7

Toward a National Framework

The statement of task for this study (Box 1-2 in Chapter 1) indicated that the committee’s work “will inform a national framework for strengthening 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 framework. 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, attitudes, and practices associated with positive developmental outcomes in children. While the committee’s 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 income 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

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 identified 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 inference, 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 Engagement, 2015). The framework is founded on the concept that a system

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). Operationalizing this concept would require incorporating evidence reviews into the policy-making and funding system, promoting innovation and improvement, and supporting implementation research.

Second, as described in a recent Institute of Medicine and National Research Council workshop summary and other sources, issues of scalability 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 system 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 programs—including prenatal care, WIC, home visiting programs, and Early Head Start and Head Start—can 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 Children’s Health Quality, 2016). Expanded parent engagement in state and local preschool and kindergarten through grade 3 education is another vehicle for reaching 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 motivating 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. Federal 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 mothers and fathers, program funders and operators cannot assume that what works for and appeals to mothers will do the same for fathers. The committee believes that including fathers is critical to the success of programs aimed at strengthening and supporting parents. Even when some components 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 bolstering 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 discussed—additional 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 supports 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 personnel 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 effective 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 providing 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 components 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 improvement 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 quality 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 communities (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 experience 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 Chapters 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 multiple 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 challenge 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 guidance, 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 examines 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 constitute 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 parenting 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 children’s 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 evaluations 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 California’s 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 parenting 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 injury 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 child’s 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 fostering community among them, providing a channel for peer-to-peer supports.

Some high schools include information on parenting as part of health

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¹ See 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 education 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 result 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 associated 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 support parenting would benefit from including family planning as a key component. 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 increasing 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 producing 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 information 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 California’s Kit for New Parents to determine whether different modes of delivering information 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 programs have found no effects on parent or child outcomes. Labor and delivery 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 children 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 parenting—such as conflictual relationships, substance use, and mental health problems—and then connecting these parents with treatment and, when needed, such supports as housing, income programs, and social services. Referrals for help in addressing any such issues would depend on the types of resources available in the community—perhaps in the health setting itself or in a managed care consortium 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 screening 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 consideration 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. Fathers—especially those in cohabiting unions—who 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 involvement 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 child’s first year of life, given the extent of children’s brain and neurological development 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 systems—well-baby care and home visiting programs—now provide services and support to new parents. In addition, many communities offer a variety of parenting education and support programs.

Well-baby care As 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 children’s 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 Children’s Health Quality, 2016).

There is evidence that this can be done. As discussed in Chapter 4, two programs—Healthy 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 during a child’s 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 approaches 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 universal, and programs—whether universal or not—often 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 Human 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 Collaborative Improvement and Innovation Network focused on a range of specific outcomes and processes (Arbour, 2015). The existing research supports attempting to expand the programs with the most evidence while continuing to improve and study them, as the Health Resources and Services Administration and Office of Planning, Research, and Evaluation are doing. In terms of priorities for expansion, universal programs such as Durham Connects and Child First in Connecticut 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 connect these parents to needed services. In addition, as discussed in Chapter 4, two specific programs—Play and Learning Strategies-Infant and My Baby and Me—have been found to have positive impacts on several important parent behaviors, including increasing contingent responsiveness, verbal stimulation, and warmth among socially disadvantaged mothers. Longitudinal follow-ups found later improvements in children’s 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 implementation 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 technical 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 implementation 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 programs 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 children’s 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 cultural 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 child’s 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 meeting 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 support—child care information—this 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 created to serve low-income children in a manner that includes parent involvement. Most programs focus on helping parents use several of the parenting practices discussed in Chapter 2, including those related to safety, discipline, 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 children’s 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 services, 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 Program and Parent Corps, which have shown success in enhancing parental activities that improve children’s learning skills and school performance (Bierman et al., 2015; Brotman et al., 2013). It would be equally beneficial to examine programs, such as Head Start-based Educare, that are attempting 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 child’s 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 providing 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 children’s 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 child’s 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 children’s learning and development. The Elementary and Secondary Education Act (reauthorized in 2015 as the Every Student Succeeds Act) requires 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 effective 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 recommendations 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. Department 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 engagement. These obstacles include enduring perceptions that parent engagement is a supplement to rather than a core element of high-quality early education; 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 effective 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 programs 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; parents with chronic conditions, such as mental health or substance use problems 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 depending on the needs of the community’s 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 parenting 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 effectiveness 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 increase 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 support for children’s mental health services. A strong children’s 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 experiencing 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 treatment. Evidence-based approaches for providing this support are discussed in Chapter 5. In addition, parents experiencing these problems would benefit 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 participate 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 programs 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 minimally 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 ongoing 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 considerably 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 behaviors of some parents may require intervention through child welfare services to ensure children’s 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 state’s 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 adversities and are often not successful in helping them—hence 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 authorized, to provide ongoing, integrated services beyond a limited period of time, usually no more than 6-12 months (see Chapter 5 and Wald, 2013). One national study of parents receiving in-home services following 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 program—child-parent psychotherapy—comes 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 adoption (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 children’s problematic behaviors (especially externalizing behavior), not to assist children who may have developed multiple problems of their own and are living in exceptionally troubled families.

A system of services—one that facilitates ongoing access to needed services and encourages their utilization—is needed to support parents facing 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 examples 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 special 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 needing 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 Chapters 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 education—and 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 programs—would 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 parents, 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 parenting 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 incorporated 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 technology 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 developmental 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 children’s 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 parenting interventions. In addition, a number of organizations are establishing peer-to-peer support networks that help perform these functions. Such networks 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 child’s well-being reached the mandated reporting threshold.

Information technologies and tools also could be used to assist in communicating across professional settings to facilitate continuous and coordinated 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 assistance, and correctional agencies. It might be hoped that parents would see the advantage of not needing to repeat information that had previously 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 benefit. 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 Institute 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 improving 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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