?Parenting has been described as the most challenging and complex of all the tasks of adulthood. It can also be argued that there is no undertaking that is more important to life of the human community. Yet that community rarely offers adequate guidance, support or preparation for parenthood?" (E
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1. Improving Child Outcomes by Targeting Parents: Easier Said Than DoneMessier Than One Would Like John D. McLennan
University of Calgary
Sept 24, 2008
3. Disclosures & Biases Priority should be placed on child outcomes
Connecting vulnerable children with effective services
Working on the services gaps
4. Outline Issues 1: Focusing on parents, parenting, and parenting programs to improve child outcomes
Issue 2: Factors undermining the impact of parenting programs on improving child outcomes
Issues 3: It gets messy
5. Assumptions in focusing on the parent
6. What do you mean by child outcomes? Good physical growth
No head injuries
7. Parenting practices contribution to child mental health problems McLeod, Wood & Weisz, 2007
Association between parenting and child anxiety
Meta-analysis (47 studies)
Parenting accounted for only 4% of the variance in childhood anxiety
McLeod, Weisz, & Wood, 2007
Association between parenting and child depression
Meta-analysis (45 studies)
Parenting accounted for only 8% of the variance in childhood depression
8. More on parenting practice contribution Rothbaum & Weisz (1994)
Parenting & externalizing behaviour
Meta-analysis (47 studies)
Parenting associated with <6% of externalizing behaviour
9. Other factors linking parents to child outcomes
10. Assumption behind parenting programs
11. But you could intervene elsewhere to improve child outcomes
12. But let’s focus on aiming at parenting practices
13. Getting exposure to good parenting practices Parenting books sections (e.g., Chapters)
Parent recommendations everywhere
14. Parenting programs galore Specific parenting programs
Canadian Association of Family Resource Programs/Parents Matter
Parenting program inventory: 82 programs http://www.parentsmatter.ca
15. Why might parenting programs not lead to improve parenting practices?
16. Access Gaps (1) Who is attending the parenting programs?
Who’s not attending?
Who are your target group?
Are the attendees your target population?
What fraction of the target group?
Universal programs (see Offord et al, 1998)
17. Use Gaps (2) How much of a program are participants exposed to?
What is the drop out rate?
What is enough exposure?
20. Research Practice gapS
21. Examples of research-practice gaps 1. Failure to use program with positive effect
[The Incredible Years]
2. Use of a program with evidence of harm
[increasing parent conflict?];
[Scared Straight-Petrosino et al, 2002]
3. Use of a program with evidence of no effect
[Families and Schools Together (FAST)?];
4. Use of a program without evidence of effect
22. But wait, it’s more complicated than that 4 X 2 table has heuristic value, but ….
“Has it been proven effective”?
Has what been proven effective?
Proven effective for what problem?
Proven effective for whom?
E.g., Does program X decrease the rate of conduct disorder in the children of those parents participating in =80% the program?
23. Is what effective? Home visitation works!
Hmmmm? …..All of them????
Nurse-Family Partnership (David Olds)
Pre and post natal home visits (>20)
Trained in a specific curriculum
24. What do you mean by Home Visitation? Do you really need 20+ visits
The need for dosing studies
Powell & Grantham-McGregor (1989)
Do you really need nurses?
Lay visitors vs. Nurses study (Olds et al 2002)
Do you really need a set curriculum?
Fidelity/adherence & Multi-systemic therapy (Schoenwald et al., 2003)
25. For what problem? Decreased child abuse
Increased self esteem
Not a proxy for child outcomes (Lambert et al., 1998)
26. For whom? Everyone?
At risk 1st time mothers
High-risk within at risk, 1st time mothers
Not for preventing re-abuse
MacMillian et al (2005)
27. But wait, its not that simple What
Lay home visitors
some late emerging benefits (Olds et al 2004)
Component piece vs. packages
Garland et al., 2007; John Weisz (pc)
Old’s Home visitation program
Child externalizing problem not improved for those receiving nursing OR paraprofessional home visits; OR high-risk subgroup (Olds et al., 2004)
Incredible-Years & ethnic minorities (Reid et al., 2001)
African, Asian, Hispanic, Caucasian Americans
28. References Farrelly A, McLennan (under review) Participation in a parent education program in the Dominican Republic: Utilization and barriers
Garland A, Hawley K, Brookman-Frazee L, Hurlburt M (2008) Identifying common elements of evidence-based psychosocial treatments for children’s disruptive behavior problems. Journal of the American Academy of Child and Adolescent Psychiatry 47(5): 505-514
Lambert W, Salzer M, Bickman L (1998) Clinical outcome, consumer satisfaction, and ad hoc ratings of improvement in children’s mental health. Journal of Consulting and Clinical Psychology 66 (2): 270-279
MacMillan H et al (2005) Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: a randomised controlled trial. Lancet 365:1786-93
29. References (2) McLennan et al (2006) Research-practice gaps in child mental health. Journal of the American Academy of Child and Adolescent Psychiatry 45(6): 658-665
McLeod, B. D., Weisz, J.R., & Wood, J. J. (2007). Examining the association between parenting and childhood depression: A meta-analysis. Clinical Psychology Review, 27, 986-1003
McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review, 27, 155-172.
30. References (3) Offord et al (1998) Lowering the burden of suffering from child psychiatric disorders: trade-offs among clinical, targeted and universal interventions. Journal of the American Academy of Child and Adolescent Psychiatry 37(7): 686-694
Olds et al (2002) Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics 110:486-496.
Olds et al (2004) Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial. Pediatrics 114: 1560-1568
Olds et al (2007) Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial. Pediatrics 120(4): e832-45.
Olds et al (1997) Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA 278: 637-43
31. References (4) Petrosino A et al (2002) “Scared Straight” and other juvenile awareness programs for preventing juvenile delinquency. Cochrane Database of Systematic Reviews 2, CD002796.
Powell C, Grantham-McGregor S (1989) Home visiting of varying frequency and child development. Pediatrics 84(1): 157-64.
Reid MJ, Webster-Stratton C, Beauchaine T (2001) Parent training in Head Start: A comparison of program response among African American, Asian American, Caucasian, and Hispanic Mothers. Prevention Science 2(4): 209-227.
Rothbaum, F., & Weisz, J. R. (1994). Parental caregiving and child externalizing behavior in nonclinical samples: A meta-analysis. Psychological Bulletin, 116, 55-74.
Schoewald et al (2003) Transportability of multisystemic therapy: evidence for multilevel influence. Mental Health Services Research 5(4): 223-239.