, and ZERO TO THREE. In addition, we appreciate the generous

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Teachers College and College of Physicians and Surgeons, Columbia Uni-

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2 PARENTING KNOWLEDGE, ATTITUDES, AND PRACTICES 45

3 FEDERAL POLICIES AND INVESTMENTS SUPPORTING

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4 UNIVERSAL/PREVENTIVE AND WIDELY USED

5 TARGETED INTERVENTIONS SUPPORTING PARENTS

6 ELEMENTS OF EFFECTIVE PARENTING PROGRAMS

7 TOWARD A NATIONAL FRAMEWORK 351

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8 CONCLUSIONS AND RECOMMENDATIONS 381

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Boxes, Figures, and Tables

4-1 Nurse-Family Partnership (NFP), 146

5-1 The Triple P-Positive Parenting Program, 240

6-1 A Fathers Story, 334

B-1 Previous National Registry of Evidence-based Programs and

Copyright National Academy of Sciences. All rights reserved.

xviii BOXES, FIGURES, AND TABLES

5 TARGETED INTERVENTIONS SUPPORTING PARENTS

B-1 Previous National Registry of Evidence-based Programs and

3-1 Share of federal budget outlays spent on children (ages 0-18),

4-1 Illustrative prenatal and early childhood home visiting logic

5-1 Linkage among family-centered practices, early childhood

4-1 Number of Favorable Impacts of Home Visiting for Primary

C-1 Evidence-Based Interventions That Support Parenting, 414