The family check-up and service use in high-risk families of young children: a prevention strategy with a bridge to community-based treatment

The Family-Check-Up® Autism Implementation Research (FAIR) Study: protocol for a study evaluating the effectiveness and implementation of a family-centered intervention within a Canadian autism service setting

Introduction

Prevalence rates of emotional and behavior problems (EBP) in autistic children and youth are high (40-70%), and often cause severe and chronic impairment. Furthermore, autistic children are also more likely to experience family "social-ecological" adversity compared to neurotypically developing peers, including social isolation, child maltreatment, caregiver mental illness, and socioeconomic risk. These family stressors increase the risk of co-occurring EBP among autistic children and can often impede access to evidence-based care, thus amplifying long-term health inequities for autistic children and their caregivers. In the current autism services landscape, there are few scalable, evidence-based programs that adequately address these needs. The Family Check-Up (FCU®) is a brief, strength-based, and tailored family-centered intervention that supports positive parenting and explicitly assesses the social determinants of child and family mental health within an ecological framework. Studies have demonstrated long-term positive child and caregiver outcomes in other populations, but the FCU® has not been evaluated in families of autistic children and youth. Therefore, we aimed to evaluate FCU® implementation within an established, publicly funded Autism Program in Ontario, Canada, with delivery by autism therapists, to demonstrate sustainable effectiveness within real-world settings.

Methods

In this study, we outline the protocol for a hybrid implementation-effectiveness approach with two key components: (1) A parallel-arm randomized controlled trial of N = 80 autistic children/youth (ages 6-17 years) and high levels of EBP and their caregivers. Primary and secondary outcomes include child EBP, and caregiver well-being and parenting. (2) A mixed methods implementation study, to describe facilitators and barriers to implementation of the FCU® within an autism service setting.

Discussion

Scalable, ecologically focused family-centered interventions offer promise as key components of a public health framework aimed at reducing mental health inequities among autistic children, youth, and their caregivers. Results of this study will inform further program refinement and scale-up.

A review of mental health disparities during COVID-19: Evidence, mechanisms, and policy recommendations for promoting societal resilience

Social and economic inequality are chronic stressors that continually erode the mental and physical health of marginalized groups, undermining overall societal resilience. In this comprehensive review, we synthesize evidence of greater increases in mental health symptoms during the COVID-19 pandemic among socially or economically marginalized groups in the United States, including (a) people who are low income or experiencing homelessness, (b) racial and ethnic minorities, (c) women and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) communities, (d) immigrants and migrants, (e) children and people with a history of childhood adversity, and (f) the socially isolated and lonely. Based on this evidence, we propose that reducing social and economic inequality would promote population mental health and societal resilience to future crises. Specifically, we propose concrete, actionable recommendations for policy, intervention, and practice that would bolster five "pillars" of societal resilience: (1) economic safety and equity, (2) accessible healthcare, including mental health services, (3) combating racial injustice and promoting respect for diversity, equity, and inclusion, (4) child and family protection services, and (5) social cohesion. Although the recent pandemic exposed and accentuated steep inequalities within our society, efforts to rebuild offer the opportunity to re-envision societal resilience and policy to reduce multiple forms of inequality for our collective benefit.

Understanding the role of parents' social connectedness in children's behavioral wellbeing in low-income communities: A study protocol

Group-based parent-training (PT) is one of the most common and well-established approaches for strengthening parenting skills and reducing child behavior problems. When offered in school settings, the social connections formed among participants may generate additional benefits for parents, schools, and children. However, to date there has been limited research on the potential benefits or harms associated with social connectedness (SC) in group-based PT. This paper describes the study protocol for an ongoing National Institute of Nursing Research-funded mixed-methods study that aims to examine the extent to which group-based PT, delivered in elementary schools serving families from predominantly low-resource communities, generates SC among parents and if SC is associated with greater (a) reduction in child behavior problems and (b) engagement in their child's education. Using a prospective descriptive design, the study is nested within an ongoing quasi-experimental parent study evaluating the group-based PT intervention, the Chicago Parent Program (CPP) in Baltimore City schools. Challenges for this study include recruitment and retention of parents with constraints caused by the COVID-19 pandemic. The study uses multiple methods and informants to understand the potential mechanisms underlying PT group effects and results have the potential to serve as an important foundation for future studies focused on SC, its impacts on parent-child outcomes in low-resource settings, and strategies for strengthening SC in health promotion interventions. PATIENT OR PUBLIC CONTRIBUTION: Chicago Parent Program was developed with input from an advisory board of parents. Additionally, the parent study protocol was written and is co-led in partnership with a community organization.

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services

BACKGROUND

Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches.

OBJECTIVES

To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes.

MAIN RESULTS

We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Implementing a School-Based, Trauma-Informed Resilience Curriculum for Parents

"Families OverComing Under Stress" (FOCUS) Resilience Curriculum for Parents (FRC-P) is a trauma-informed group parenting program adapted for school social workers to deliver to parents of racial/ethnic minority urban public schoolchildren, an under-researched group of parents in the literature. The objective was to describe implementation of the pilot FRC-P in terms of possible effectiveness, feasibility, and acceptability. Social workers delivered FRC-P to parents at 16 schools. We analyzed (1) changes in parent well-being; (2) parent satisfaction; and (3) a focus group of participating social workers. Ninety-six of 261 parents (37%) who attended FRC-P completed pre and post surveys. Parents reported significant improvements (p < .01) in family functioning (Cohen's d = 0.41), parent connectedness (d = 0.71), and social support (d = 0.66). Social workers linked parents to needed services. Parents and social workers found FRC-P feasible and acceptable. With refinement, FRC-P could help schools foster resilience in under-resourced parents.

Therapeutic alliance as a predictor of behavioral outcomes in a relationally focused, family-centered telehealth intervention

This study evaluates therapeutic alliance as a mediator of the relationship between dosage and clinical outcomes for the Family Check-Up (FCU) Online, a telehealth adaptation of an evidence-based parenting intervention for parents of middle school youth. The sample consisted of N = 111 parents with children in middle school who received the FCU Online as part of an ongoing clinical trial. They were randomly assigned to receive telehealth coaching and participated in the intervention and follow-up assessment 12 months later. Data was collected using parent and child questionnaires as well as engagement data collected as part of the online intervention, using both parents and children as reporters of parent behavioral change. Using parent report measures, there was clear support for a mediation model, with parent report of alliance predicting parent self-report ratings of clinical progress (parent behavior change) at 12-month follow-up. However, for the child-report data, there was no clear relationship between dosage or therapeutic alliance with child reports of parenting. Clinical implications and future research directions are discussed.

Parenting stress during infancy is a risk factor for mental health problems in 3-year-old children

BACKGROUND

Although research on the relationship between parent and child mental health is growing, the impact of early parenting stress on preschool-aged children's mental health remains unclear. The objective was to evaluate the association between parenting stress during infancy and mental health problems in 3-year-old children.

METHODS

A prospective cohort study of healthy preschool-aged children recruited from 9 primary care practices in Toronto, Canada was conducted through the TARGet Kids! primary care practice-based research network. Parenting stress was measured when children were between 0 to 16 months of age, using the Parent Stress Index Short Form, PSI-SF. Parent-reported child mental health problems were measured at 36 to 47 months using the preschool Strengths and Difficulties Questionnaire, total difficulties score (TDS). Hierarchical linear regression analysis was used to investigate the association between standardized PSI-SF and TDS, adjusted for child age, sex, temperament, sleep duration and household income. To strengthen clinical interpretation, analysis was repeated using adjusted multivariable logistic regression (TDS dichotomized at top 20%).

RESULTS

A total of 148 children (mean ± SD age, 37.2 ± 1.7 months, 49% male) were included in the analysis. Parenting stress during infancy (11.4 ± 3.1 months of age) was significantly associated with mental health problems in 3-year-old children (β = 0.35; 95% CI = 0.20-0.49, p < 0.001). Higher parenting stress was also associated with increased odds of higher TDS (OR = 2.26, 95% CI = 1.69-2.83, p < 0.01).

CONCLUSION

Healthy preschool-aged children with parents reporting parenting stress during infancy had a 2 times higher odds of mental health problems at 3 years.

Indirect Effects of the Family Check-Up on Youth Extracurricular Involvement at School-Age through Improvements in Maternal Positive Behavior Support in Early Childhood

Extracurricular involvement in the school-age years has widespread potential benefits for children's subsequent socioemotional development, especially for low-income youth. However, there is a dearth of research on interventions aimed at increasing school-age extracurricular involvement in low-income youth. Thus, the present study aimed to test the collateral effect of a brief, family-focused intervention for low-income families, the Family Check-Up, on children's school-age extracurricular involvement via improvements in maternal Positive Behavior Support in early childhood. The sample (n = 630, 50% female, 50% White, 28% Black/African American) represented a subsample of families from the Early Steps Multisite Study. At age 2, families were randomly assigned to the Family Check-Up or Women, Infants, and Children Nutritional Supplement Services as usual. Mother-child dyads participated in observed interaction tasks at child ages 2 and 3 that were subsequently coded to assess positive behavior support. Primary caregivers reported on children's school-age extracurricular involvement at ages 7.5, 8.5, and 9.5. Results indicated that although there was not a direct path between intervention status and children's school-age extracurricular involvement, a significant indirect path emerged from intervention group to changes in positive behavior support between ages 2 to 3 to children's school-age extracurricular involvement. The results are discussed in terms of implications for designing preventive interventions in early childhood that promote extracurricular involvement at school-age, particularly for children at risk for maladaptive outcomes.

Establishing a nurse-managed health center for the urban poor in Dhaka, Bangladesh

OBJECTIVES

Despite the rise in community health problems in populations living in urban slums, activities of community health nurses are limited in Bangladesh. This study aimed to describe how a nurse-managed health center (NMHC) was developed in Dhaka, Bangladesh.

DESIGN

An exploratory-descriptive research design was used.

SAMPLE AND MEASUREMENTS

The commitment phase was conducted to establish partnerships in the community. Involvement of community leaders and members and partnerships with various organizations were established successfully in the commitment phase. The assessment phase was completed by implementing personal interviews, community site visits, and household surveys of 172 households in the community. Action plans were developed and strategies were followed to change the community during the planning phase.

RESULTS

Household survey results showed that community people suffered from non-communicable diseases, risk behaviors, and inadequate housing conditions. The high-priority community needs included nutrition and chronic management services, behavior change programs, and a clean environment. Action plans for health programs based on community needs and strategies such as securing manpower and equipment were developed.

CONCLUSIONS

The systematic process of creating a NMHC, and the necessity of the community health nurse's role in responding to health needs of the urban poor in Dhaka, Bangladesh was confirmed.

Social Factors Associated with the Effectiveness of a Spanish Parent Training Program-An Opportunity to Reduce Health Inequality Gap in Families

Parent training programs (PTPs) have been used extensively in Anglo-Saxon countries, but less so in Southern Europe. Several characteristics of families have been linked to effective parenting and positive development of children, but few studies have examined the social determinants of the effectiveness of PTPs. The Parenting Skills Program for families (PSP) is a PTP from Spain. This study aimed to identify the social characteristics (sex, age, country of birth, marital status, educational level, and employment status) of parents that determine the success of the PSP in relation to social support, parenting skills, parental stress, and negative behaviors among children. A quasi-experimental study with a prepost design with no control group was used. We conducted a survey before (T0) and after the intervention (T1). Sample size was 216. We fit multiple logistic regression models. Parenting skills increased more among parents with a lower educational level. Parents' stress decreased more among parents who had a lower educational level, were unemployed, and were men. Social support increased among parents who were younger, unemployed, or non-cohabiting. We found no significant differences in the effect on children's negative behaviors according to the social factors evaluated. The PSP is effective for socioeconomically diverse families, but the success differs according to the parents' social profile. Unlike most previous studies, the results were better among more socially disadvantaged people, highlighting the potential of this kind of intervention for reducing the social inequality gap between groups.

Evaluating the efficacy of the Family Check-Up Online: A school-based, eHealth model for the prevention of problem behavior during the middle school years

This study evaluated the efficacy of a family-centered preventive intervention, the Family Check-Up (FCU), delivered as an online, eHealth model to middle school families. To increase accessibility of family-centered prevention in schools, we adapted the evidence-based FCU to an online format, with the goal of providing a model of service delivery that is feasible, given limited staffing and resources in many schools. Building on prior research, we randomly assigned participants to waitlist control (n = 105), FCU Online as a web-based intervention (n = 109), and FCU Online with coaching support (n = 108). We tested the effects of the intervention on multiple outcomes, including parental self-efficacy, child self-regulation, and child behavior, in this registered clinical trial (NCT03060291). Families engaged in the intervention at a high rate (72% completed the FCU assessment) and completed 3-month posttest assessments with good retention (94% retained). Random assignment to the FCU Online with coaching support was associated with reduced emotional problems for children (p = .003, d = -0.32) and improved parental confidence and self-efficacy (p = .018, d = 0.25) when compared with waitlist controls. Risk moderated effects: at-risk youth showed stronger effects than did those with minimal risk. The results have implications for online delivery of family-centered interventions in schools.

Predictors of Participation in the Family Check-Up Program: a Randomized Trial of Yearly Services from Age 2 to 10 Years

A key challenge of community-based prevention programs is engaging families in the context of services settings involving children and families. The Family Check-Up (FCU) program is designed to engage families in parenting support appropriate to their level of need by use of assessment-enhanced motivational interviewing. This study involved families screened for risk who were seeking services at women, infant, and children's offices in three geographical regions (N = 731). Families in the randomized intervention group (N = 367) were offered the FCU yearly, from age 2 through 10. The results of multivariate modeling indicated that caregivers reporting high levels of perceived caregiving stress (i.e., depression, low parenting satisfaction, daily hassles) participated at a higher rate in two critical components (feedback and follow-up support interventions) of the FCU program over the 8-year trial period than caregivers reporting lesser degrees of stress. The implications of these findings are discussed in the context of family-centered programs for the prevention of child behavior problems and directions for future research.

Confounding in statistical mediation analysis: What it is and how to address it

Psychology researchers are often interested in mechanisms underlying how randomized interventions affect outcomes such as substance use and mental health. Mediation analysis is a common statistical method for investigating psychological mechanisms that has benefited from exciting new methodological improvements over the last 2 decades. One of the most important new developments is methodology for estimating causal mediated effects using the potential outcomes framework for causal inference. Potential outcomes-based methods developed in epidemiology and statistics have important implications for understanding psychological mechanisms. We aim to provide a concise introduction to and illustration of these new methods and emphasize the importance of confounder adjustment. First, we review the traditional regression approach for estimating mediated effects. Second, we describe the potential outcomes framework. Third, we define what a confounder is and how the presence of a confounder can provide misleading evidence regarding mechanisms of interventions. Fourth, we describe experimental designs that can help rule out confounder bias. Fifth, we describe new statistical approaches to adjust for measured confounders of the mediator-outcome relation and sensitivity analyses to probe effects of unmeasured confounders on the mediated effect. All approaches are illustrated with application to a real counseling intervention dataset. Counseling psychologists interested in understanding the causal mechanisms of their interventions can benefit from incorporating the most up-to-date techniques into their mediation analyses. (PsycINFO Database Record

Early Childhood Mental Health: Starting Early with the Pregnant Mother

Perinatal mental health has important implications for maternal and child outcomes. Most women with psychiatric disorders during pregnancy go undiagnosed and untreated, despite widespread initiatives for early identification. Universal screening for psychiatric disorders, particularly depression and anxiety, has been implemented in obstetric and primary care settings. However, there is little evidence regarding the effectiveness on psychiatric symptom reduction or prevention of adverse outcomes in children. Recently, comprehensive screening and follow-up programs integrated within obstetric or primary care settings have shown promising results in improving maternal mental health outcomes. Further work is needed to determine best clinical and most cost-effective practices.

The Oregon Model of Behavior Family Therapy: From Intervention Design to Promoting Large-Scale System Change

This paper reviews the evolution of the Oregon model of family behavior therapy over the past four decades. Inspired by basic research on family interaction and innovation in behavior change theory, a set of intervention strategies were developed that were effective for reducing multiple forms of problem behavior in children (e.g., Patterson, Chamberlain, & Reid, 1982). Over the ensuing decades, the behavior family therapy principles were applied and adapted to promote children's adjustment to address family formation and adaptation (Family Check-Up model), family disruption and maladaptation (Parent Management Training-Oregon model), and family attenuation and dissolution (Treatment Foster Care-Oregon model). We provide a brief overview of each intervention model and summarize randomized trials of intervention effectiveness. We review evidence on the viability of effective implementation, as well as barriers and solutions to adopting these evidence-based practices. We conclude by proposing an integrated family support system for the three models applied to the goal of reducing the prevalence of severe problem behavior, addiction, and mental problems for children and families, as well as reducing the need for costly and largely ineffective residential placements.

The long-term effectiveness of the Family Check-Up on school-age conduct problems: Moderation by neighborhood deprivation

Several studies suggest that neighborhood deprivation is a unique risk factor in child and adolescent development of problem behavior. We sought to examine whether previously established intervention effects of the Family Check-Up (FCU) on child conduct problems at age 7.5 would persist through age 9.5, and whether neighborhood deprivation would moderate these effects. In addition, we examined whether improvements in parent-child interaction during early childhood associated with the FCU would be related to later reductions in child aggression among families living in the highest risk neighborhoods. Using a multisite cohort of at-risk children identified on the basis of family, child, and socioeconomic risk and randomly assigned to the FCU, intervention effects were found to be moderated by neighborhood deprivation, such that they were only directly present for those living at moderate versus extreme levels of neighborhood deprivation. In addition, improvements in child aggression were evident for children living in extreme neighborhood deprivation when parents improved the quality of their parent-child interaction during the toddler period (i.e., moderated mediation). Implications of the findings are discussed in relation to the possibilities and possible limitations in prevention of early problem behavior for those children living in extreme and moderate levels of poverty.