8
Conclusions and Recommendations
This chapter presents the committee’s conclusions and recommendations. As directed in the statement of task for this study (Box 1-2 in Chapter 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 identifying 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 community services each year. Along with improvements in workforce preparation
(see Recommendations 3 and 4 below), better leveraging the services with which many parents already have ongoing 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 Services, 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 limited. 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 efficiently 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 Outcomes Research Institute, and private philanthropies should fund research focused on developing guidance for policy makers and program administrators and managers on how to scale effective parenting programs 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 implementation guidelines.
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1 This 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.
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 children’s services 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 Medicine, 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 interventions. In so doing, it should support research designed to further operationalize the common elements of effective parenting interventions and to compare the 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 terminology 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 delivery of evidence-based parenting interventions; 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 children’s learning is associated with improvements in children’s 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 making with diverse families about their children’s 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 mutually respectful and reciprocal, set goals with families, and prepare them to engage in behaviors and activities that enhance children’s 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 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 designed to prepare teachers and providers often do not include professional development related to working with parents (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 committee’s 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.
Recommendation 4: The U.S. Department of Health and Human Services 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 professional development for providers who work with families of young children across sectors (e.g., education, child welfare, health). Professional 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 caregivers, 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 Transforming 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 (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 implement parent engagement policies designed to bolster student outcomes. Yet despite the availability of evidence-based approaches for increasing parent engagement in children’s learning and thereby improving child development outcomes, limited official guidance is available on how to do so (U.S. Department of Health and Human Services and U.S. Department of Education, 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 Education, 2016).
Recommendation 5: The U.S. Department of Health and Human Services and the U.S. Department of Education should convene experts in parent engagement to create a toolbox of evidence-informed engagement 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 adherence 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 dissemination efforts 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 children’s 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 children’s 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 promote 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). Moreover, 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 distributed 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).
Recommendation 6: The U.S. Department of Health and Human Services and the U.S. Department of Education, working with state and local departments of health and education and private partners, including businesses and employers, should lead an effort to expand and improve the communication to parents of up-to-date information on children’s 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 minorities; 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 methodologies most likely to produce evidence that can inform policy or practice. These gaps include interventions previously subjected to rigorous evaluation 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. 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 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 Resources and Services Administration, 2016), described in Chapter 4, 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 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 (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 Education 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 improvement 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 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 reduce 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 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.
Recommendation 8: The U.S. Department of Health and Human Services and the U.S. Department of Education, in coordination with private philanthropies, should fund research aimed at evaluating existing interventions that have shown promise with 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 targeting both mothers and fathers. Funders should incentivize the use of state and local data to support this research.
STRENGTHENING THE EVIDENCE ON FATHERS
Children’s 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 proximal—and most important—influence on children’s development.
Substantial evidence shows that young children have optimal developmental 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 children’s 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 children’s development. Research is needed to identify promising interventions for parents both in their individual relationships with their children and in their coparenting 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.
Recommendation 9: The U.S. Department of Health and Human Services, 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 parents’ 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 building 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 Visitation program, Head Start, and Early Head Start.
STRENGTHENING THE EVIDENCE FOR DIVERSE POPULATIONS
The U.S. population of young children and their parents is demographically, culturally, linguistically, and socially diverse. Although research suggests that some parenting knowledge, attitudes, and practices vary across groups (Brooks-Gunn and Markman, 2005; Brooks et al., 2013; Burchinal et al., 2010; Leyendecker et al., 2002; Rowe, 2008), little is known about whether and how these differences matter for children’s 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 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 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 multipronged 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 practices 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 parenting 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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